Every finding on record at Farmersville Health and Rehabilitation

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during medical treatment and personal care and confidentiality of personal and medical records for four of twenty residents (Resident #1, #36, #69, and Resident #75) reviewed for privacy and confidentiality. The facility failed to ensure LVN E pulled the privacy curtain while connecting Resident #1's formula to his g-tube on 03/15/2026. The facility failed to ensure CNA J provided privacy while transferring Resident #36 on 03/16/2026. The facility failed to ensure LVN E closed, locked, or minimized her laptop monitor before leaving her cart, thus exposing Resident #69's medical information, on 03/15/2026. The facility failed to ensure RN D did not disclose Resident #75's treatment to her roommate and the roommate's family member on 03/16/2026. These failures could place the residents at risk of not having their personal privacy maintained while treatment and care were provided, which could result in the residents feeling uncomfortable during treatment and having their personal and medical record exposed to unauthorized individuals.Findings included: Record review of Resident #1's Face Sheet, dated 03/16/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support). Record review of Resident #1's Quarterly MDS Assessment, dated 02/24/2026, reflected that the resident had severe cognitive impairment (resident required significant assistance and support in daily life) with a BIMS score of 03. The Quarterly 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 #1's Comprehensive Care Plan, dated 03/05/2026, reflected the resident required a PEG tube (procedure to place a feeding tube in the stomach), (a flexible feeding tube inserted directly to the stomach) and one of the interventions was to check for placement and gastric residuals (food, liquid, and secretions remaining in the stomach). Record review of Resident #1's Physician Order, dated 02/26/2026, reflected Enteral Feed (delivery of food through feeding tube). Order every 4 hours G-TUBE - FLUSH [routine] = Flush g-tube w/ 225 cc of water Q 4 hours. HOB elevated 30-45 degrees at all times. Check tube placement prior to each feeding, meds and fluids per auscultation (listening to the sounds produced within a body using a stethoscope) and residual Q shift. If 100 cc, HOLD feeding. Record review of Resident #1's Physician Order, dated 02/09/2026, reflected Enteral Feed Order every shift G-TUBE - ENTERAL FORMULA [CONTINUOUS] = Enteral Formula: NUTREN 2.0 @ 50 cc for 22 hours/day via g-tube and pump. Head of bed elevated 30-45 degrees at all times. During an observation on 03/15/2026 at 1:04 PM revealed LVN E was about to connect Resident #1's enteral formula to his g-tube. She went inside the resident's room and started the process. It was observed that Resident #1 was in a wheelchair and his roommate was sitting at the side of the bed facing Resident #1. LVN E did not pull the privacy curtain while she was connecting Resident #1's feeding formula. During an interview on 03/15/2026 at 2:06 PM, LVN E said she should have pulled the privacy curtain when she was connecting Resident #1's feeding formula because his roommate was in the room. She said she closed the door so that nobody from the hallway could see the treatment she was providing. She said she should have pulled the privacy curtain to provide privacy from the Resident's roommate. During an observation and interview on 03/15/2026 at 2:12 PM revealed when Resident #1 was asked if it was okay that his roommate could see what treatment was being done to him, the resident did not reply. Record review of Resident #36's Face Sheet, dated 03/16/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #36's Comprehensive MDS Assessment, dated 02/25/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated that the resident required maximal assistance for transfer. Record review of Resident #36's Comprehensive Care Plan, dated 03/01/2026, reflected the resident required assist with ADLs and one of the interventions was to provide level of support to complete transferring needs every shift. During an observation on 03/16/2026 at 2:26 PM revealed CNA J was about to transfer Resident #36 from wheelchair to bed. She ushered the resident to her room and positioned the resident parallel to the bed. She sanitized her hands and put on a pair of gloves. She then transferred the resident to her bed using the stand and pivot. It was observed that Resident #36's roommate was in her bed, awake. CNA J did not pull the privacy curtain and did not close the door while transferring the resident. During an interview on 03/16/2026 at 2:35 PM, CNA J said she should have pulled the privacy curtain and closed the door to provide privacy during Resident #36's transfer. She said she did not know why she forgot to close the door and pull the privacy curtain since the resident's roommate was inside the room. During an observation and interview on 03/16/2026 at 2:41 PM revealed when Resident #36 was asked if it was okay if she was being transferred with the door open, the resident shrugged her shoulders. Record review of Resident #69's Face Sheet, dated 03/15/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic pain and gastro-esophageal reflux disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #69's Comprehensive MDS Assessment, dated 01/24/2026, reflected that the resident had moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated that the resident had chronic pain and gastro-esophageal reflux disease. Record review of Resident #69's Comprehensive Care Plan, dated 03/01/2026, reflected the resident was on opioid (medication for pain) medication as part of pain management and the interventions were to administer opioid medication as prescribed by the physician and to monitor for constipation. The plan indicated that the resident was using an anticoagulant and one of the interventions was to monitor diarrhea. Record review of Resident #69's Physician Order, dated 02/24/2026, reflected Mylanta Maximum Strength Oral Suspension 400-400-40 MG/5ML (Alum & Mag Hydroxide-Simethicone) Give 15 ml by mouth every 4 hours as needed for GI UPSET Give 15ML (=1200-1200-120MG) Record review of Resident #69's Physician Order, dated 02/24/2026, reflected Senna Oral Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth every 24 hours as needed for CONSTIPATION. Record review of Resident #69's Physician Order, dated 02/24/2026, reflected Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 1 tablet by mouth every 8 hours as needed for pain. Record review of Resident #69's Physician Order, dated 02/24/2026, reflected Tylenol Tablet 325 MG (Acetaminophen). Give 2 tablets orally every 6 hours as needed for PAIN/ELEVATED TEMP Give 2tabs (=650MG) Document level of pain [0-10]. In progress note describe pain scale used and location of pain and any painbehaviors observed. DO NOT EXCEED 3,000MG/DAY OF ACETAMINOPHEN FROM ALL SOURCES UNLESS APPROVED BY MD. During an observation on 03/15/2026 at 9:17 AM revealed a cart was parked in a hallway. On top of the cart was a laptop with its screen open and displayed Resident #69's name, date of birth , name of his physician, location, code status, allergies, special instructions, her latest vital signs, her latest weight, her latest pain level, and some of her medications. The screen of the laptop was facing the hallway and was unattended. During an observation and interview on 03/15/2026 at 9:21 AM, LVN E said she went to check on a resident, that was why she left her cart. She said it was a HIPAA violation because the personal and medical information of Resident #69 was exposed. She said the said information should be secure and confidential. Record review of Resident #75's Face Sheet, dated 03/16/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus. Record review of Resident #75's Comprehensive MDS Assessment, dated 01/30/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident had diabetes mellitus (high blood sugar). Record review of Resident #75's Comprehensive Care Plan, dated 02/12/2026, reflected the resident had diabetes mellitus and the intervention was to administer diabetic medications as ordered. Record review of Resident #75's Physician Order, dated 03/13/2026, reflected FINGERSTICK BLOOD SUGAR - AC & HS = Fingerstick blood sugar [BBG/FSBS] before meals and at bedtime. Document results. IF FSBS LESS THAN 69 ORGREATER THAN 400 AND UNRESOLVED, NOTIFY PHYSICIAN before meals and at bedtime. During an observation on 03/16/2026 at 11:40 AM revealed Resident #75 was in her bed, awake. It was observed that RN D was about to check the resident's blood sugar. It was also observed that the resident's roommate and the roommate's family member were inside the room. RN D told the resident and the roommate's family member that she needed to pull the privacy curtain because she needed to check Resident #75's blood sugar. During an interview on 03/16/2026 at 11:55 AM, RN D said getting the blood sugar of Resident #75 was a medical treatment and should not be disclosed to anybody that did not have anything to do with resident care. She said she should be mindful before talking about a resident's medical condition or treatment because their medical information should be confidential. During an interview on 03/16/2026 at 12:03 PM, Resident #75 said she was not aware about it was not right to share with anybody about one's medical information. During an interview on 03/17/2026 at 7:02 AM, ADON A said the staff should close the door and/or pull the privacy curtain when they were providing treatment and care to the residents. She said the staff needed to get used to providing privacy during treatment and care so that individuals that did not have anything to do with the residents' care would not see it. 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 might want their door closed or the privacy curtain pulled during treatment. She said checking the blood sugar was a medical procedure and should not be disclosed to anyone. She said disclosing a medical procedure to somebody that had nothing to do with the resident's care could be a HIPAA violation. She said, aside from disclosing medical information, leaving the laptop open with resident's medical information open could also be a HIPAA violation because the medications and the vital signs of the resident were exposed. She said the expectation was that residents were given privacy during care and treatment and that the staff would secure the residents' personal and medical information. She said the DON had already initiated an in-service about privacy and confidentiality of medical information. During an interview on 03/17/2026 at 7:41 AM, the DON said personal and medical information about a resident should not be disclosed to anybody that had nothing to do with the resident's care because it was a HIPAA violation. She said leaving the computer open with a resident's medical information exposed was also a HIPAA violation. She said the medical information of a resident should be protected and could not be shared without the permission of the resident or the resident's responsible party. She said the door should be closed every time the staff provided care or treatment to give privacy and prevent improper exposure of any body part. She said if somebody else was inside the room, the privacy curtain should be pulled for the same reason. She said other individuals, like non-clinical personnel, visitors, and other residents, would see the treatments being done and might cause embarrassment. She said, the issue was not if the residents minded or not, but that the staff did not provide privacy. She said all the staff were expected to provide full privacy and confidentiality of information for all residents. The DON stated she had already started an in-service about privacy during care and treatment and about confidentiality of medical information. During an interview on 03/17/2026 at 8:12 AM, the Administrator said the staff should not disclose any medical information about a resident to another resident or to their family member because it was a HIPAA violation. She said leaving the computer open, with exposed medical information about a resident, was also a HIPAA violation. She said medical information should be secured because it was confidential. She said the staff must make sure that the residents were provided privacy during treatment and transfer to avoid any discomfort or embarrassment. She said the expectation was for the staff to be mindful about privacy when providing treatment and secure all the medical information. She said the DON already started an inservice about HIPAA and providing privacy to the residents during care and treatment, but she would monitor closely if the staff understood the in-service. Record review of the facility's policy, Resident Rights Policy Operational/Resident Care Policies, undated reflected Privacy and Confidentiality . Residents' personal and clinical records are protected to assure confidentiality . Personal privacy will be provided for . medical treatment . personal care. Record review of the facility's in-service Privacy, dated 03/15/2026, reflected Remember to provide privacy to residents by pulling the curtain or closing the door. Record review of the facility's In-Service HIPAA, dated 03/16/2026, reflected Remember when performing cares or administering medications to residents, be mindful of HIPAA rules when the roommate is present. Record review of the facility's in-service HIPAA, dated 03/17/2026, reflected If you walk away from your computer, be sure to close or turn off your screen.

Based on observations, interviews, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for five of eighteen residents (Residents #4, #17, #38, #51, and #67) reviewed for medication storage. 1. The facility failed to ensure an antifungal powder was not inside Resident #4's room and his medication was not left with him to take unattended on 03/15/2026.2. The facility failed to secure Resident #4's TUMS when it was left inside his room on 03/15/2026. 3. The facility failed to ensure an eyedrop was not inside Resident #17's room on 03/15/2026. 4. The facility failed to ensure an antifungal powder and a wound cleanser were not inside Resident #38's room on 03/15/2026. 5. The facility failed to ensure a cup of barrier cream was not inside Resident #51's room on 03/15/2026. 6. The facility failed to ensure an antifungal powder was inside Resident #67's room on 03/15/2026. 7. The facility failed to ensure the Treatment Nurse did not leave the dressing with medication inside the Resident #38's room on 03/16/2026. 8. The facility failed to ensure that the treatment cart was locked when left unattended on 03/15/2026. These failures could place the residents at risk of accidental overdose, misuse of medications, and possible adverse reactions. Findings included: 1. Record review of Resident #4's Face Sheet, dated 03/15/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dementia. Record review of Resident #4's Comprehensive MDS Assessment, dated 03/07/2026, reflected the resident had severe impairment in cognition with a BIMS score of 05. The Comprehensive MDS Assessment indicated the resident had dementia. The assessment did not indicate that the resident had a skin issue. Record review of Resident #4's Comprehensive Care Plan, dated 03/01/2026, reflected that the resident had impaired cognitive function and one of the interventions was to monitor any changes in cognitive function. During an observation on 03/15/2026 at 10:38 AM revealed Resident #4 was not inside his room. It was observed that there was a container of anti-fungal powder on top of the resident's drawer. During an observation and interview on 03/15/2026 at 10:46 AM, ADON A said antifungal powder should not be inside the residents' rooms and should be stored inside the carts. She said the medications should be secured so the residents, especially the confused resident, would not get a hold of them and misuse them. She said the staff should be mindful that no medications were inside the rooms. She said this was not only applicable for the nurses, but the CNAs must report to the nurse if they saw any. She went inside Resident #4's room and saw the anti-fungal powder on top of the resident's drawer. She took the anti-fungal powder and said she would put it inside a plastic bag and put the resident's name on it. During an interview on 03/17/2026 at 10:59 AM, Resident #4 said he did not have any rashes, so he did not know why there was an antifungal powder inside his room.2. Record review of Resident #4's Face Sheet, dated 03/15/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with gastro-esophageal reflux disease and dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #4's Comprehensive MDS Assessment, dated 03/07/2026, reflected the resident had severe impairment in cognition with a BIMS 05. The Comprehensive MDS Assessment indicated the resident had gastro-esophageal reflux disease and dementia. Record review of Resident #4's Comprehensive Care Plan, dated 03/01/2026, reflected that the resident had impaired cognitive function and one of the interventions was to monitor any changes in cognitive function. Record review of Resident #4's Physician's Order, dated 02/23/2026, reflected Calcium Carbonate Tablet Chewable 500 MG Give 2 tablet by mouth every 12 hours as needed for indigestion AND Give 1 tablet by mouth three times a day for phosphorus binder (medication that prevents high level of phosphorus in the blood) give with meals. Record review on 03/15/2026 of Resident #4's Assessment Notes reflected that the resident did not have an assessment for self-administration of medication. During an observation on 03/15/2026 at 10:38 AM revealed Resident #4 was not inside his room. It was observed that there was a small plastic cup with a pill on top of the resident's drawer. During an observation and interview on 03/15/2026 at 10:48 AM, MA F said during medication administration, the staff administering the medications should stay with the resident to make sure that the resident took the medications. She went inside Resident #4's room and saw the medication that was inside a small cup. She said the medication was TUMS and was given three times a day. She said she gave the resident morning medication, including his TUMS, and the resident took all his morning medications. She said she did not notice the TUMS on top of the resident's drawers, and she did not know who left the medication with the resident to take unattended. She said medications should be secured inside the cart. she said if the resident did not take the medication, then it should have been discarded. She said the resident might take it with the next dose that could lead to overdosing. She took the cup with TUMS in it and discarded it. During an interview on 03/16/2026 at 7:01 AM, RN E said she would sometimes help in passing medications if needed. She said she did not pass medication prior to Sunday, 03/15/2026. She said medications should not be inside the residents' room but locked inside the cart because residents might use them inappropriately.During an interview on 03/15/2026 at 10:46 AM, ADON A said Resident #4's TUMS should not be inside the room but inside the cart. she said if the resident did not take it, then it should have been disposed. She said the resident might take them more that what was recommended or someone else might, like another resident or a visitor. She said the resident might aspirate or choke while taking the medications, and nobody would know. She said the DON had already started an in-service about not leaving the medications with the residents. 3. Record review of Resident #17's Face Sheet, dated 03/16/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with depression (persistent feeling of sadness or loss of interest). Record review of Resident #17's Comprehensive MDS Assessment, dated 03/05/2026, reflected that the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had depression. Record review of Resident #17's Comprehensive Care Plan, dated 01/18/2026, reflected that the resident was using an anti-depressant and one of the interventions was to administer medications as ordered. Record review on 03/16/2026 of Resident #17's Physician's Order reflected no order for eyedrops. During an observation and interview on 03/15/2026 at 10:53 AM revealed that Resident #17 was in her bed, awake. It was observed that a container of eye drops was on her windowpane. The resident said she did not know if the staff knew about the eyedrops being inside her room, but it had always been in her windowpane. She said she was not using the eyedrops. During an observation and interview on 03/15/2026 at 10:58 AM, ADON A said, just like the anti-fungal powder, the residents could not have eye drops inside their rooms because the staff were the ones administering the eye drops. She said she was not even sure if the resident had an order for the eyedrops. She went inside Resident #17's room and talked to the resident regarding the eyedrops. She told the resident that she would put the eyedrops in the cart and request an order for it. 4. Record review of Resident #38's Face Sheet, dated 03/16/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dementia and a non-pressure ulcer (wound not caused by pressure) of the left foot. Record review of Resident 38's Comprehensive MDS Assessment, dated 03/05/2026, reflected that the resident had severe impairment in cognition with a BIMS score of 04. The Comprehensive MDS Assessment indicated the resident had dementia and non-pressure ulcer of the left foot. Record review of Resident #38's Comprehensive Care Plan, dated 03/01/2026, reflected that the resident had impaired cognitive function and one of the interventions was to administer medications as ordered. Record review of Resident #38's Physician's Order, dated 02/09/2026, reflected Clean abrasions/skin tears with normal saline. Apply steri-strips as needed. Apply protective dressing as needed. Change daily and prn. Monitor until healed. During an observation and interview on 03/15/2026 at 9:07 AM revealed Resident #38 was in his bed, awake. It was observed that a container of anti-fungal powder and wound cleanser were on top of his shelf. When asked about the anti-fungal powder and wound cleanser, the resident shrugged his shoulders. During an interview on 03/16/2026 at 9:00 AM, the Treatment Nurse said she was using normal saline for the Resident #38's wound care, so she did not know who used a wound cleanser for wound care. 5. Record review of Resident #51's Face Sheet, dated 03/16/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dementia and muscle weakness. Record review of Resident #51's Comprehensive MDS Assessment, dated 02/13/2026, reflected that the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident was incontinent (unable to control) for bladder and bowel. Record review of Resident #51's Comprehensive Care Plan, dated 02/24/2026, reflected that the resident was incontinent for bladder and bowel and one of the interventions was to do perineal (area between the thighs) care after each incontinent episode. Record review of Resident #51's Physician's Order, dated 02/09/2026, reflected May apply skin protectant/barrier cream to affected/reddened areas every shift and/or prn as preventative. During an observation and interview on 03/15/2026 at 9:11 AM revealed Resident #51 was in his bed awake. It was observed that a small cup with white cream was on top of the resident's side table. The resident said the staff used the cream when they cleaned and changed him. He said he did not know who left the cup of cream on his side table. During an observation and interview on 03/15/2026 at 9:29 AM, LVN E said the antifungal powder and the wound cleanser should not be inside Resident #38's room because the resident might use them inappropriately or might use them more than the recommended. She said confused residents might consume them as well; that could result in upset stomach and nausea. She said she knew the resident had a wound that was being treated, but she said she was not sure why the resident had an anti-fungal powder inside his room. She went inside the room and took the anti-fungal powder and the wound cleanser and said she would put them in the treatment cart. During an observation and interview on 03/15/2026 at 9:32 AM, LVN E then went to Resident #38's room and saw the cup of white cream on top of Resident #51's side table. She said, most probably, it was barrier cream that was used when the resident was being changed. She took the cup of barrier cream and disposed of it. She said the barrier cream should not be also inside the residents' rooms for the same reason as the antifungal powder and wound cleanser. 6. Record review of Resident #67's Face Sheet, dated 03/16/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dementia. Record review of Resident #67s Comprehensive MDS Assessment, dated 02/15/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident had moisture associated with skin damage. Record review of Resident #67's Comprehensive Care Plan, dated 02/24/2026, reflected that the resident had a rash under left breast related to moisture and one of the interventions was to administer nystatin powder as ordered. Record review of Resident #67's Physician's Order, dated 07/23/2025, reflected Nystatin Powder (Nystatin (Bulk)) Apply to Under Left Breast topically one time a day for yeast. During an observation, an interview on 03/15/2026 at 12:23 PM revealed Resident #67 was in her bed, awake. It was observed that she had a small white cart at the bedside. On the second tier of the cart was a container of an antifungal powder. The resident said the staff were using the powder for the rash under her breast. She said after the staff use the antifungal powder; they would return it to her cart. During an interview on 03/16/2026 at 8:55 AM, CNA I said she was not aware there was an anti-fungal powder inside Resident #67's room. She said the powder should be in the cart of the nurses. She said the residents might use them inappropriately, or confused residents might use them to powder their faces. She said she would go to the resident's room and would check if the anti-fungal powder was still inside the room. She said the barrier creams should not be inside the rooms of the residents for the same reason. 7. Record review of Resident #38's Face Sheet, dated 03/16/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with a non-pressure chronic ulcer on the left foot. Record review of Resident 38's Comprehensive MDS Assessment, dated 03/05/2026, reflected that the resident had severe impairment in cognition with a BIMS score 04. The Comprehensive MDS Assessment indicated the resident had a non-pressure chronic ulcer of the left foot. Record review of Resident #38's Comprehensive Care Plan, dated 03/12/2026, reflected that the resident had a chronic venous/stasis ulcer of the left lower leg r/t PVD and one of the interventions was to treat the wound as ordered. Record review of Resident #38's Physician's Order, dated 02/09/2026, reflected LEFT LOWER EXTREM - VASCULAR WOUND - Cleanse with NORMAL SALINE, pat dry with GAUZE, apply MUPIROCIN, apply CALCIUM ALGINATE, cover with, DRY DRESSING secure with ROLLED GAUZE, and ELASTIC COMPRESSION WRAP one time a day for wound care. During an observation on 03/16/2026 at 9:15 AM revealed the Treatment Nurse was about to do Resident #38's wound care. She sanitized her hands and put on a pair of gloves. She then sanitized the resident's overbed table. She took off her gloves, sanitized her hands, and put on a pair of gloves. She then prepared some normal saline, mupirocin ointment, calcium alginate, some gauze, and a dry dressing. She placed the things needed for wound care on top of the resident's overbed table. She then put the mupirocin ointment on top of the dressing. She pushed the resident's overbed table and placed it at the bedside. When she was about to start wound care, she asked the resident if he was in pain; the resident said he was in pain with a pain scale of 8/10. She told the resident that she would ask the nurse to give him a pain medication. She went to the nurse's station and left the dressing with medication at bedside. During an interview on 03/16/2026 at 9:31 AM, the Treatment Nurse said she should have not left the dressing with medication on it when she went out of Resident #38's room to call the call at the nurse's station. She said the resident, if confused, might consume it. She said she should have flagged a staff to call the nurse, or she should have discarded the dressing with medication and prepared another one once the pain medication was administered. 8. During an observation on 03/15/2026 at 9:17 AM revealed a cart parked in the hallway was not locked. It was observed that there were two tubes of topical antibiotics on the first drawer of the cart. The cart was facing the hallway and was unattended. It was observed that several residents were passing-by the unlocked cart During an observation and interview on 03/15/2026 at 9:21 AM, LVN E said the carts should be locked when left unattended because the residents could open the drawers and could get medications from the drawer and consume them. She said she did not know who left the treatment cart open. She then locked the cart. During an interview on 03/17/2026 at 7:02 AM, ADON A said the Treatment Nurse should have pushed the call light so that she could let somebody tell the nurse that the resident needed a pain pill. She said she could have called from outside the room, with the dressing with medication still within her vision. She said any cart should be left unlocked because the resident might be able to open the drawers and get medications that they do not need. She said the DON already started an in-service about not having any medications inside the rooms of the resident and not leaving the carts unlocked. She said the in-service was for the CNAs also because the CNAs must report to the nurse if they saw any medication inside the rooms of the residents. She said the DON had already started an in-service about medication storage. During an interview on 03/17/2026 at 7:41 AM, the DON said medications, of any form, should not be stored inside the residents' rooms. She said nasal antifungal powder, eye drops, and barrier creams should be inside the carts to secure them. She said the staff should be the one administering them if the residents had orders for the said medications. She said the residents might use them inappropriately that could result in adverse reactions. She said the Treatment Nurse should have called somebody to call the nurse for the pain pill instead of leaving the medicated dressing inside the room unattended. She said all the carts should be locked when the staff were not using the carts because the residents and visitors could get medications from the drawers. She said residents might consume the medication they took from the cart that they were allergic to. She said the expectation was there would be no medications inside the rooms of the residents, that staff should scan the room for any medications, and the carts would be locked when the staff were not using them. She said she already started an in-service about medication storage and not locking the carts. During an interview on 03/17/2026 at 8:12 AM, the Administrator said that the expectation was for the staff to make sure there was no medications inside the rooms of the residents because the residents might consume the medications or use them inappropriately. She said the carts should be locked before the staff left the carts unattended. She said the DON already started an in-service about not storing medications inside the rooms of the residents and to lock the carts always. Record review of the facility's policy, Medication Cart, reflected Procedure . 16. If the cart is left at any time . it must be locked. Record review of the facility's policy, Storage of Drugs Operational/Resident Care Policies, undated, reflected All drugs and biologicals are stored in locked compartments . Only authorized personnel are permitted to have access to the medication keys. Record review of the facility' policy, Drug Security Operational/Resident Care Policies, undated, reflected A drug distribution cart is used by the facility and when not in use it will be locked. Record review of the facility' policy, Drug Orders Operational/Resident Care Policies, undated, reflected All drugs must be prescribed by the resident's physician or consulting physician.

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 one of one kitchen reviewed for food and nutrition services. The facility failed to ensure dietary staff properly labeled and dated stored food received by vendors.The facility failed to ensure the ice machine was thoroughly cleaned and/or sanitized.The facility failed to ensure the serving table had the appropriate amount of sanitizer in the container (red bucket) for sanitization.The facility failed to ensure the deep fryer was properly cleaned.The facility failed to ensure expired food in the refrigerator was discarded. These failures could place residents at risk of exposure to food contamination and illness. Findings included:Observations on 03/15/26 from 9:05 a.m. to 9:16 a.m. in the facility's only kitchen revealed: The deep fryer in the kitchen area had extremely dark grease and built-up brownish stain along the inside walls of the fryer. One plastic bag of sliced cheeses, located in the refrigerator, was dated 2/16/26 and another date of 3/10/26. One silver container labeled sandwiches, located in the refrigerator, was dated 3/11/26 to 3/14/26. Item should have been discarded. One large bag with a yellow substance (later identified as scrambled eggs), located in the refrigerator, was not labeled and dated. One large container of frozen apple streusel coffee cake, located in the freezer, was dated with a stored date of 9/03/25. An ice machine, located in the kitchen had reddish stains along the inside white panel wall of the ice machine and white stains along the inside of the opening door.During an interview and observation on 03/16/26 at 11:34 p.m., the DM and [NAME] O tested the Red bucket, which was supposed to contain sanitizer solution to sanitize the serving table during lunch. The DM used a test strip to test the PPM and the test indicated no sanitizer fluid was present. [NAME] O stated she had tested the solution during the breakfast serving and it tested at 200 PPM, she stated she was not sure why it tested at 0 PPM for the lunch serving. The DM stated they tested the solution in the Red bucket every meal prior to serving the meals. She stated if the solution did not have the appropriate amount of sanitizer fluid in the solution, it would not decontaminate the surface.During an interview on 03/16/26 at 12:34 p.m., the DM was shown photos of the concerns observed in the kitchen area on 03/15/26. She stated she had spoken with her staff later that day and was informed of some of the concerns. She stated she cleaned the fryer every two weeks, but the cooks forgot to strain the grease daily. She stated she had cleaned the deep fryer on 03/15/26. She stated she had observed some of the foods not labeled and dated and had since labeled and dated the foods. She stated she had someone clean the ice machine. She stated she was unsure of the expiration date for the food when there was no expiration date on them and would have to research it. She stated the concerns observed could result in food contamination and residents getting sick.During an interview on 03/17/26 at 12:00 p.m., the Administrator was informed of the concerns observed in the kitchen area. She stated she had spoken with the DM and was informed of the findings. She stated she expected her kitchen to meet guidelines to avoid infection and food contamination. Record Review of the Facility's policy titled Proper labeling and dating, undated, revealed, Food must be labeled and dated. Why labeling and dating is important. Protects residents from foodborne illnesses. Maintains food quality and freshness. Ensures proper food rotation. Required during state and health inspections. Foods that must be labeled. All foods must be labeled when stored in refrigerators, freezers, or dry storage. Ready to eat food must be discarded after 7 days. Food must be discarded if past discard date. It is the policy of this facility that the food services shall be maintained in a clean and sanitary manner. Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD Texas Chapter 228 Retail Food adopts the U.S FDA Food Code. 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Commercially processed food Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Pf (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepare.

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 1 of 6 residents (Resident #20) reviewed for care plan. The facility failed to ensure Resident #20's care plan reflected a plan of care for the resident's use of a Nebulizer. This failure could place the resident at risk of not receiving the necessary care and services.Findings included:Record review of Resident #20's Face Sheet, dated 03/16/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20 had a diagnosis of COPD (lung disease).Record review of Resident #20's Quarterly MDS Assessment, dated 02/10/26, reflected Resident #20's BIMS (11) indicated a moderate cognitive impairment. The Quarterly MDS Assessment reflected the resident had active diagnosis of COPD.Record review of Resident #20's Physician orders, dated 03/16/26, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/ML 1 vial inhale every 6 hours for COPD. Nebulizer - Clean and change tubing every week on Sunday. Record review of Resident #20's Comprehensive Care Plan, dated 01/25/26, did not reflect a plan of care for the use of the Nebulizer. During an observation on 03/15/26 at 10:29 a.m., Resident #20 had a nebulizer mask sitting on top of her nightstand unbagged.During an interview on 03/17/26 at 09:15 a.m., the DON was informed of Resident #20 not being care planned for the use of a nebulizer. She stated it was the MDS nurse's responsibility to ensure care plans were updated with the resident's plan of care because they had orders for the use of a nebulizer. She stated not care planning the use of the nebulizer could result in missed care.During an interview on 03/17/26 at 09:30 a.m., the MDS nurse was informed of Resident #20 not being care planned for the use of a nebulizer. She stated she thought the intervention of the resident using the broad term of the resident's use of an aerosol/bronchodilator was sufficient. She was informed Resident #20 had physician orders for an aerosol/bronchodilator medication; however, it was orders for a different form of medication, and the resident's care plan was not specific to the referencing the resident's use of the nebulizer. She stated the intervention should include the use of the nebulizer because it was part of her plan of care.During an interview on 03/17/26 at 10:20 a.m., ADON B was informed of Resident #20 not being care planned for the use of a nebulizer. She stated it was the MDS nurse's responsibility to ensure care plans were updated with the resident's plan of care. She stated not care planning the use of the nebulizer could result in the resident not receiving the care needed. She stated as a nurse it should have been care planned. Record review of the facility's policy, Comprehensive Person-Centered Care Planning, undated, reflected The facility will develop and implement a Comprehensive Care plan in place of the baseline care plan for each resident that includes instructions needed to provide effective person-centered care of the resident that meet professional standards of quality of care. The care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to, B. Physician Orders.

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 two of eighteen resident (Resident #1 and Resident #2) reviewed for infection control. 1. The facility failed to ensure LVN E performed hand hygiene and changed her gloves while preparing Resident #1's formula for g-tube on 03/15/2026. 2. The facility failed to ensure LVN E sanitized the tray she used between Resident #1 and Resident #2 during g-tube management on 03/15/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings included: 1. Record review of Resident #1's Face Sheet, dated 03/16/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support). Record review of Resident #1's Quarterly MDS Assessment, dated 02/24/2026, reflected that the resident had severe impairment with a BIMS score of 03. The Quarterly MDS Assessment indicated that the resident had a feeding tube. Record review of Resident #1's Comprehensive Care Plan, dated 03/05/2026, reflected that the resident required a PEG tube and one of the interventions was to check for placement and residuals. Record review of Resident #1's Physician Order, dated 02/09/2026, reflected Enteral Feed Order every shift G-TUBE - ENTERAL FORMULA [CONTINUOUS] = Enteral Formula: NUTREN 2.0 @ 50 cc for 22 hours/day via g-tube and pump. Head of bed elevated 30-45 degrees at all times. During an observation on 03/15/2026 at 1:04 PM revealed LVN E was about to connect Resident #1's enteral feeding formula to his g-tube. She prepared the bag of pre-filled enteral formula, a tray, a flush bag, water for the flush bag, two cups of water, a syringe, and some tubings inside an open plastic bag. She sanitized her hands and put on a gown. She went inside the resident's room and hung the pre-filled enteral formula on one of the hooks of the IV pole with a feeding pump attached to it. She placed the other things that she prepared on the tray and placed the tray on the resident's side table. She then pulled the trash can near her using her gloved right hand. After pulling the trash can, she started to pour water on the flush bag. She did not sanitize her hands and change her gloves after touching the trash can. After pouring water into the flush bag, she hung the flush bag on the other hook of the IV pole. She then removed the cap of the pre-filled formula and connected the tube. She connected the tubes of both bags to the pump and started to prime the feeding set pointing the ends of the tubes towards the trash can. After priming the formula set, she hung the tubings to one of the hooks of the IV pole. After hanging out the tubes, she checked the placement of the g-tube and gastric residuals. After checking the placement of the g-tube and the gastric residual, she connected the formula to the resident's g-tube. She did not change her gloves after touching the trash and all through the process of connecting the formula bag. 2. Record review of Resident #2's Face Sheet, dated 03/16/2026, 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 #2's Comprehensive MDS Assessment, dated 01/06/2026, reflected that the resident had moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #2's Quarterly Care Plan, dated 01/14/2026, reflected that the resident required a PEG and one of the interventions was to check for tube placement and feeding before initiating feeding. Record review of Resident #2's Physician Order, dated 03/11/2026, reflected every 4 hours G-TUBE - FLUSH [routine] = Flush g-tube w/ 200 cc of water Q 4 hours. HOBelevated 30-45 degrees at all times. Check tube placement prior to each feeding, meds and fluids per auscultation and residual Q shift. If 100 cc, HOLD feeding. During an observation on 03/15/2026 starting at 1:04 PM revealed LVN E was about to connect Resident #1's feeding formula to his g-tube. She prepared the bag of pre-filled enteral formula, a tray, a flush bag, water for the flush bag, two cups of water, a syringe, and some tubings inside an open plastic bag. She sanitized her hands and put on a gown. She went inside the resident's room and hung the pre-filled enteral formula on one of the hooks the IV pole with a feeding pump attached to it. She placed the other things that she prepared on the tray and placed the tray on Resident #1's side table and proceeded to connect the feeding formula. After connecting Resident #1's feeding formula, she went back to her cart and placed the tray on top of her cart. She did not sanitize the bottom of the tray that she placed on Resident #1's side table before putting it on top of her cart. She then went to the sink with the tray, placed the tray at the side of the sink, and washed her hands and the syringe that she used for Resident #1. After washing the syringe, she went back to her cart and put the tray on top of her cart. She then went to Resident #2's room and prepared to give Resident #2's bolus feeding (method of delivering enteral nutrition through a feeding tube, providing large doses several times a day). She prepared one big cup of water and four small cups of water. She placed the cups of water on the tray that she used for Resident #1. She went inside the room and placed the tray on Resident #2's overbed table and proceeded to give Resident #2's bolus feeding. After giving the bolus formula to Resident #2, she returned to her cart and put the tray on top of her cart. She then went to the sink to wash her hands and the syringe she used for Resident #2. She went back to her cart and placed the tray back to the top of her cart. She did not sanitize the bottom of the tray after she used it from one resident to another and after she placed it on the Resident #1's side table and Resident #2's overbed table. During an interview on 03/15/2026 at 2:06 PM, LVN E said she should have used her foot to pull the trash can be closer to her or she should have changed her gloves after touching the trash can. She said she was taught to use a tray if she needed to bring the things she needed for treatment inside, but it did not occur to her to sanitize the bottom of the tray after it had contact with the residents' side table and overbed table. She said she did not know what probable microorganisms were on top of the table, and she could have brought them to her cart and to the sink. She said her actions could result in cross contamination and probable infection of any kind. During an interview on 03/17/2026 at 7:02 AM, ADON A said the staff should be mindful that they were not causing any spread of infection in the facility. She said when the staff touched something dirty, like the trash can, the staff should have sanitized her hands and changed her gloves. She said since the tray that was used for Resident #1 touched his side table, then the tray should have been sanitized inside and outside. She said both incidents could cause cross contamination and probable spread of infection. She said the DON already started an in-service about hand hygiene and sanitizing re-usable items used for the residents. During an interview on 03/17/2026 at 7:41 AM, the DON said that hand hygiene was the most effective way to prevent cross contamination and spread of infection. She said staff should have sanitized her hands and changed her gloves after touching the trash can and before connecting the resident's feeding formula. She said the staff should sanitize the tray she used for the things she needed for g-tube because if there were microorganisms in the resident's tables, then it would be also on top of the cart and on the side of the sink. She said the expectation was for the staff to be mindful that they were not causing cross contamination and could lead to development of infections. She said she did a one-on-one in-service with LVN E and in-service for all the staff about infection control and disinfecting reusable equipment. During an interview on 03/17/2026 at 8:12 AM, the Administrator said they always remind the staff to be vigilant with hand hygiene. She said after touching something dirty, the staff should sanitize their hands and change their gloves to make sure their gloves were clean while doing any treatment. She said the tray used should have been sanitized to prevent cross contamination. She said the DON already started an inservice but she would closely monitor if the staff understood the in-service provided. Record review of the facility's policy Infection Control Operational/Resident Care Policies, undated, reflected All employees are required to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice . Staff performances will be monitored to ascertain that proper procedures are followed . environmental waste . Routine cleaning and disinfection of resident care equipment including equipment shared among residents id also implemented.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for one of three direct care staff (RN D) reviewed for other environmental conditions. The facility failed to ensure that RN D did not leave a container of germicidal wipes on top of the nurse's cart unattended on 03/16/2026. This failure could prevent the residents from having an environment that was safe for the residents, staff, and public. Findings included: Record review of Resident #75's Face Sheet, dated 03/16/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus. Record review of Resident #75's Comprehensive MDS Assessment, dated 01/30/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident had diabetes mellitus. Record review of Resident #75's Comprehensive Care Plan, dated 02/12/2026, reflected the resident had diabetes mellitus and one of the interventions was to administer diabetic medications as ordered. Record review of Resident #75's Physician Order, dated 03/13/2026, reflected FINGERSTICK BLOOD SUGAR - AC & HS = Fingerstick blood sugar [BBG/FSBS] before meals and at bedtime. Document results. IF FSBS LESS THAN 69 OR GREATER THAN 400 AND UNRESOLVED, NOTIFY PHYSICIAN before meals and at bedtime. During an observation on 03/16/2026 at 11:40 AM revealed RN D was about to check Resident #75's blood sugar. She prepared the glucometer, alcohol wipes, test strips, and the push-button safety lancets. Before going inside the room, she took a container of germicidal wipes from the last drawer of the cart she was using, opened it, pulled a wipe, and cleaned the glucometer. After cleaning the glucometer, she went inside the resident's room and brought with her the glucometer, alcohol wipes, some test strips, and some push button safety lancets and placed them on top of the resident's overbed table with a parchment paper on it. She closed the door and left the opened container of germicidal wipes on top of her cart. When she was about to start checking the blood sugar, she remembered that she forgot to prepare some gauze. She went to her cart to get some gauze, went back inside the room, and closed the door, leaving the opened container of germicidal wipes again. It was observed that some wipes were peeking out from the opening of the container and several residents were walking in the hallway. During an observation and interview on 03/16/2026 at 11:55 AM, RN D said she used the germicidal wipes to clean the glucometer that she was about to use. She said she should put it back inside the cart because residents might take some and use them to wipe their face. She closed the container of the germicidal wipes and put it back inside her cart. During an interview on 03/17/2026 at 7:02 AM, ADON A said the germicidal wipes should be stored inside the cart for safety reasons. She said residents might think they were ordinary wipes and use them to clean their eyes, nose, ears, and skin. She said it might cause irritation and toxicity. She said anything that indicated Keep out of reach of children should be considered harmful because the facility had confused residents that may not know the outcome if the germicidal wipes were used. She said the DON already started an in-service about not leaving the germicidal wipes on top of the carts unattended. During an interview on 03/17/2026 at 7:41 AM, the DON said the germicidal wipes should be locked inside the carts and not left on top of the carts unattended. She said it should be secured inside the carts so that the residents would not be able to access the wipes that had chemicals on them. She said confused residents might get hold of the wipes, wipe their face, and body that could result to irritations. She said the expectation was for the staff to be mindful and never leave the germicidal wipes on top of the carts unattended. She said she already did an in-service about not leaving the germicidal wipes unattended. During an interview on 03/17/2026 at 8:12 AM, the Administrator said the germicidal wipes should not be placed somewhere accessible to the residents because the wipes had chemicals in them that could be harmful when consumed or had contact with the eyes. She said the DON already started an in-service about germicidal wipes, and she would monitor closely if the staff understood the in-service. In an interview on 03/17/2026 at 9:38 AM, the Dietary and Housekeeping Manager said the germicidal wipes should not be within reach of the resident because they could cause adverse reactions such as irritation. She said the wipes were usually locked inside the cart. She said the nurses used gloves when they use the wipes because it could cause irritation to the skin. Record review of the facility's policy Housekeeping Services Operational/Resident Care Policies, undated, reflected The facility provides a safe, functional, sanitary, and comfortable environment for all residents, staff, and the public . All poisonous items and or other items with cautionary labels are kept secured and are only accessible to employees.

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 to meet the needs of each resident for one of eighteen residents (Resident #4) reviewed for pharmaceutical services. The facility failed to ensure Resident #4's medication was not left with the resident to take unattended on 03/15/2026. This failure could place residents at risk of not receiving medications as ordered, taking medications without a self-administration assessment, potential overdose, and adverse effect.Findings included: Record review of Resident #4's Face Sheet, dated 03/15/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with gastro-esophageal reflux disease and dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #4's Comprehensive MDS Assessment, dated 03/07/2026, reflected the resident had severe impairment in cognition with a BIMS 05. The Comprehensive MDS Assessment indicated the resident had gastro-esophageal reflux disease and dementia. Record review of Resident #4's Comprehensive Care Plan, dated 03/01/2026, reflected that the resident had impaired cognitive function and one of the interventions was to monitor any changes in cognitive function. Record review of Resident #4's Physician's Order, dated 02/23/2026, reflected Calcium Carbonate Tablet Chewable 500 MG Give 2 tablet by mouth every 12 hours as needed for indigestion AND Give 1 tablet by mouth three times a day for phosphorus binder (medication that prevents high level of phosphorus in the blood) give with meals. Record review on 03/15/2026 of Resident #4's Assessment Notes reflected that the resident did not have an assessment for self-administration of medication. During an observation on 03/15/2026 at 10:38 AM revealed Resident #4 was not inside his room. It was observed that there was a small plastic cup with a pill on top of the resident's drawer. During an observation and interview on 03/15/2026 at 10:48 AM, MA F said during medication administration, the staff administering the medications should stay with the resident to make sure that the resident took the medications. She went inside Resident #4's room and saw the medication that was inside a small cup. She said the medication was TUMS and was given three times a day. She said she gave the resident morning medication, including his TUMS, and the resident took all his morning medications. She said she did not notice the TUMS on top of the resident's drawers, and she did not know who left the medication with the resident to take unattended. She said leaving medications with the resident to take later without anybody supervising could lead to the resident not taking the medication, underdosing, overdosing, or misuse of medications. She said the resident might choke on the medication, and nobody would know. She also said other residents who wandered around might take the medication that she did not need. She took the cup with TUMS in it and discarded it. During an interview on 03/16/2026 at 7:01 AM, RN E said she would sometimes help in passing medications if needed. She said she did not pass medication prior to Sunday, 03/15/2026. She said medications should never be left with the residents to take later, unattended because the best practice was to give the medications and wait until the resident took them before leaving the room. She said the resident might not take the medication and might take it with the next pill and might overdose. During an interview on 03/15/2026 at 10:46 AM, ADON A said staff should not leave any medications with the residents for the residents to take unsupervised. She said the staff administering the medications should stay with the resident until the resident was done with the medications. She said the resident might not take them, or someone else might, like another resident or a visitor. She said the resident might aspirate or choke while taking the medications, and nobody would know. She said the residents could not take medications by themselves except if they were assessed that they could self-administer. She asked around, but nobody knew who left the medication inside Resident #4's room. She said the DON had already started an in-service about not leaving the medications with the residents. During an interview on 03/17/2026 at 7:41 AM, the DON said staff should never leave the medications at the bedside for the resident to take later. She said the staff must ensure the resident took all his medications before leaving the room. She said so much could go wrong like the resident could hoard or hide the pills to avoid taking them, could overdose on hoarded pills, and could choke without anybody to help the resident. She said another resident could get hold of it and take the medication that was the resident allergic to. She said the expectation was that no residents were administering their medications without proper assessment. She said if the resident refused the medication, the staff should discard it and document that the resident refused the medication. The DON said she had already started an in-service about medication administration. During an interview on 03/17/2026 at 8:12 AM, the Administrator said she was not a clinician and she would let the DON be the lead about the issue. She said the expectation was if leaving the medication with the resident could cause probable harm, then the staff should not do it. During an interview on 03/17/2026 at 10:59 AM, Resident #4 said he was taking TUMS because of his indigestion. He said staff would bring the medication to him and would tell him to take if wanted to or not. Record review of the facility's policy, Medication Administration undated, reflected 12. Residents observed to ensure medications are swallowed .14. Medications are not left on top of the cart or at resident's bedside.

Based on observations, interviews, and record reviews the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of six residents (Resident #20) reviewed for respiratory care.The facility failed to ensure Resident #20's Nebulizer mask was properly stored in a bag when not in use on 03/15/26. This failure could place the resident at risk for respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #20's Face Sheet, dated 03/16/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20 had a diagnosis of COPD (lung disease).Record review of Resident #20's Quarterly MDS Assessment, dated 02/10/26, reflected Resident #20's BIMS (11) indicated a moderate cognitive impairment. The Quarterly MDS Assessment reflected the resident had active diagnosis of COPD.Record review of Resident #20's Physician orders, dated 03/16/26, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/ML 1 vial inhale every 6 hours for COPD. Nebulizer - Clean and change tubing every week on Sunday.During an observation on 03/15/26 at 10:29 a.m., Resident #20 had a nebulizer mask sitting on top of her nightstand unbagged.During an Interview and observation on 03/15/26 at 10:32 a.m., RN D was shown by the Surveyor Resident #20's nebulizer mask sitting on top of her nightstand unbagged. She stated they try to ensure all masks and nasal cannulas were bagged when not in use to avoid them from getting contaminated. She stated it was the nurse's responsibility to ensure the devices were bagged.During an interview on 03/17/26 at 09:15 a.m., the DON was informed by the Surveyor of Resident #20's nebulizer mask sitting on top of her nightstand unbagged. She stated the breathing devices should be bagged when not in use to avoid them from getting contaminated. She stated it was the nurse's responsibility to ensure the devices were bagged. She stated she in-serviced her nursing staff on the importance of properly bagging masks and nasal cannulas when not in use on 03/16/26.During an interview on 03/17/26 at 10:20 a.m., ADON was informed by the Surveyor of Resident #20's nebulizer mask sitting on top of her nightstand unbagged. She stated the breathing devices should be bagged when not in use to avoid the resident getting an infection. She stated it was the nurse's responsibility to ensure the devices were bagged when not in use.Record review of the facility's policy Oxygen Concentrator, revised 11/01/2025, reflected POLICY: It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner . PROCEDURES . 1. Oxygen Tanks, Connectors and Concentrators . E. When mask or cannula is temporarily not being used, it will be covered loosely to prevent contamination from airborne microorganisms . 2. Nebulizer Equipment Procedures . F. Store, clean, and dry until next use.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one of two residents (Resident #2) reviewed for feeding tube management. The facility failed to ensure LVN E flushed Resident #2's g-tube before administering the resident's bolus feeding on 03/15/2026. This failure could place residents with g-tubes at risk for tube displacement, clogging, aspiration, and discomfort.Findings included: Record review of Resident #2's Face Sheet, dated 03/16/2026, 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 #2's Comprehensive MDS Assessment, dated 01/06/2026, reflected that the resident had moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #2's Quarterly Care Plan, dated 01/14/2026, reflected that the resident required a PEG and one of the interventions was to check for tube placement and gastric residual (food, liquid, and secretions remaining in the stomach) before initiating feeding. Record review of Resident #2's Physician Order, dated 03/11/2026, reflected every 4 hours G-TUBE - FLUSH [routine] = Flush g-tube w/ 200cc of water Q 4 hours. HOB elevated 30-45 degrees at all times. Check tube placement prior to each feeding, meds and fluids per auscultation (listening to the sounds produced within a body using a stethoscope) and residual (food, liquid and secretions remaining in the stomach) Q shift. If 100cc, HOLD feeding. During an observation on 03/15/2026 at 1:44 PM revealed LVN E was about to give Resident #2's bolus feeding (giving large doses of formula through g-tube several times a day) via g-tube. She sanitized her hands, prepared one big cup of water and four small cups of water, and placed the cups of water on a tray. She went inside the room and placed the tray on the resident's overbed table. She took a small box of feeding formulas and a 60 ml piston syringe and placed them on the tray. She sanitized her hands and put on a gown. She checked for placement and gastric residuals. After checking the placement and the gastric residual, she pulled the plunger out of the syringe and attached it to the g-tube. After attaching the syringe to the g-tube, she took the feeding formula from the tray and poured some into the barrel of the syringe attached to the g-tube. She did not flush the g-tube prior to pouring the formula. She then poured 30 ml of water into the formula inside the syringe. She did it twice. She continued to pour the formula until the box was empty. After the formula was consumed, she flushed the g-tube with 30 ml of water and detached the syringe. During an interview on 03/15/2026 at 2:06 PM, LVN E said she brought a big cup of water because she needed to flush the g-tube that was flushed every four hours. She said she did not know why she forgot to flush the g-tube before pouring the formula. She said the g-tube should be flushed prior to giving the formula to make sure the g-tube was working and not obstructed. During an interview on 03/15/2026 at 2:14 PM, when asked how he was doing after the bolus feeding, Resident #2 gave a thumb up. During an interview on 03/17/2026 at 7:02 AM, ADON A said the best practice was to flush the g-tube before giving the feeding formula to make sure the g-tube was functioning well and had no issues. She said, especially for bolus feeding, because the staff needed to give the formula at a certain time. She said sometimes some formulas were left in the tube causing it to be clogged if not flushed. She said the g-tube should be flushed before and after bolus feeding. She said the expectation was for the staff not to forget to flush the g-tube before giving the bolus. She said she would coordinate with the DON on what to do about the issue. During an interview on 03/17/2026 at 7:41 AM, the DON said the purpose of flushing the g-tube before giving the formula was to verify if the tube was not blocked before giving the formula. She said flushing before bolus feeding was to ensure that the tube was working properly and to clear out the tube from an old formula that could cause blockage. She said it would be a mess when the staff would only realize that the g-tube was clogged once the formula was already poured. She said flushing should be done before bolus feeding and before medication administration. She said the expectation was to use the water that was prepared to flush the g-tube. She said she already did a one-on-one in-service with LVN E regarding not flushing the g-tube prior to giving the feeding formula. She said she would also do an in-service to all the staff on using the g-tube for formula and medications. During an interview on 03/17/2026 at 8:12 AM, the Administrator said she was not a clinician, and she would let the DON be the lead about the issue. She said the expectation was for the staff to follow the right procedure regarding g-tube. Record review of the facility's policy G-tube Medication Administration undated, reflected, 18. Check for placement and residual . 19. Flush with warm water by gravity flow . 20. Administer dissolved medication.

Based on interview and record review, the facility failed to ensure 34 (Room numbers 2, 3, 4, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 and 39) out of 34 multiple-resident bedrooms, measured at least 80 square feet per resident. The facility failed to ensure multiple resident Room numbers 2, 3, 4, 6, 7, 8, 10, 18, 20, 24, 25, 26, 27, 28, 29, 30, 32, 33, 34, 35, 37 and 39 met the required minimum of 80 square feet per resident. The facility failed to ensure all resident rooms had the required minimum of 80 square feet per resident in rooms occupied by multiple residents. This failure could place residents who reside in these rooms at-risk for a limitation in their ability to move around the room and a decreased quality of life. Findings included: During the survey entrance conference on 03/14/26 at 9:25 AM, the ADM revealed the facility had a room size waiver in place for the bedrooms measuring less than the required square footage. She also advised nothing has changed in the past years regarding resident's room square footage. Review of Form DADS 3740 (Bed Classifications Form), completed by the facility on 03/15/2026, revealed all 37 bedrooms in the facility had two beds and were classified as Medicare and Medicaid. Review of the facility's license on 03/15/2026 at 10:30 AM revealed the facility was licensed for 74 beds. Review of the resident bedroom measurements listing, undated provided by the ADM on 03/16/2026 revealed the following: 1) Resident Rooms 2, 3 and 4 measured 127 square feet. 2) Resident Rooms 6, 8 and 10 measured 132 square feet 3) Resident room [ROOM NUMBER] measured 146 square feet 4) Resident rooms [ROOM NUMBERS] measured 147 square feet 5) Resident Rooms 12, 14, 15, 16, 17 and 19 measured 156 square feet 6) Resident room [ROOM NUMBER] measured 159 square feet 7) Resident Rooms 20, 22, 24, 26 and 28 measured 151 square feet 8) Resident Rooms 23, 25, 27, 29, 30, 31, 32, 33, 34, 35, 36, 37 and 39 measured 153 square feet. During an interview on 03/16/2026 at 1:30 PM ADM provided a copy of a signed Form 3762-Room Size Waiver request form. ADM stated the facility would be requesting that the same room size waiver be continued for the next year. The ADM stated there had been no change in the number or size dimensions of the affected rooms requested for waiver consideration. ADM stated the facility did not have a policy regarding the room size waiver.No policy was provided prior to exit.

Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of one resident (Resident #1) reviewed for abuse and neglect. The facility failed to ensure Resident #1 was free from abuse when CNA A spoke to the resident in a rude, demeaning, and inappropriate manner, including making unnecessary and offensive comments. This failure could place residents at risk for emotional distress, verbal abuse, and violation of their rights. Record review of Resident #1's face sheet on 01/16/26, stated Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE], with the following diagnoses: Parkinson's disease (a neurological condition that impacts movement and can cause tremors, stiffness, slow movement, and difficulty with balance), cognitive communication deficit (difficulty understanding information, expressing thoughts clearly, or communicating needs effectively). Record review of Resident #1's Quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment. During an interview on 01/16/26 at 11:45 AM Resident #1 revealed he reported to the ADMIN that CNA A was rude and mean to him during care. Resident #1 stated described the employee's behavior was disrespectful and inappropriate. He was unable to recall the exact statements made but stated the interaction was upsetting and should not have occurred. Resident #1 revealed the employee was typically kind and did not know what caused the behavior on that day. He stated he was not fearful of CNA A and reported satisfaction with the facility's response in suspending CNA A from the facility. Resident #1 was observed lying in bed. He appeared calm, pleasant, and cooperative, and was willing and able to engage in conversation. He did not display any signs of fear, distress, or intimidation, and there were no indications that he was currently fearful of any staff member or of the facility. During an interview with Resident #1's family member revealed they became aware of the incident after Resident #1 reported CNA A's behavior. Resident #1's family member stated this prompted them to review surveillance video from a camera located in the resident's room. Resident #1's family member reported observing CNA A speak to Resident #1 in a rude and demeaning manner and made inappropriate comments, including statements regarding God not helping mean people, implying the resident's family did not visit because they did not care about him. Resident #1's family member reported the family contacted the facility Administrator and reviewed the video with facility leadership. The surveyor was not provided a copy of the surveillance video. Record review of Resident # 1's progress note, dated 12/02/25 at 3:37 PM by a Registered Nurse, reflected the physician was notified regarding verbal abuse by a staff member towards Resident #1. Record review of Resident #1's progress note dated 12/08/25 by a Registered Nurse reflected Resident #1 reported he was doing fine and had no residual issues related to the incident. Documentation reflected the family expressed satisfaction with the care being provided. Review of a statement from the ADMIN dated 12/2/25, reflected the ADMIN interviewed Resident #1 regarding the allegation that CNA A was rude and disrespectful. Documentation reflected Resident #1's family member played video footage for facility leadership, which showed CNA A making rude, demeaning, and inappropriate statements toward Resident #1. Documentation of the termination notice dated 12/2/25 reflected CNA A was initially suspended and subsequently terminated following review of the video footage. CNA A's employment file did not reflect previous behaviors towards residents. During an interview on 01/16/26 at 11:55 AM with the ADON revealed she was notified of the allegation by the lead CNA. She stated the incident was investigated, video footage was reviewed by facility leadership, and CNA A made inappropriate verbal comments to the resident, including religious statements implying blame for the resident's condition, which was determined to be verbally abusive. During an interview on 01/16/26 at 12:17 PM with a Regional Nurse revealed she was notified of the allegation of abuse and informed that video footage existed. She stated CNA A's behavior toward Resident #1 was verbally abusive and that the incident was reported December 2, 2025 to herself and ADMIN per protocol. She confirmed CNA A was terminated December 2, 2025. During an interview on 01/16/26 at 12:05 PM, with the Social Worker revealed she became aware of the allegation after notification by the Administrator. She stated she conducted facility-wide safety surveys and identified no additional abuse concerns. The social worker did not indicate if she spoke with Resident #1 after being notified of the incident between Resident #1 and CNA A. During an attempted telephone interview on 01/16/26 at approximately 11:30 AM, 1:00 PM, and 2:15 PM, CNA A did not return the call. Record review of in-service training records, dated 12/2/25, reflected staff education was completed related to abuse and neglect, resident rights, customer service expectations, and reporting requirements. Surveyor did not observe CNA A's name on the in-service roster. Record review of the facility's Abuse/Neglect and Resident Rights policies, undated reflected residents have the right to be free from verbal abuse and that all allegations must be immediately reported, investigated, and addressed to ensure resident safety.

Based on observation, interview 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 4 of twelve residents (Resident #20, Resident #27, Resident #36, and Resident #57) reviewed for Respiratory Care. 1. The facility failed to ensure Resident #20's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) on her wheelchair was properly stored when not in use on 01/05/2025. 2. The facility failed to ensure Resident #27's nasal cannula at the back of the wheelchair was properly stored when not in use on 01/05/2025. 3. The facility failed to ensure Resident #36's nasal cannula at the back of the wheelchair was properly stored when not in use on 01/05/2025. 4. The facility failed to ensure Resident #57's nasal cannula attached to the oxygen concentrator was properly stored when not in use on 01/05/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Record review of Resident #20's Face Sheet, dated 01/06/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20 was diagnosed with upper and lower respiratory infection, emphysema (a lung disease that damages the air sacs in the lung causing shortness of breath), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #20's Comprehensive MDS Assessment, dated 11/01/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident had oxygen therapy while a resident of the facility. Record review of Resident #20's Comprehensive Care Plan, dated 11/10/2024, reflected the resident used Oxygen Therapy via nasal cannula @ 2-4 lpm continuously r/t SOB d/t COPD and one of the interventions was apply oxygen. The resident's care plan did not indicate that the resident was the one taking off her nasal cannula. Record review of Resident #20's Physician Orders, dated 08/18/2020, reflected OXYGEN - CONTINUOUSLY = Oxygen at 2-4 L/PM via nasal cannula continuously. Check every shift. Check O2 sats Q shift and keep O2 at or greater than 92%. Record O2 sats every shift. Observation and interview with Resident #20 on 01/05/2025 at 9:13 AM revealed the resident was sitting at the side of her bed. The resident was on oxygen via nasal cannula that was connected to an oxygen concentrator. The resident said she had the oxygen for as long she could remember. She said she wore her oxygen day and night. She said she would also use her oxygen when she went outside her room. It was observed that the resident had a nasal cannula attached to a portable oxygen tank. The nasal cannula was sitting on the wheelchair seat and was not bagged. It was also noted that there was no bag behind the wheelchair. She said she did not know she was supposed to put the nasal cannula in a plastic bag. 2. Record review of Resident #27's Face Sheet, dated 01/06/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease. Record review of Resident #27's Comprehensive MDS Assessment, dated 11/10/2024, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility. Record review of Resident #27's Comprehensive Care Plan, dated 12/24/2024, reflected the resident used oxygen continuously and one of the interventions was apply oxygen. Record review of Resident #27's Physician Order, dated 10/25/2023, reflected OXYGEN - CONTINUOUSLY = Oxygen at 2_L/PM via nasal cannula continuously. Check every shift. Check O2 sats Q shift and keep O2 at or greater than 92%. Record O2 sats every shift. Observation on 01/05/2025 at 9:39 AM revealed Resident #27 was still sleeping. It was observed that the resident's wheelchair was placed at the foot of his bed. A portable oxygen tank was observed at the back of the wheelchair with a nasal cannula connected to it. The nasal cannula was coiled on the seat of the wheelchair. The nasal cannula was not bagged. Observation and interview with Resident #27 on 01/05/2025 at 1:46 PM revealed the resident was in his wheelchair inside the room. The resident was on oxygen administration via nasal cannula that was connected to the portable oxygen behind his wheelchair. Resident #27 stated he had respiratory issues and that was why he was using oxygen continuously. He said staff would assist him with transfer to bed and wheelchair and wheelchair to bed. He said staff would also assist him with his nasal cannula. He said he was not aware where the staff would put it after they take it off. He said he did not see any plastic bag for his nasal cannula. 3. Record review of Resident #36's Face Sheet, dated 01/06/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease. Record review of Resident #36's Comprehensive MDS Assessment, dated 11/05/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 5. The Comprehensive MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility. Record review of Resident #36's Comprehensive Care Plan, dated 12/24/2024, reflected the resident had oxygen therapy continuously 2 L/min via nasal cannula and the goal was the resident will have no signs and symptoms of poor oxygen absorption. Record review of Resident #36's Physician Order, dated 07/03/2024, reflected OXYGEN - CONTINUOUSLY = Oxygen at 2 L/PM via nasal cannula continuously. Check every shift. Check O2 sats Q shift and keep O2 at or greater than 92%. Record O2 sats every shift. Observation and interview with Resident #36 on 01/05/2025 at 9:20 AM revealed the resident was in her bed, awake. It was observed that the resident had a nasal cannula attached to a portable oxygen tank. The tube of the nasal cannula was sitting on the wheelchair seat. The prongs of the nasal cannula were hanging and about to touch the right wheel of the wheelchair. The nasal cannula was not bagged. 4. Record review of Resident #57's Face Sheet, dated 01/06/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with Alzheimer's disease (brain disorder that destroys memory and thinking). Record review of Resident #57's Comprehensive MDS Assessment, dated 11/05/2024, reflected the resident had a score of 99 on her BIMS summary score suggesting that the resident was not able to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated the resident was on hospice care while a resident of the facility. Record review of Resident #57's Comprehensive Care Plan, dated 11/24/2024, reflected the resident received hospice care and one of the interventions was to coordinate with hospice team. Record review of Resident #57's Physician Order, dated 08/19/2024, reflected HOSPICE - ADMIT = Admit to . for DX: ALZHEIMER'S DISEASE. Record review of Resident #57's Physician Order, dated 08/09/2024 reflected OXYGEN PRN = Oxygen at 2-4 L/PM via nasal canula OR 5-8 L/PM via mask PRN for SOB [SHORTNESS OF BREATH]. Record review of resident #57's Physician Order from Hospice, dated 5/16/2024, reflected Administer 2 to 4 liters per minute via nasal cannula as needed for dyspnea (shortness of breath). Observation and interview with Resident #57 on 01/05/2025 at 9:27 AM revealed the resident was in her bed, awake. An oxygen concentrator was observed on the resident's bedside. A nasal cannula was attached to the oxygen concentrator and was hanging on top of the oxygen concentrator. The nasal cannula was not bagged, and no plastic bag was observed. When asked about her use of oxygen, the resident did not answer and just smiled. Observation and interview with RN A on 01/05/2025 at 9:55 AM, RN A stated the nasal cannulas should be in a plastic bag when the residents were not using them. She said they should be bagged to prevent cross contamination and respiratory infection. She said the residents using oxygen had respiratory issues and that was why they had orders for oxygen therapy. RN A entered Resident #20's room and saw the nasal cannula on the wheelchair that was not bagged. She disconnected the nasal cannula and said she would get a new nasal cannula for Resident #20. She said she would also get a plastic bag for the nasal cannula. While she was disconnecting the nasal cannula, Resident #20 asked her what she was doing. RN A told resident that she changed the nasal cannula because it was not bagged and was already deemed dirty. RN A also told the resident she should put her nasal cannula in a plastic bag every time she would remove it. RN A said the resident was the one taking it off, but staff should educate the resident or monitor if the resident put it in a bag. RN A went out of Resident #20's room and went to Residents' #57 and #36's room. RN A saw Resident #57's nasal cannula on top of the oxygen concentrator and Resident #36's nasal cannula on the resident's wheelchair. She disconnected both nasal cannulas and said she would also get the residents new nasal cannulas. RN A went out of Residents #57 and #36's room and went to Resident #27's room and saw the nasal cannula on the wheelchair that was not bagged. She disconnected Resident #27's nasal cannula and said she would do the same. RN A went to storage room and gathered some nasal cannulas and some plastic bags and went to the rooms of Residents #20, #27, #36, and #57, and changed their nasal cannulas and placed plastic bags behind the wheelchair and the oxygen concentrator. She said she did not notice the nasal cannulas were not bagged when she did her morning round. She said she would check the other residents with oxygen if their nasal cannulas were bagged if they were not using it. She also said that whoever transferred the resident to bed should put the residents' nasal cannulas in a bag. In an interview with the DON on 01/06/2025 at 11:38 AM, The DON stated the nasal cannulas should be bagged when the residents were not using them for infection control and prevention of cross contamination. She said whoever was caring for the resident should check if the nasal cannula was bagged when not in use or needed to be changed because it touched something dirty. She said the expectation was for the staff who transferred the residents to bed should have bagged the nasal cannulas that were in the wheelchairs. She said the staff should check during their rounds that the nasal cannula was bagged. She said she was made aware by RN A about the issue and already did an in-service about bagging the nasal cannula when not in use. She also said Resident #57 was on Hospice that was why she had an oxygen concentrator. She said Hospice provided it and had an order for it. In an interview with CNA C on 01/06/2025 at 11:56 AM, CNA C said the nasal cannulas should be bagged to prevent them from getting dirty. She said the staff that transferred the resident was responsible in bagging the nasal cannula. She said she did not notice the nasal cannulas were not bagged when she did her morning round. In an interview with the Administrator on 01/06/2025 at 12:27 PM, the Administrator stated the nasal cannulas should be properly stored to prevent respiratory infections or exacerbation of whatever respiratory issues the residents already had. She said the expectation was for the staff to be mindful during their rounds and make sure the nasal cannulas were bagged and kept clean. She said the DON already initiated the in-service about bagging the nasal cannulas. In an interview with RN A on 01/07/2025 at 9:21 AM, RN A stated Resident #57's oxygen was a standing order from hospice. She said the resident seldom used it. Policy for bagging the nasal cannula was requested on 01/06/2025 at 12:44 PM via email but was not provided prior to exit. In an interview with the Administrator on 01/07/2025 at 9:31 AM, the Administrator said they do not have a policy specific to bagging the nasal cannula.

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 one (Resident #34) of eight residents reviewed for Infection Control. The facility failed to ensure CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #34 on 01/05/2025. This failure could place residents at risk of cross-contamination and development of infections. Findings included: Record review of Resident #34's Face Sheet, dated 01/06/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with acute kidney failure (a condition in which one or both kidneys no longer work on their own). Record review of Resident #34's Comprehensive MDS Assessment, dated 11/19/2024, reflected the resident had a score of 99 on her BIMS summary score implying that the resident was not able to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated the resident was always incontinent for both bowel and bladder. Record review of Resident #34's Comprehensive Care Plan, dated 12/01/2024, reflected the resident had urinary incontinence and one of the interventions was to give perineal care. Observation and interview with CNA B on 01/05/2025 at 10:56 AM revealed CNA B entered Resident #34's room holding a plastic bag with a brief in it. She said she would change the resident's brief first and then she would transfer her to her wheelchair. CNA B put on a pair of gloves. She did not sanitize or wash her hands before putting on the pair of gloves and before starting incontinent care. CNA B then said the resident did not have any wipes. CNA B removed her gloves and said she would go out to get some wipes. After a few moments, CNA B returned with some wipes. CNA B put on a pair of gloves. CNA B, again, did not sanitize or wash her hands before putting on the gloves. She unfastened the brief on both sides and pushed the front part of the brief between the resident's thighs. CNA B pulled some wipes and cleaned the resident's perineal area (area between the thighs) using the front to back technique. After cleaning the perineal area, CNA B rolled the resident towards the wall and cleaned the resident's bottom. It was noted that the resident had some dry feces. CNA B pulled the soiled brief and threw it on the trash can. CNA B then opened the plastic bag, took the brief inside it, opened it, and put it under the resident. She did not change her gloves after cleaning the resident's bottom and before touching the new brief. She rolled back the resident, fixed the brief, and fastened it on both sides. CNA B stated hand hygiene should be done before doing incontinent care. She said she just put on a pair of gloves before doing incontinent care and did not even sanitize her hands. She said hands should be washed or sanitized to prevent infection. She said the gloves should be changed after she cleaned the resident's bottom and before touching the new brief because the gloves that she used to clean the resident's bottom were already soiled. She said she would be mindful the next time she does incontinent care to wash her hands and change her gloves during incontinent care. She said she had trainings for pericare but did not know why she forgot to wash her hands and change her gloves. In an interview with the DON on 01/06/2025 at 11:38 AM, The DON stated hand hygiene was the most effective way to prevent cross contamination and spread of infection. She said staff should do hand hygiene before and after any care. She said gloves should be changed after cleaning the resident's bottom because the gloves were already deemed dirty. She said the expectation was for the staff to wash their hands before and after any care and change their gloves when going from dirty to clean. She said she was made aware by CNA B about the issue, and she already did a one-on-one in-service with CNA B about hand hygiene and pericare. She said she will be doing an in-service for all the direct care staff about hand hygiene and pericare. She said she will personally monitor the staff. In an interview with the Administrator on 01/06/2025 at 12:27 PM, the Administrator stated not washing the hands before any care and not changing the gloves from soiled to clean could contribute to cross contamination and infection. She said the expectation was for the staff to follow the policy and procedures pertaining to infection control. She said the DON already in-serviced the staff about hand hygiene and pericare. Record review of the facility policy, Hand Washing undated, revealed Standard: Mechanical removal of pathogenic organisms from the skin is accomplished by hand washing . Policy: Hand washing is required before and after a procedure that involves direct or indirect contact with a resident, after contact with any wastes or contaminated materials, before handling any food or food receptacle, or at any time the hands are soiled. Record review of the facility policy for Perineal Care undated, revealed Purpose: To cleanse the genitalia (organs of the reproductive system) and rectum. Procedure is given after each incontinent episode . Procedure . 4. Wash hands and put on gloves . 11 . clean the rectum by wiping from the front to the back . dry resident and change gloves . 12. Place a dry, clean incontinent pad under resident . 15. Place the soiled items in a plastic bag . 17. Remove gloves and wash hands. 50444

Based on interview and record review, the facility failed to ensure 34 (Room numbers 2, 3, 4, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 and 39) out of 34 multiple-resident bedrooms, measured at least 80 square feet per resident. The facility failed to ensure multiple resident Room numbers 2, 3, 4, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 and 39 met the required minimum of 80 square feet per resident. This failure could place residents at risk of not having sufficient space. Findings included: Review during the survey's Offsite Survey Preparation, conducted on 01/02/2025, prior to the start of the survey on 01/05/2025, and documented on ASE-Q offsite revealed the facility had a room size waiver. During this survey's entrance conference on 01/05/25 at 9:30 AM, the Administrator revealed the facility had a room size waiver in place for the bedrooms measuring less than the required square footage. She also advised nothing has changed in the past years regarding resident's room square footage. Review of Form DADS 3740 (Bed Classifications Form), completed by the facility on 01/05/2025, revealed all 37 bedrooms in the facility had two beds and were classified as Medicare and Medicaid. Review of the facility's license on 01/05/2025 at 10:57 AM revealed the facility was licensed for 74 beds. Review of the resident bedroom measurements listing, undated provided by the Administrator on 01/07/2025 revealed the following: 1) Resident Rooms 2, 3 and 4 measured 127 square feet. 2) Resident Rooms 6, 8 and 10 measured 132 square feet 3) Resident room [ROOM NUMBER] measured 146 square feet 4) Resident rooms [ROOM NUMBERS] measured 147 square feet 5) Resident Rooms 12, 14, 15, 16, 17 and 19 measured 156 square feet 6) Resident room [ROOM NUMBER] measured 159 square feet 7) Resident Rooms 20, 22, 24, 26 and 28 measured 151 square feet 8) Resident Rooms 23, 25, 27, 29, 30, 31, 32, 33, 34, 35, 36, 37 and 39 measured 153 square feet. No policy was provided prior to exit.

Based on observations, interviews, and record reviews 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 areas in the facility for 8 of 20 rooms (Room # 2, 13, 14, 15, 17, 18, 19, 20) observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that resident rooms were cleaned and serviced in accordance with the facility's policy on Housekeeping Services. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings include: Observation of room [ROOM NUMBER] on 09/26/23 at 10:30 AM and on 09/28/23 at 10:00 AM revealed, the floor displayed light grayish and light brownish stains throughout the room. Observation of room [ROOM NUMBER] on 09/26/23 at 10:44 AM and on 09/28/23 at 10:05 AM revealed, the floor had a dark rust in color stain near the resident's nightstand. Observation of room [ROOM NUMBER] on 09/26/23 at 10:44 AM and on 09/28/23 at 10:06 AM revealed, the floor had a dark rust in color stain near the resident's nightstand. Observation of room [ROOM NUMBER] on 09/26/23 at 10:53 AM and on 09/28/23 at 10:10 AM revealed, the Floor had small clumps of black dirt stuck to the floor, near the entrance of the doorway. Observation of room [ROOM NUMBER] on 09/26/23 at 10:57 AM and on 09/28/23 at 10:13 AM revealed, the Floors displaying a yellowish stain near the resident's bed side table and the corners of floor near resident's bed had dirt particles Observation of room [ROOM NUMBER] on 09/26/23 at 11:04 AM and on 09/28/23 at 10:15 AM revealed, the walls near the resident's bed displayed black markings and brownish stains. Observation of room [ROOM NUMBER] on 09/26/23 at 11:09 AM revealed, the floor had cracks in the tiles. The tiles appeared very worn and broken throughout the room. Observation of room [ROOM NUMBER] on 09/26/23 at 11:13 AM revealed, the floor had cracks in the tiles and the surface underneath the tiles appeared uneven and loved wavy. Interview on 09/28/23 at 10:50 AM with Housekeeping Supervisor revealed the housekeeping staff uses a cleaning calendar to determine when rooms are to be deep cleaned. She stated that they are required to clean all rooms daily, which consisted of mopping the floor and emptying the trash. She stated that they deep clean all rooms at least once a week, and this involves scrubbing the floors, wiping down the walls, dusting, etc. She stated she checked the rooms to ensure that they are thoroughly cleaned. The Housekeeping Supervisor was shown pictures of concerns observed in the resident rooms and she stated that she will retrain her staff on how to thoroughly clean rooms. She stated she had taken over as Housekeeping Supervisor in July 2023 and she had just rolled out the cleaning schedule. She was asked about the cracked tiles on some of the room floors and she stated she had reported it to maintenance, and it was placed on his maintenance log. She stated the risk of rooms not being thoroughly cleaned, is an infection control concern. Interview on 09/28/23 at 11:00 AM with Maintenance Director revealed he was shown the pictures of the damaged tiles in resident rooms, and he stated that he was fully aware of the damages to tiles in resident rooms and he is trying to get to all of them. He stated that it was just him making all repairs at the facility and he had not gotten time to get to all of them. He stated that the impact to the resident was that they could have an accident and it was not good. Interview on 09/28/23 at 11:15 AM with Housekeeping Aide D, revealed she had been at the facility for 9 years. She stated that they utilize a cleaning calendar to determine which room was to be deep cleaned for the day. She stated that they are required to strip the floor, wipe down the bed and walls, dust, and clean whatever else needed to be cleaned. She stated they clean all rooms at least once a day and on non-deep cleaning days, they mop the floors and empty the trash. She was shown pictures of the concerns observed and she stated that she thoroughly cleaned her rooms and thinks her co-worker was responsible for cleaning the rooms observed. She stated she had pointed out the cracked tiles to the maintenance director and she writes it into the maintenance repair book. She was asked the risk to the residents of theses concerns not being addressed and she stated that it is not good. Interview on 09/28/23 at 10:30 AM with Director of Corporate Compliance and Assistant Director of Operations revealed, they were sitting in for the Administrator because she was hospitalized . They were shown the pictures of the concerns observed in resident rooms. They advised that the Housekeeping Supervisor was fairly new and they planned to have her shadow a more seasoned Housekeeping Supervisor to observe how she ensures the rooms and all other areas are thoroughly cleaned. They advised the risk of the concerns not being addressed impact the resident's right to a clean and sanitary environment. Review of the facility's Housekeeping Services (undated), revealed The Facility provides a safe, functional, sanitary, and comfortable environment for all residents, staff, and the public.

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 kitchen sanitation. The facility failed to ensure kitchen equipment was clean and sanitary. This failure could place residents at risk for cross contamination and other illnesses. Findings include: Observation on 09/26/23 at 09:15 AM in the facility's only kitchen revealed: Sugar, rice, breadcrumbs, and flour Bins, located in the dry storage area were dirty on the outside and along the opening of the bins. The sugar bin had dirt particles along the walls of the inside of the bin and some unidentified particles were in the sugar. One cast iron griddle, used for cooking steaks had rust all over it. Interview and Observation with Dietary Manager on 09/26/23 at 09:15 AM revealed she had been employed at the facility for three years and the Dietary Manager for over three months. She observed the rusted Cast Iron Griddle and the dirty bins. She stated the kitchen equipment are cleaned thoroughly once a month but should also be observed for cleanliness daily. She stated the risk of these concerns not being addressed could result in food contamination and residents becoming ill. Interview on 09/28/23 at 10:30 AM with Director of Corporate Compliance and Assistant Director of Operations revealed, they were sitting in for the Administrator because she was hospitalized . They were shown the pictures of the concerns observed in the kitchen. They advised that their expectations are for the kitchen to follow state and federal guidelines and they will follow up with staff to ensure these concerns are addressed. They advised of these items not being cleaned could result in contamination. Record Review of the Facility's policy on Kitchen Sanitation dated 01/01/10, revealed Food bins will be cleaned when empty or a minimum of once a month All kitchen equipment must be cleaned and sanitized. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, All equipment and utensils must be cleaned and sanitized.

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 and misappropriation of resident property and that establish policies and procedures to investigate any such allegations for 1 of 3 residents (Resident #64) reviewed for abuse and neglect. The facility did not follow their policy for Abuse and Neglect and thoroughly investigate when Resident #64 had an allegation of sexual abuse reported on 09/22/23. This failure could place residents at risk for not having their allegations of abuse and neglect investigated. Findings included: Record review of Resident #64's quarterly MDS assessment, dated 08/31/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills were severely impaired. She was frequently incontinent of bladder and bowel. Her diagnoses included non-Alzheimer's dementia and non-cancerous brain tumor. Record review of Resident #64's Comprehensive Care Plans, dated 09/26/23, reflected: 1. FM A visiting on 9/22/23 and witnessed by 2 staff members touching resident inappropriately. Goal: Resident's FM A will not act inappropriately when visiting the resident. She is not able to consent to the sexual behavior he is initiating, and FM A's behavior agitates the resident. Facility interventions: .FM A can visit resident, but only when supervised by a staff member. 2. The resident is at risk for bruises r/t use of aspirin, combativeness w/ care, hx of falls, and FM A visits w/ inappropriate touching. Goal: The resident will be free from injury or further bruises x 90days Facility interventions: Provide supervised visits in a common area w/FM A for resident safety. Record review of the Facility Provider Investigation Report, dated 09/22/23, reflected: An email from the DON : The FM A of resident involved came in for a visit. He was observed by two CNA's sexually fondling this resident. His hand was seen under the resident's skirt, to her genitals. Statements were obtained from the CNA's . Future visits made by FM A will be supervised. Statement from the facility SW, dated 09/25/23, reflected: This social worker called .and reported .inappropriate touching incident of resident's vagina by FM A . witnessed by two CNAs in this facility .resident is residing in skilled nursing facility and is unable to give verbal consent due to her poor cognition relating to her diagnosis of dementia and senile degeneration of the brain . Statement from CNA C, dated 09/22/23, reflected: On 09/22/23 at or around 4:25 PM, I witnessed FM A with his hand under the resident's gown in the vagina area. I did not physically see his hand inside of her vaginavagina, but I witnessed an in and out motion and the resident looked very uncomfortable and disturbed. FM A did report a bruise on the resident at the panty line that was about the size of a quarter to the facility on [DATE]. The bruise was reported to the physician. FM A denied touching Resident #64 inappropriately and said he was agreeable to having all visits with Resident #64 supervised by staff. An observation on 09/26/23 at 1:39 PM with Resident #64 revealed she was lying in bed. She was awake and alert and turned her head when spoken to. CNA A entered the room. The resident was Spanish-speaking only. The resident spoke, but it was nothing understandable. CNA A translated and said the resident was not saying anything that made sense. An interview on 09/26/23 at 1:09 PM with CNA B revealed on 09/22/23 she was assigned to Resident #64's hall. She said she went to her room and saw FM A sitting in a chair next to the resident and her gown was raised up. CNA B said FM A's right hand was on her vagina, inside of her brief. CNA D said FM A told her the resident was wet and used his left hand to point to the brief. CNA B said the resident was not wet. The resident was lying in bed with her eyes closed and she was stiff in the bed. CNA B said after she started talking, the resident sat up in bed, got up, walked to CNA B and started patting her vagina area and saying eeee. CNA B could not understand what the resident was saying. CNA B said she reported what she saw to the nurse who entered the room. CNA B said the resident had a history of being very combative and agitated when FM A came to visit. CNA B said FM A needed to be counseled because he needed to understand that because of her mental capacity, that behavior was no longer acceptable. An interview was attempted on 09/28/23 at 11:32 AM with FM A of Resident #64, but he refused to speak to the Surveyor. An interview on 09/26/23 at 1:46 PM with the DON revealed the treatment nurse did a skin assessment the next day (09/23/23), but the resident was not sent for a vaginal exam because FM A said not to send the resident to the hospital. The DON said the incident was abuse because the resident could not consent. She said FM A was talked to and said he was just checking to see if the resident was wet. The DON said they were doing supervised visits with him because he visited her every day. An interview on 09/26/23 at 1:58 PM with the SW revealed she thought FM A had abused the resident. She said she was told the resident was in bed and he was feeding her. He would give her a bite with one hand. Her dress was up, and his hand other hand was down in the brief. The CNA had just checked the brief and said it was dry. He said he was just checking the brief. The SW said the facility was trying to keep the resident safe. She said the resident was not sent for a vaginal exam because they asked FM A and he refused . An interview with 09/27/23 at 12:14 PM with LVN D revealed she did a head-to-toe exam on Resident #64 with no new findings. The resident already had a nickel-sized bruise at the top of her vagina at the panty line. She said she did not do a vaginal exam because it was outside of her scope of practice and the resident was not sent to the emergency room for an exam because FM A said not to. An interview on 09/27/23 at 12:50 PM with the Corporate Nurse for Resident #64 revealed she was asked what assessment should be completed when there was an allegation of inappropriate touching. The Corporate nurse did not answer the question but did say the facility offered to send the resident to the ER and FM A refused. The Corporate Nurse said the facility allowed FM A to make the determination of whether to send her to the ER because he was her representative party. She said to keep the resident safe going forward, the facility was allowing the resident to have supervised visits with FM A. She said the results of the investigation revealed the resident had a bruise found on the top area of her vagina on 09/21/23 and then FM A was seen touching the resident on 09/22/23. The Corporate Nurse said they thought FM A could have caused the bruise due to inappropriate touching. An interview on 09/27/23 at 2:53 PM with the FNP revealed she was not notified about the allegation of sexual abuse. She said she was on-call and should have been notified. She said it might have been the best thing to do to order a vaginal exam following the allegation, but she was not notified and so she could not say for sure. A phone message was left for RN E on 09/28/23 at 1:14 PM to find out why she did not notify the FNP, but she did not return the call of the Surveyor. An interview on 09/27/23 at 2:04 PM with the Medical Director revealed Resident #64 was on Hospice services and a pelvic exam would have been very traumatic for her. The Administrator was not available for interview during the survey. The Surveyor re-entered the facility following administrative review on 10/19/23 at 5:45 PM. An interview on 10/19/23 at 6:05 PM with the DON revealed Resident #64 passed away on 10/01/23. She said FM A visited the resident on 09/29/23 and was supervised by facility staff as agreed. FM A visited again on 09/30/23 and was supervised by facility staff. On 09/30/23, Resident #64 had a deterioration in condition and was actively dying. FM A stayed with the resident while being supervised by facility staff. Hospice was called and stayed with the resident. The resident passed away on 10/01/23. Review of the Facility Policy and Procedure, Abuse and Neglect, not dated, reflected: . Investigation: All staff in the nursing facility and all residents, responsible parties, and or legal representatives has been properly notified through facility policy that any abuse will not be tolerated at all. All allegations, no matter what types of incidents reported will be investigated fully .

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 physical, mental, or psychosocial status for 1 of 3 residents (Resident #64) reviewed for abuse. The facility failed to notify the facility physician/FNP following an allegation of abuse reported for Resident #64 on 09/22/23. This failure could place residents at risk for not having their allegations of abuse reported to the physician/FNP. Findings included: Record review of Resident #64's quarterly MDS assessment, dated 08/31/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills were severely impaired. She was frequently incontinent of bladder and bowel. Her diagnoses included non-Alzheimer's dementia and non-cancerous brain tumor. Record review of Resident #64's Comprehensive Care Plans, dated 09/26/23, reflected: 1. Resident 's FM A visiting on 9/22/23 and witnessed by 2 staff members touching resident inappropriately. Goal: Resident 's FM A will not act inappropriately when visiting the resident. She is not able to consent to the sexual behavior he is initiating, and FM A's behavior agitates the resident. Facility interventions: . FM A can visit resident, but only when supervised by a staff member. 2. The resident is at risk for bruises r/t use of aspirin, combativeness w/ care, hx of falls, and FM A visits w/ inappropriate touching. Goal: The resident will be free from injury or further bruises x 90days Facility interventions: Provide supervised visits in a common area w/ FM A for resident safety. Record review of the Facility Provider Investigation Report, dated 09/22/23, reflected: An email from the DON dated 09/22/23 at 9:37 PM : FM A of resident involved came in for a visit. He was observed by two CNA's sexually fondling this resident. His hand was seen under the resident's skirt, to her genitals. Statements were obtained from the CNA's . Future visits made by FM A will be supervised. Statement from the facility SW, dated 09/25/23, reflected: This social worker called .and reported .inappropriate touching incident of resident's vagina by her FM A . witnessed by two CNAs in this facility .resident is residing in skilled nursing facility and is unable to give verbal consent due to her poor cognition relating to her diagnosis of dementia and senile degeneration of the brain . Statement from CNA C, dated 09/22/23, reflected: On 09/22/23 at or around 4:25 PM, I witnessed FM A with his hand under the resident's gown in the vagina area. I did not physically see his hand inside of her vagina but I witnessed an in and out motion and the resident looked very uncomfortable and disturbed. FM A denied touching Resident #64 inappropriately and said he was agreeable to having all visits with Resident #64 supervised by staff. An observation on 09/26/23 at 1:39 PM with Resident #64 revealed she was lying in bed. She was awake and alert and turned her head when spoken to. CNA A entered the room. The resident was Spanish-speaking only. The resident spoke, but it was nothing understandable. CNA A translated and said the resident was not saying anything that made sense. An interview on 09/26/23 at 1:09 PM with CNA B revealed on 09/22/23 she was assigned to Resident #64's hall. She said she went to her room and saw FM A sitting in a chair next to the resident and her gown was raised up. CNA B said FM A's right hand was on her vagina, inside of her brief. CNA D said FM A told her the resident was wet and used his left hand to point to the brief. CNA B said the resident was not wet. The resident was lying in bed with her eyes closed and she was stiff in the bed. CNA B said after she started talking, the resident sat up in bed, got up, walked to CNA B and started patting her vagina area and saying eeee. CNA B could not understand what the resident was saying. CNA B said she reported what she saw to the nurse who entered the room. CNA B said the resident had a history of being very combative and agitated when FM A came to visit. CNA B said FM A needed to be counseled because he needed to understand that because of her mental capacity, that behavior was no longer acceptable. An interview was attempted on 09/28/23 at 11:32 AM with FM A, but he refused to speak to the Surveyor. An interview with 09/27/23 at 12:14 PM with LVN D revealed she did a head-to-toe exam on Resident #64 with no new findings. The resident already had a nickel-sized bruise at the top of her vagina at the panty line. She said she did not do a vaginal exam because it was outside of her scope of practice and the resident was not sent to the emergency room for an exam because FM A said not to. An interview on 09/27/23 at 2:53 PM with the FNP revealed she was not notified about the allegation of sexual abuse. She said she was on-call and should have been notified. She said it might have been the best thing to do to order a vaginal exam following the allegation, but she was not notified and so she could not say for sure. An interview on 09/28/23 at 9:15 AM with the DON revealed she did not know why the physician/FNP was not notified. A phone message was left for RN E on 09/28/23 at 1:14 PM to find out why she did not notify the FNP, but she did not return the call of the Surveyor. The Administrator was not available for interview during the survey. Review of the Facility Policy and Procedure, Change of Condition-Notification, not dated, reflected: . Procedure: 1. The charge nurse will notify the resident, his/her physician .when there is: a. A change in the resident's condition . c. A need to alter treatment significantly .

Based on interview and record review, the facility failed to ensure all alleged violations of abuse and neglect were thoroughly investigated for 1 of 3 residents (Resident #64) reviewed for abuse and neglect. The facility did not thoroughly investigate when Resident #64 had an allegation of sexual abuse reported on 09/22/23. This failure could place residents at risk for not having their allegations of abuse and neglect investigated. Findings included: Record review of Resident #64's quarterly MDS assessment, dated 08/31/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills were severely impaired. She was frequently incontinent of bladder and bowel. Her diagnoses included non-Alzheimer's dementia and non-cancerous brain tumor. Record review of Resident #64's Comprehensive Care Plans, dated 09/26/23, reflected: 1. FM A visiting on 9/22/23 and witnessed by 2 staff members touching resident inappropriately. Goal: FM A will not act inappropriately when visiting the resident. She is not able to consent to the sexual behavior he is initiating, and FM A's behavior agitates the resident. Facility interventions: . FM A can visit resident, but only when supervised by a staff member. 2. The resident is at risk for bruises r/t use of aspirin, combativeness w/ care, hx of falls, and FM A's visits w/ inappropriate touching. Goal: The resident will be free from injury or further bruises x 90days Facility interventions: Provide supervised visits in a common area w/ FM A for resident safety. Record review of the Facility Provider Investigation Report, dated 09/22/23, reflected: An email from the DON: FM A of resident involved came in for a visit. He was observed by two CNA's sexually fondling this resident. His hand was seen under the resident's skirt, to her genitals. Statements were obtained from the CNA's . Future visits made by FM A will be supervised. Statement from the facility SW, dated 09/25/23, reflected: This social worker called .and reported .inappropriate touching incident of resident's vagina by FM A . witnessed by two CNAs in this facility .resident is residing in skilled nursing facility and is unable to give verbal consent due to her poor cognition relating to her diagnosis of dementia and senile degeneration of the brain . FM A did report a bruise on the resident at the panty line that was about the size of a quarter to the facility on [DATE]. The bruise was reported to the physician. FM A denied touching Resident #64 inappropriately and said he was agreeable to having all visits with Resident #64 supervised by staff. Statement from CNA C, dated 09/22/23, reflected: On 09/22/23 at or around 4:25 PM, I witnessed FM A with his hand under the resident's gown in the vagina area. I did not physically see his hand inside of her vagina but I witnessed an in and out motion and the resident looked very uncomfortable and disturbed. An observation on 09/26/23 at 1:39 PM with Resident #64 revealed she was lying in bed. She was awake and alert and turned her head when spoken to. CNA A entered the room. The resident was Spanish-speaking only. The resident spoke, but it was nothing understandable. CNA A translated and said the resident was not saying anything that made sense. An interview on 09/26/23 at 1:09 PM with CNA B revealed on 09/22/23 she was assigned to Resident #64's hall. She said she went to her room and saw FM Asitting in a chair next to the resident and her gown was raised up. CNA B said FM A's right hand was on her vagina, inside of her brief. CNA D said FM A told her the resident was wet and used his left hand to point to the brief. CNA B said the resident was not wet. The resident was lying in bed with her eyes closed and she was stiff in the bed. CNA B said after she started talking, the resident sat up in bed, got up, walked to CNA B and started patting her vagina area and saying eeee. CNA B could not understand what the resident was saying. CNA B said she reported what she saw to the nurse who entered the room. CNA B said the resident had a history of being very combative and agitated when FM A came to visit. CNA B said FM A needed to be counseled because he needed to understand that because of her mental capacity, that behavior was no longer acceptable. An interview was attempted on 09/28/23 at 11:32 AM with FM A of Resident #64, but he refused to speak to the Surveyor. An interview on 09/26/23 at 1:46 PM with the DON revealed the treatment nurse did a skin assessment the next day (09/23/23), but the resident was not sent for a vaginal exam because FM A said not to send the resident to the hospital. The DON said the incident was abuse because the resident could not consent. She said FM A was talked to and said he was just checking to see if the resident was wet. The DON said they were doing supervised visits with him because he visited her every day. An interview on 09/26/23 at 1:58 PM with the SW revealed she thought FM A had abused the resident. She said she was told the resident was in bed and he was feeding her. He would give her a bite with one hand. Her dress was up, and his hand other hand was down in the brief. The CNA had just checked the brief and said it was dry. He said he was just checking the brief. The SW said the facility was trying to keep the resident safe. She said the resident was not sent for a vaginal exam because they asked FM A and he refused. An interview with 09/27/23 at 12:14 PM with LVN D revealed she did a head-to-toe exam on Resident #64 with no new findings. The resident already had a nickel-sized bruise at the top of her vagina at the panty line. She said she did not do a vaginal exam because it was outside of her scope of practice and the resident was not sent to the emergency room for an exam because FM A said not to. An interview on 09/27/23 at 12:50 PM with the Corporate Nurse for Resident #64 revealed she was asked what assessment should be completed when there was an allegation of inappropriate touching. The Corporate nurse did not answer the question but did say the facility offered to send the resident to the ER and FM A refused. The Corporate Nurse said the facility allowed FM A to make the determination of whether to send her to the ER because he was her representative party. She said to keep the resident safe going forward, the facility was allowing the resident to have supervised visits with FM A. She said the results of the investigation revealed the resident had a bruise found on the top area of her vagina on 09/21/23 and then FM A was seen touching the resident on 09/22/23. The Corporate Nurse said they thought FM A could have caused the bruise due to inappropriate touching. An interview on 09/27/23 at 2:53 PM with the FNP revealed she was not notified about the allegation of sexual abuse. She said she was on-call and should have been notified. She said it might have been the best thing to do to order a vaginal exam following the allegation, but she was not notified and so she could not say for sure. A phone message was left for RN E on 09/28/23 at 1:14 PM to find out why she did not notify the FNP, but she did not return the call of the Surveyor. An interview on 09/27/23 at 2:04 PM with the Medical Director revealed Resident #64 was on Hospice services and a pelvic exam would have been very traumatic for her. The Administrator was not available for interview during the survey. The Surveyor re-entered the facility following administrative review on 10/19/23 at 5:45 PM. An interview on 10/19/23 at 6:05 PM with the DON revealed Resident #64 passed away on 10/01/23. She said FM A visited the resident on 09/29/23 and was supervised by facility staff as agreed. FM A visited again on 09/30/23 and was supervised by facility staff. On 09/30/23, Resident #64 had a deterioration in condition and was actively dying. FM A stayed with the resident while being supervised by facility staff. Hospice was called and stayed with the resident. The resident passed away on 10/01/23. Review of the Facility Policy and Procedure, Abuse and Neglect, not dated, reflected: . Investigation: All staff in the nursing facility and all residents, responsible parties, and or legal representatives has been properly notified through facility policy that any abuse will not be tolerated at all. All allegations, no matter what types of incidents reported will be investigated fully .

Based on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for one (Resident #36) of three resident assessments reviewed for PASRR evaluations. 1. The facility did not complete a new PASRR Level 1 Screening for Resident #36 when he was diagnosed with PTSD on 06/21/23. These failures could affect residents with psychiatric diagnoses who may not be evaluated and receive needed PASRR services. Findings included: 1. Review of Resident #36's quarterly MDS Assessment, dated 07/18/23, revealed he had active diagnoses of PTSD, anxiety disorder, and depression. The resident's cognition was intact. Review of Resident #36's care plan, dated 06/21/23, reflected: The resident had ineffective coping skills related to diagnosis of PTSD. (Loss of wife and daughter one year apart) Resident can have verbal outbursts and be argumentative. Review of Resident #36's PASRR Level 1 screening, dated 06/01/22, reflected he did not have a mental illness. There was no PASRR Level 2 screening. An interview on 09/28/23 at 1:05 PM with Resident #36 revealed he did not receive PASRR services and did not know what PASRR services were. He said he was interested in receiving PASRR services. An interview on 09/27/23 at 1:30 PM with the MDS Coordinator revealed she said she added the new diagnosis of PTSD on 06/21/23 and should have completed a new PASRR Level 1 screening. An interview on 09/28/23 on 9:22 AM with the DON revealed the SW and MDS Coordinator were responsible for completing new PASRR Level 1 screenings as needed. An interview on 09/28/23 at 11:37 AM with Corporate MDS Coordinator Joy [NAME] revealed the facility MDS Coordinator was responsible for completing a new PASRR Level 1 screening if a new qualifying diagnosis was added. She said if a resident did not receive the correct PASRR Level 1 screening the resident was at risk for not receiving the proper services. Review of the facility policy for, Pre-Admission Screening for Individuals with Mental Illness and Intellectual of Development Disabilities, not dated, reflected: If during a resident's stay they receive a new diagnosis from their physician that could be considered a positive PASRR for MI, ID, DD, the facility will complete a form 1012 and follow through to see if a physical and mental evaluation is needed.

Based on interview and record review, the facility to ensure based on their comprehensive assessment residents received treatment and care in accordance with professional standards of practice, the comprehensive person center care plan, and the residents' choice for one (Resident #1) of three residents reviewed for quality of care. The facility failed to assess, monitor, and notify the resident's physician when Resident #1 began to exhibit a change in condition on 08/13/20. Resident #1 continued to experience a change in condition until routine labs on 08/17/20 revealed critically high sodium levels. Resident #1 ordered the resident be immediately transferred to the hospital where she was admitted and treated for [REDACTED]. On 09/01/20 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/02/20, the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received and signed the IJ template on 09/01/20 at 5:10 PM. These failures placed residents at risk of serious illness, hospitalization and death. Findings included: Review of Resident #1's Minimum Data Set (MDS) Quarterly Resident Assessment, dated 08/04/20, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. The MDS assessment indicated Resident #1 required extensive assistance with eating and drinking, and support from two+ persons physical assist. Per the MDS assessment, Resident #1 did not have sign or symptoms of a swallowing disorder including loss of liquids or solids from mouth when eating or drinking. Her active [DIAGNOSES REDACTED]. She had severe cognitive impairment and required extensive assistance with two-persons for her activities of daily living (ADLs). Review of Resident #1's comprehensive care plan, dated 08/19/20, reflected she had potential for weight loss and dehydration. The interventions included to administer 4-6oz juice between meals, administer supplements per Dr. orders., milk with all meals, . monitor for s/sx of dehydration and monitor labs report to MD as indicated . Review of Resident #1's labs reflected on 07/29/20, Sodium 145 .Urea nitrogen (BUN) 29H (high). Normal range for blood sodium levels was 135 to 145 milliequivalents per liter (mEq/L). Normal range of BUN levels was 7 to 20 mg/dL (milligrams per deciliter). Review of Resident #1's physician's progress notes dated 08/04/20 revealed: BUN increased can indicate mild dehydration. Pt not on diuretic. Review of the physician's orders [REDACTED]. VS (vital signs) q (each) wk (week). Repeat BMP (Basic Metabolic Panel). Review of Resident #1's August 2020 Medication Administration Record, [REDACTED]. Review of Resident #1's intake records from 06/01/20 through 08/17/20 revealed meal consumption was documented for each meal as a percentage. Fluid intake was not documented. Review of Resident #1's progress notes from 06/01/20 through 08/16/20, revealed no documentation of Resident #1's change in status, change in meal intake, or notification of physician or family. Review of Resident #1's labs on 08/17/20 revealed, Sodium 160CH (critically high) .BUN 39H (high ). Normal range for blood sodium levels was 135 to 145 milliequivalents per liter (mEq/L). Normal range of BUN levels was 7 to 20 mg/dL (milligrams per deciliter). According to the website https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/electrolyte-disorders/[MEDICAL CONDITION], accessed on 08/28/20, .[MEDICAL CONDITION] is a serum sodium concentration > 145 mEq/L (> 145 mmol/L). It implies a deficit of total body water relative to total body sodium caused by water intake being less than water losses. A major symptom is thirst; other clinical manifestations are primarily neurologic (due to an osmotic shift of water out of brain cells), including confusion, neuromuscular excitability, [MEDICAL CONDITION], and coma. According to the website https://medlineplus.gov/lab-tests/bun-blood-urea-nitrogen/, accessed 08/28/20, .Higher than normal BUN levels can also be caused by dehydration . Review of Resident #1's progress note dated 08/17/20 at 1:39 PM reflected LVN A documented, Received call from (Lab Company) on resident labs critical sodium 160. Called (physician) who stated to send resident to hospital. Called (Resident #1's family member), No ans, left message for call back . Resident was transferred to the hospital on [DATE] at 2:03 PM. Review of Resident #1's hospital records revealed she was admitted to the hospital on [DATE] with the Diagnoses: [REDACTED]. According to website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 73/ accessed on 09/18/20, consequences of hypovolemia include: arterial [MEDICAL CONDITION] . increased [MEDICAL CONDITION] oxygen demand . reduced tissue perfusion . [MEDICAL CONDITION] failure . acidosis . [MEDICAL CONDITION] dysfunction . multi-organ failure. Review of the 24-hour nursing reports for August 2020 revealed Resident #1 was first added to the 24- hour nursing report on 08/25/20 when she was discharged from the hospital on [DATE]. Prior to this date there was no documentation of Resident #1's change in status, change in meal intake, or notification of physician or family. In an interview on 09/01/20 at 12:14 PM, the DON stated that the nurses would be expected to document a change in condition on the 24-hour nursing report and in a progress note. In an interview on 08/18/20 at 1:10 PM, CNA D indicated she regularly worked with Resident #1. She said that Resident #1 was really quiet, but when she worked last week on 08/13/20 and 08/14/20, Resident #1 did not talk at all. She stated that Resident #1 could not feed herself and was dependent on staff to feed her meals and assist with fluid intake. Per CNA D, Resident #1 received regular fluids and pureed meals. CNA D stated that on 08/12/20 and 08/13/20 she noted a decrease in Resident #1's meal consumption. CNA D stated that Resident #1 would normally eat the whole thing (meals), but on 08/12/20 and 08/13/20, Resident #1 was consuming 25 to 50 percent of her meals. CNA D said that water cups were placed in Resident #1's room, but she never drank water. CNA D also said that Resident #1 was to receive a milkshake between meals, but she refused because she doesn't like milkshakes. CNA D said she notified LVN A of the Resident's change of condition on 08/14/20. In an interview on 08/18/20 at 1:17 PM, LVN A revealed she worked with Resident #1 on 08/14/20 and noted a change in Resident #1's condition on 08/14/20. LVN A stated she was aware of Resident #1's order to provide assistance with beverages four times a day. LVN A said she would encourage fluids and provide Resident #1 with a 4-ounce cup of water, and Resident #1 would accept a little bit, but she would close her mouth and let it dribble out the side of her mouth. LVN A said she also noted that Resident #1 was less vocal on 08/14/20. LVN A said she notified the doctor of Resident #1's change in condition in passing during weekly rounds. LVN A stated she could not remember if she documented notifying the doctor, but she should have. In an interview on 08/19/20 at 11:05 AM, CNA E stated she regularly worked with Resident #1. CNA E said that Resident #1 required total assistance with activities of daily living (ADLs). Per CNA E, Resident #1 was dependent on staff for meals and fluids, and Resident #1 received a pureed diet with regular consistency fluids. CNA E said that she worked with Resident #1 on 08/10/20, 08/11/20, 08/14/20, 08/15/20, and 08/16/20 from 6:00 AM to 6:00 PM. CNA E said she noted that on 08/14/20 Resident #1 was weaker and not herself. CNA E indicated this was a marked change from when she worked with Resident #1 on 08/11/20. CNA E stated that Resident #1 would regularly grab for stuff and pat the aides on the back. CNA E said Resident #1 was not grabbing or patting on 08/14/20. CNA E said that she fed Resident #1 on 08/14/20, 08/15/20, and 08/16/20 and Resident #1 didn't eat, she wasn't hungry. CNA E said that Resident #1 would drink about 25 percent of an eight-ounce cup of water. CNA B said she did not report this change in Resident #1's behavior or intake to a nurse. CNA E said that the facility's policy was to report changes to the nurse if it was serious. She stated the change in Resident #1 was serious, but she did not notify the nurse because she was really busy. CNA E said, I know I was wrong for not reporting it. CNA E could not identify signs of dehydration. In an interview on 09/01/20 at 2:30 PM, CNA F stated she worked 08/14/20 from 6:00 PM to 10:00 PM. She stated she was not notified of a change in condition for Resident #1. CNA F did not notice anything different with Resident #1 on 08/14/20 because most residents, when they go to bed, they fall asleep. In an interview on 08/19/20 at 10:15 AM, LVN B was unable to name signs or symptoms of dehydration. LVN B stated she did not know the facility's policy on monitoring or documenting for dehydration. LVN B said she did not regularly worked with Resident #1, but she assisted LVN A when Resident #1 was sent to the hospital on [DATE]. LVN B stated that on 08/17/20, she observed Resident #1 as lethargic. In an interview on 08/19/20 at 11:30 AM, LVN C stated she worked 08/15/20 and 08/16/20 from 6:00 AM to 10:00 PM. LVN C said that she was not notified of a change in condition or intake for Resident #1. LVN C stated that if a change in condition was reported, she would notify the doctor. LVN C said that CNAs were to document meal intake of residents, and we don't record fluid intake. LVN C stated if she noted signs of dehydration in a resident, she would notify the doctor and encourage fluids. In an interview on 09/01/20 at 11:26 PM, LVN A stated if there was a change in a resident's condition, a nurse must complete an initial change in condition note, notify the DON, physician, and family. LVN A stated there was not a place for CNAs to document that the nurse was notified of a change in condition. LVN A stated the notification of the doctor could be completed in a message in the electronic health record, during the physician's rounds, or by telephone. LVN A stated she would document a progress note that the doctor was notified and what the plan was after that. LVN A stated she did not document on Resident #1's change in condition because the conversation about residents not taking in an adequate amount of fluids was regarding three different residents. LVN A stated the conversation should have been documented for all three residents. In an in interview on 09/01/20 at 10:30 AM, CNA D stated that if a change in condition was noted, she would communicate that to the nurse verbally because there is nothing in writing. CNA D indicated that CNAs were made aware of new interventions, such as added snacks, because the nurse would verbally inform the CNAs. CNA D stated there is a list of who gets snacks, but we (CNAs) don't have it. We only know by what shows up on the snack tray. CNA D could not identify all residents with orders to encourage fluids. In an interview on 09/01/20 at 10:41 AM, CNA F stated if she noticed a change in a resident's status, she would tell nurse verbally; I don't document anything. If something is different about the resident, I'll tell the oncoming shift. It's only verbal, nothing in writing, only nurses do in writing. CNA F stated she would be made aware of new orders regarding residents' intake if nurses verbally inform her. She stated there was no written documentation CNAs could review to review new dietary or intake orders. CNA F could not identify all residents with orders to encourage fluids. In an interview on 09/01/20 at 10:56 AM, CNA G stated that if a resident was not drinking, she would notify a nurse, but there was not a place to document fluid intake. CNA G stated that nurses would need to verbally notify CNAs of change in intake orders, because there was not a place documented for CNAs to review. CNA G could not identify all residents with orders to encourage fluids. In an interview on 08/18/20 at 1:50 PM, the DON stated we could have done a better job with documenting the amount of fluid intake for Resident #1. The DON stated that fluid intake and output were not monitored or recorded unless a resident was on strict fluid restrictions or ordered by the physician. In a telephone interview on 08/18/20 at 2:00 PM, Physician F stated she was Resident #1's primary physician. Physician F said she wrote the order for Resident #1 to be provided assistance with fluids four times a day. Physician F said it was her expectation for facility staff to monitor and document fluid intake and output. Physician F said she did not write for fluid intake to be monitored in her order for Resident #1 because it goes without saying. Physician F said that prior to this incident, a feeding tube had not been discussed for Resident #1 because meal and fluids refusals had not been an issue in the past. Physician F said that on 07/29/20, Resident #1's BUN was slightly elevated and that was the reason for the order to provide assistance with fluids. Physician F said she was not notified that Resident #1 had a change in condition and was not accepting fluids or that Resident #1 had a decrease in meal consumption. Physician F stated she was disappointed because there was a problem with communication, and had she been notified. She stated there was a process to address it immediately such as IV hydration or a speech therapy consult to address fluids falling out of Resident #1's mouth. Physician F stated that due to the critically high level of sodium of 161 mEq/L on 08/17/20, Resident #1 was sent to the hospital. Physician F stated she did not believe Resident #1 can live through this. It's a fatal number. Physician F said she was concerned about all the residents who cannot reach for their own beverage. In an interview on 08/18/20 at 3:11 PM, the DON stated that the expectation when monitoring for dehydration was for nurses to know what to look for. The DON said the expectation was that anytime anyone goes into a room, they are to offer them (residents) something to drink. The DON stated dehydration was a common issue in nursing homes, because the residents were old. The DON stated if they went to the ER today, half of them would have dehydration and UTIs. When asked, the DON did not identify what monitoring for dehydration would include nor if training had been completed with staff. In an interview on 09/01/20 at 12:14 PM, the DON stated that their documentation was very poor in the case of Resident #1. When asked how CNAs would document a resident's change of condition, the DON stated that CNAs documentation is limited, it's basically check boxes. The DON also said there is not a place for CNAs to document that they notified the nurse of a resident's change in condition. The DON stated that the expectation regarding a resident's change in condition was that CNAs are to notify their immediate supervisor, their nurses. Nurse is to assess resident, notify the MD and family, and review the active orders. The DON stated that the nurse would also be expected to document the change in the 24-hour nursing report and in a progress note. She stated there were three types of notes regarding a change of condition from which a nurse could select: initial, follow-up, and resolved. When asked about the facility's policy titled Hydration Policy and Procedure and what monitoring would be implemented for at risk residents, the DON stated, calling doctor, PO or IV hydration, and encouraging fluids. When asked again about what monitoring would be implemented, the DON stated, it's a vague policy. When asked how CNAs would be made aware of new diet orders or intake interventions, the DON stated CNAs would not know because those orders go on nurses' orders, but not on CNAs (electronic medical record). The DON said CNAs would know about new dietary orders because dietary brings out snacks with the residents' name on them. The DON also stated that orders for snacks and fluids default to the medication aide MAR. The DON stated the task to encourage fluids was to be done by the medication aide and that CNAs wouldn't know. The DON also said it would be helpful if CNAs knew who had orders to encourage fluids. When asked for the reason orders to encourage fluids were changed to include a specific amount to offer and to document amount given, the DON said it was to better keep track of how much (fluids) they're (residents) are getting. Review of facility policy titled Hydration Policy and Procedure, not dated, reflected, All at risk residents will be monitored for dehydration. Nurse aides will notify the charge nurse if a resident refuses fluids. Examples of at risk: A. Change in mental status B. Require extensive assistance C. Hand dexterity problems D. Frequent constipation or use of laxatives, enemas, or diuretics E. Depression, sad mood, grief reaction F. Infection, fever, vomiting, diarrhea/nausea G. Excessive urine output due to drugs or disease H. Previous [DIAGNOSES REDACTED]. Review of facility policy titled Change of Condition-Notification, not dated, reflected, The charge nurse will notify the resident, his/her physician, his/her legal representative, and his legal representative, and his/her family member, when there is .A change in the resident's condition in either life-threatening conditions or clinical complications .A need to alter treatment significantly .notifications will be made within 24 hours of a change in condition or status .Documentation will include: a. Notification of resident's physician b. notification of family/legal representative c. What the condition is d. date and time of each event. On 09/02/20 at 5:10 PM, the Administrator and the DON were informed an IJ was identified and a plan of removal was requested. Review of facility's Plan of Removal dated 09/01/20, reflected the following: Purpose: The purpose of this action plan is to take steps to remove the immediate jeopardy in failing to ensure residents receive adequate hydration, failing to have an effective communication system in place between CNAs, nurses, and physicians when there is a change in condition. The resident indicated in this immediate jeopardy is (Resident #1). On August 14, 2020 a CNA reported to the day shift nurse that (Resident #1) was not eating and fluids were falling out of her mouth and she was not acting like herself. The nurse failed to assess (Resident #1) at that time. The day shift CNA failed to notify the day shift nurse of (Resident #1's) decreased fluid and meal intake on 08/15/20 and 08/16/20. There was no system in place for communication between, CNAs, nurses, and physicians of a change in condition for residents. On 08/17/20 at 2:03 PM (Resident #1) was sent to the hospital after the day shift nurse received a call from the laboratory of a critically high sodium level of 160 (normal range 135-145). Resident was admitted to the hospital with [REDACTED]. Action Plan incorporated to ensure systems are in place to ensure correction and removal of the Immediate Jeopardy: 1. RN DON, RN K, RN L and RN Mon 09/01/20 immediately assessed all current residents in the facility for any condition changes or behaviors that are out of the ordinary for that particular resident. These assessments will include any weight deviations, signs of dehydration or infection, and meal intake deviations. Any immediate assessments that are being done by the four Registered Nurses that appear to indicate a change in a resident's condition, the attending physician will be notified by the RN DON for further orders and disposition. These assessments were completed on 09/01/20. 2. RN DON on 09/01/20 contacted all resident's attending physicians for lab orders to ensure that all resident's lab values are in range for proper hydration and to evaluate for any abnormalities that warrant follow-up. Complete Blood Count (CBC) and Complete Metabolic Panel (CMP) laboratory tests were ordered by the attending physicians through recommendation by Physician N. Laboratory tests will be done on 09/02/20-09/03/20.Once the laboratory results are received the attending physicians will review for further orders, if any. 3. Prior to this Immediate Jeopardy the RN DON conducted an in-service training on 08/18/20 and 08/19/20 to all nurses, CMAs, and CNAs on identifying and reporting resident changes in condition and also reporting to the physician any change in condition. Examples of changes in condition were presented in the training sessions along with verbal interaction to confirm the understanding, importance and competency of the training. 4. CNAs will receive a new CNA/Nurse communication tool (STOP and WATCH) to be utilized for identification and documenting resident changes in condition. The procedure for implementation will be covered in an in-service to be held on 09/01/20 by the Corporate RN O and LVN P. Implementation will begin 09/01/20 on the 6pm-6am shift. This procedure covers completing a 24 hour report sheet on all assigned residents and review with charge nurse at shift change. Charge nurse will review and attach CNA resident report to main 24 hour report. DON or designee to review daily to ensure follow-up. The STOP and WATCH document will be laminated and posted throughout the facility to familiarize clinical staff with STOP and WATCH program. This document is printed in English and Spanish. Competency was verified by attestation and verbal interaction during the training and post training. (STOP and WATCH is attached to this plan for review) 5. On 09/01/20 at 8:30 pm all CMAs, CNAs and licensed nurses received in person classroom in-service training by RN O and LVN P. This in-service training included the following subject matter: (a) what to look for in resident condition changes or behaviors that are out of the ordinary for that particular resident, any resident weight deviations, signs of dehydration or infection, and meal intake deviations; (b) required written/verbal critical communication between CNAs, CMAS, nurses, and physicians in addressing resident changes in condition and the proper notifications required to ensure resident needs are being met when these changes occur; and (c) Implementation of new CNA/Nurse communication tool (STOP and WATCH) to be used for resident's changes in condition. This tool is to be completed on all assigned residents and reviewing with charge nurse at shift change. Charge nurse will then attach CNA resident report to main 24 hour report. DON or designee will review daily to ensure follow-up. Once a change in condition is written/verbally conveyed the CNAs, CMAs, nurses or physicians will immediately follow-up and address and resolve the issue. All attendees will attest that they fully understand and acknowledge what was covered in the in-service training. All training was completed on 09/01/20. Verbal interaction quizzes completed with staff after in-person in-service training. (d) Any and all clinical new hires such as CMAs, CNAs, and nurses will receive in person training by the RN DON upon hire as part of their Orientation concerning identifying and reporting resident changes in condition to include dehydration issues. The STOP and WATCH program will be included and competency will be verified by attestation and verbal interaction during this training. 6. Facility management has determined that all residents are at risk for dehydration. On 9/2/2020 and 9/03/2020 the RN DON requested from the attending physicians that laboratory tests be ordered (CBC/CMP tests) for each resident to establish base line tests for all current residents. RN DON or her designee will review labs daily and will report any inconsistently or abnormalities to the physician. 7. The facility's current practices at this time is encouraging and ensuring that all facility residents are offered and receive hydration by the clinical staff every two hours. This practice consist of the CNA entering each resident's room, offering and assisting with fluid intake. The clinical staff will document a Hydration Record to verify intake and submit the Record to the RN DON or designee daily. 8. RN DON will ensure that if the MD Orders each resident will have an encouraged by mouth fluid physician order [REDACTED]. This order requires amount taken to be documented four times daily. Action plan to be incorporated to ensure systems are in place to monitor corrections. The Administrator and the RN DON starting 09/02/20 and going forward, will review all 24 hour reports at the facility's daily stand-up meetings, which are current daily on-going meetings, to ensure that any and all changes of conditions were addressed and resolved. The Administrator, and the RN DON will review and sign off on the reports to confirm that there were reviewed and acted upon if necessary. RN O starting, 09/02/20 until 10/02/20, will do monitoring with reviews of the 24 hour reports to ensure that all issues with resident changes in conditions are being documented and addressed. Included in these reviews RN O will randomly interview clinical staff on the items covered in the in-service training that was concluded on 09/01/20 to ensure that staff continue to be aware of changes in resident conditions and what the communication procedures are in documenting and reporting. These 24 hour reports will be scanned to RN O daily who will review each report and e-mail back to the facility Administrator and the RN DON with comments or further action to be done. The CNA and/or designee assigned for the hydration pass and the hospitality cart will initial the Resident Hydration Record. Charge Nurse will monitor q shift to ensure the pass has taken place. Administrator will monitor the Hydration Record form weekly starting 9/2/2020 and ongoing for compliance. RN O and LVN P, to ensure that all clinical nurse staff understood the in-service training concerning dehydration and changes in resident conditions will be administered a knowledge check quiz. This quiz to be conducted on 9/2/2020 and 9/3/2020 to confirm staff understanding and knowledge of completed in-service. Physician Q and Physician F were notified on 09/01/20 of the SQC/IJ and received a copy of this action plan on 09/02/20. Administration and management are confident that the immediate jeopardy to any and all residents at (facility name) has been removed and addressed as of 09/02/20. Monitoring of the Plan of Removal revealed: Observation on 09/02/20 at 1:08 PM revealed Receptionist J was going down the hallways giving residents ice and water in their mugs. Observation on 09/02/20 at 4:16 PM revealed STOP and Watch forms posted on the walls in the hallway and inside the nurses' station. Observation on 09/03/20 at 9:00 AM revealed Receptionist J was walking down hall with the hydration cart. She was entering rooms to obtain residents' mugs and refilling them with ice and water. In an interview conducted on 09/02/20 at 1:41 PM, LVN B stated she had received in-services on signs and symptoms of dehydration and on the new facility communication tool STOP and WATCH. She was able to name signs and symptoms of dehydration. She indicated the purpose of the STOP and WATCH tool was for more communication, if there is any change in condition CNAs would report on there. CNAs are trained that if there is a change in condition bring it to the nurse right away. LVN B stated if there was a reported change in condition with a resident she would start a change in condition (progress note), contact the doctor, go in to assess and start an intervention. She stated she would review orders for PRN orders. LVN B was able to name changes in condition listed on the STOP and WATCH form. LVN B said that there was one form per day and it was kept at the nurses' station. CNAs would come to the nurses' station to document. LVN B said there was also STOP and WATCH form on the walls in the hallways and one at the nurses station. In an interview on 09/02/20 at 2:03 PM, LVN I said she normally worked the 2:00 PM to 10:00 PM shift. She stated she received in-services on dehydration and STOP and WATCH form. She said she would review the STOP and WATCH form after supper and 2 hours before the end of her shift. She said anytime CNAs reported anything on the form, she would go assess the resident. LVN I said Stop and watch is posted at the nurses' station in big red letters. They (CNAs) can come to the desk any time and they also have nurses to remind them about the stop and watch. LVN I said she would notify the doctor of change of condition immediately, ask for an intervention, and document in a progress note and 24-hour nursing report. In an interview on 09/02/20 at 2:28 PM CNA H said she received in-services on the STOP and WATCH form and dehydration. CNA H was able to verbalize signs of dehydration. CNA H said the purpose of STOP and WATCH forms was for CNAs to pay attention to residents, report changes to the nurse, and so that the doctor can do something about it. CNA H stated STOP and WATCH forms were located on the walls hanging up. In an interview on 9/3/20 at 9:32 AM, Receptionist J said it was her responsibility to take the hydration cart at 9:00 AM and 1:00 PM and refill every residents' cup with ice and water. She stated she was also responsible for initialing the Hydration Record at those times to ensure hydration rounds were done and so that the residents can stay hydrated or they can become dehydrated. Receptionist J was able to verbalize signs of dehydration and stated if she noted any signs of dehydration, she would tell the nurses or (DON) immediately. In an interview on 09/03/20 at 10:10 AM CNA H said hydration forms were filled out every two hours by CNA. She said that the receptionists passed ice and water at 9:00 AM and 1:00 PM, the Activities Director passed out snacks and drinks at 10:00 AM and 3:00 PM. She said that on the weekends, CNAs would complete the 10:00 AM and 3:00 PM hydration and snack rounds. She said hydration rounds were also completed by CNAs at 6:00 PM and 3:00 AM. CNA H said that CNAs must document every two hours on every resident regarding how much was offered and how much they took in on the Hydration Monitoring form. In an interview on 09/03/20 at 10:13 AM, CNA E said she was in-serviced yesterday (09/02/20) on Hydration Monitoring forms. She stated that hydration rounds were completed by the receptionist at 9:00 AM and 1:00 PM, by CNAs at 6:00 PM and 3:00 AM, and by the Activities Director at 10:00 AM and 2:00 PM. She said the Hydration Monitoring forms were filled out every two hours by CNAs, and they documented how much was offered and how much the residents took. She said CNAs completed hydration rounds at 10:00 AM and 2:00 PM on the weekends since the Activities Director was not there on the weekends. In an interview on 09/03/20 at 10:18 AM, the Activities Director said it was her responsibility to pass out the hydration cart and snacks at 10:00 AM a (TRUNCATED)