Every finding on record at Harmony Care at Floresville

Based on observation, interview, and record review, the facility failed to ensure drugs and biological were stored in a manner that permitted only authorized personnel to have access to the keys for 1 of 2 Medication Rooms (Medication room [ROOM NUMBER]) and, 1 of 4 carts (medications cart #1) reviewed for pharmacy services. 1. The facility failed to ensure Medications cart #1 remained locked while not being used.2. The facility failed to ensure Medications room [ROOM NUMBER]'s doors remained locked. This failure could place residents receiving medication at risk of potential harm, medication diversion and access of medications by unauthorized personnel, visitors and residents. Findings included: 1. During an observation on 7/30/2026 at 5:30 a.m., Medication cart #1 was observed to be unlocked. The lock was pulled out, and the drawers could be open. The cart contained multiple prescriptions and non-prescriptions medications. LVN A was standing by another medication cart and was not using cart#1. During an interview on 7/30/2026 at 5:33 a.m., LVN A stated the cart was left unlocked. She stated the cart was supposed to be locked at all times when not being used. She stated the medication cart had over the counter meds and prescription medications. LVN A stated it was important for the medication cart to remain locked because the cart held medications and residents could get to them if left unlocked. 2. During an observation on 7/30/2026 at 5:40 a.m., Medication room [ROOM NUMBER] was found to be open. Further observation revealed the door could not latch properly to be locked. Medications and supply could be found in the Medication room. LVN B was standing by her medication cart and was not looking toward Medication room [ROOM NUMBER]. During an interview on 7/30/2026 at 5:42 a.m., LVN B stated the Medication room was left unlocked. She did not know when it was left unlocked because she had not gone to the Medication room during her shift. She stated the Medications room was supposed to be locked at all times. LVN B stated it was important for the Medication room to remain locked because the room held medications and residents could get to them if left unlocked. During an interview on 07/30/2026 at 6:25 a.m., the DON stated the Medication room and Medications carts should remain locked at all times. She stated only licensed staff had keys and should have access to the room and cart. The DON stated it was important because there were meds stored in the room that could have been accessed. Record review of the facility policy, titled Storage of Medications dated 08/2024 revealed: Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. Medication rooms, carts and medication supplies are locked when they are not attended by persons with authorized access.

Based on interviews and record reviews, the facility failed to ensure an encoded, accurate and complete discharge MDS was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 4 residents (Resident #2) reviewed for discharge MDS assessments. The facility failed to ensure a discharge MDS was completed and transmitted for Resident #2's within 14 days of his discharge to the hospital. This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required.The findings included: Record review of Resident #2's electronic face sheet, accessed on 06/11/2026, revealed the resident was a [AGE] year-old male admitted on [DATE], and readmitted on [DATE], with diagnoses that included Type 2 diabetes mellitus (high level of sugar in the blood) , Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood) , Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Peripheral vascular disease (narrowed arteries reduce blood flow to the arms or legs) , Depression (mood disorder that causes a persistent feeling of sadness and loss of interest) , Chronic pain and Hypertension (High blood pressure). Firther review revealed Resident #2 indicated a transfer to an acute care hospital on [DATE] at 6:20PM. Record review of Facility's census, dated 06/11/2026, for Resident #2 revealed a stop billing date/discharge date of 05/24/2026 Record review of Resident #2s electronic MDS assessments accessed 06/11/2026, revealed a Quarterly MDS Assessment with an ARD of 04/10/2026. As of 06/11.2026, there was no evidence of a discharge MDS completed or transmitted to CMS. During an interview with the DON and Administrator on 6/11/2026 at 2:00 PM, hey revealed the MDS nurse was not in the facility and was usually working remotely. They stated Resident #2's discharge MDS should have been initiated the day the resident left or the day after. It was the MDS nurse's responsibility to complete and transmit the discharge MDS and she missed it. They stated the MDS nurse was relatively new. The administrator stated it was important that MDS assessments were completed in a timely manner, so the facility knew how to care for the residents. Record review of CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 October 2025, 2.5 Assessment Types and Definitions, revealed, Discharge refers to the date a resident leaves the facility or the date the resident's Medicare Part A stay ends but the resident remains in the facility. A day begins at 12:00 a.m. and ends at 11:59 p.m. Regardless of whether discharge occurs at 12:00 a.m. or 11:59 p.m., this date is considered the actual date of discharge. There are three types of discharges: two are OBRA required-return anticipated and return not anticipated; the third is Medicare required-Part A PPS Discharge. A Discharge assessment is required with all three types of discharges.Discharge Assessment refers to an assessment required on resident discharge from the facility, or when a resident's Medicare Part A stay ends, but the resident remains in the facility (unless it is an instance of an interrupted stay, as defined below). This assessment includes clinical items for quality monitoring as well as discharge tracking information. OBRA Discharge assessments consist of discharge return anticipated and discharge return not anticipated. [ .] Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days).

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. Dietary Aide E had a moustache, was not wearing a moustache guard, and was preparing food. 2. The wall air conditioning unit above the dry goods storage was emitting small pieces of gray pellets onto the stored dry goods items. 3. A 22-gallon container of loose sugar also contained a cup for scooping the sugar. 4. A 16-ounce container of beef base paste labeled refrigerate after opening had been opened and was not stored in a refrigerator. 5. A 5-pound container of cottage cheese was labeled use by March 2026.6. A box of lettuce dated 04/07/2026 was withered and brown with parts covered by a wet and slimy substance. 7. A box of lettuce dated 04/30/2026 had a wet and slimy substance which was white with black spots on the plastic wrapping around the lettuce.8. A 20-pound container of frozen potatoes was labeled use by May 6, 2026.9. A 15-ounce container of mango dessert sauce was labeled best by February 2025, three 15-ounce containers of caramel dessert sauce were labeled best by August 2025, a 15-ounce container of cinnamon dessert sauce was labeled best by January 2025, and two 15-ounce containers of cinnamon dessert sauce were labeled best by March 2025.10. A substance resembling particles of sand were on top of the dish sanitizing machine, near the roll down doors, and able to touch the inside of the doors and come into contact with clean dishes. This deficient practice could result in resident weight-loss and/or diminished life satisfaction for residents who consume meals and snacks prepared within the facility kitchen. The findings were: 1. Observation on 05/08/2026 at 10:20 a.m. revealed Dietary Aide E was preparing pinwheel sandwiches. Further observation revealed Dietary Aide E had a moustache and was not wearing a moustache guard. During an interview with Dietary Aide E on 05/08/2026 at 10:21 a.m., Dietary Aide E stated, I don't usually wear one [a moustache guard], should I? During an interview with the Dietary Manager on 05/08/2026 at 10:22 a.m. the Dietary Manager stated to Dietary Aide E and to the surveyor that all dietary staff with facial hair should utilize beard or moustache guards. Observations on 05/08/2026 between 10:25 a.m. and 11:30 a.m. revealed: 2. The wall air conditioning unit above the dry goods storage was emitting small pieces of gray pellets onto the stored dry goods items. 3. A 22-gallon container of loose sugar also contained a cup for scooping the sugar. 4. A 16-ounce container of beef base paste labeled refrigerate after opening had been opened and was not stored in a refrigerator. 5. A 5-pound container of cottage cheese was labeled use by March 2026.6. A box of lettuce dated 04/07/2026 was withered and brown with parts covered by a wet and slimy substance. 7. A box of lettuce dated 04/30/2026 had a wet and slimy substance which was white with black spots on the plastic wrapping around the lettuce.8. A 20-pound container of frozen potatoes was labeled use by May 6, 2026.9. A 15-ounce container of mango dessert sauce was labeled best by February 2025, three 15-ounce containers of caramel dessert sauce were labeled best by August 2025, a 15-ounce container of cinnamon dessert sauce was labeled best by January 2025, and two 15-ounce containers of cinnamon dessert sauce were labeled best by March 2025.10. A substance resembling particles of sand were on top of the dish sanitizing machine, near the roll down doors, and able to touch the inside of the doors and come into contact with clean dishes. During a kitchen tour and interview with the Dietary Manager on 05/08/2026 at 11:55 a.m., the Dietary Manager confirmed the items listed below and stated he had only been in the position for two weeks and would conduct an inspection of the kitchen and storage area closely to ensure no additional items were being stored improperly. 2. The wall air conditioning unit above the dry goods storage was emitting small pieces of gray pellets onto the stored dry goods items. 3. A 22-gallon container of loose sugar also contained a cup for scooping the sugar. 4. A 16-ounce container of beef base paste labeled refrigerate after opening had been opened and was not stored in a refrigerator. 5. A 5-pound container of cottage cheese was labeled use by March 2026.6. A box of lettuce dated 04/07/2026 was withered and brown with parts covered by a wet and slimy substance. 7. A box of lettuce dated 04/30/2026 had a wet and slimy substance which was white with black spots on the plastic wrapping around the lettuce.8. A 20-pound container of frozen potatoes was labeled use by May 6, 2026.9. A 15-ounce container of mango dessert sauce was labeled best by February 2025, three 15-ounce containers of caramel dessert sauce were labeled best by August 2025, a 15-ounce container of cinnamon dessert sauce was labeled best by January 2025, and two 15-ounce containers of cinnamon dessert sauce were labeled best by March 2025.10. A substance resembling particles of sand were on top of the dish sanitizing machine, near the roll down doors, and able to touch the inside of the doors and come into contact with clean dishes. Record review of the facility's policy titled, Employee Sanitation, dated 10/1/18, revealed, Hair nets or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. Record review of the facility's policy titled, Food Storage, dated 10/1/18, revealed, All containers must be labeled and dated.

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 6 residents (Resident #3) reviewed for infection control: The facility failed to ensure LVN C sanitized her hands between change of gloves while providing colostomy care for Resident #3. This failure could place residents at-risk for infection due to improper care practices.Findings included: Record review of Resident #3's face sheet, dated 05/08/2026, revealed an admission date of 08/15/2025, and a readmission date of 11/26/2025, with diagnoses that included: Osteomyelitis (infection in a bone), Type 2 diabetes mellitus (high level of sugar in the blood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood) and paraplegia (inability to voluntarily move or control the lower parts of the body) Record review of Resident #3's Quarterly MDS assessment, dated 04/16/2026, revealed the resident had a BIMS score of 15, which indicated no cognitive impairment, and was indicated to have an ostomy (opening (stoma) in the body for the discharge of body wastes) and an indwelling catheter. Record Review of Resident #3's care plan, dated 04/18/2026, revealed a problem of OSTOMY: requires the use of an Ostomy and is at risk for skin break down and ostomy malfunction and an intervention of Provide colostomy care per order During an observation on 05/07/2026 at 1:49 p.m. LVN C provided colostomy care for Resident #3. LVN C after removing the colostomy bag and cleaning the stoma and skin of the resident, changed her gloves, but did not sanitize or wash her hands. During an interview with LVN C on 05/07/2026 at 2:02 p.m., she stated she did not use sanitizer but knew she needed to use sanitizer between change of gloves. She forgot to take her sanitizer bottle with her in the room. She stated she received infection control training within the current year. During an interview with the DON on 05/07/2026 at 3:57 p.m., the DON stated the staff needed to sanitize or wash their hands between change of gloves to prevent infection and cross contamination. The DON provided training on infection control to the staff at least annually and she checked their skills annually. She would also do sport check if needed Review of facility policy, titled Fundamentals of infection control precautions, dated 03/2024, revealed The following is a list of some situations that require hand hygiene: [ .] after contact with a resident's mucous membranes and body fluids or excretions. [ .] after removing gloves or aprons.

Number of residents sampled: Number of residents cited: Based on observations, interviews, and record reviews, the facility failed to ensure the safe and sanitary storage of residents' food items in 1 of 5 reviewed residents' refrigerators. The facility failed to date open food items in the resident's #39 personal room refrigerator. This deficient practice could put residents at risk of foodborne illness from consuming spoiled food. The findings were: Record review of Resident #39's face sheet, dated 5/05/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses that included:Benign Prostatic Hyperplasia (a non-cancerous condition in men where the prostate gland becomes enlarged as they get older), Bipolar disorder (a mental health condition that causes extreme mood swings), and Borderline personality disorder (a mental health condition characterized by intense emotions, unstable relationships, and a distorted self-image). Record review of Resident #39's BIMS assessment, dated 1/30/26, revealed a BIM score of 15, which indicated intact cognition. Observations on 5/05/2026 at 11:20 a.m. revealed that the personal refrigerator for Resident #39 contained an unlabeled, undated bean dip container with unidentified, fuzzy, slimy patches. During an Interview with Resident #39 on 5/05/2026 at 12:08 p.m. revealed that he was unaware of the unlabeled bean dip container in his personal refrigerator. Resident #39 stated, he stored snacks in his personal refrigerator but forgot the bean dip was even there . During an Interview on 05/5/2026 at 12:40 p.m. with CNA B, and she stated was assigned to Resident #39 and the personal refrigerator in Resident #39's room contained a bean dip container that was undated and unlabeled. She did not know who was responsible for checking the rresident's personal refrigerator for expired food, but would check with the charge nurse. Interview with LVN A on 5/05/2026 at 1:00 p.m. she stated she was the assigned nurse for Resident # 39 and confirmed that there was an unlabeled/undated bean dip storage container in resident 39's personal refrigerator. She stated nursing staff were responsible for removing undated and unlabeled food items from residents' personal refrigerators;but she did not check them today. LVN A stated Resident # 39 risked some form of food-borne illness by possibly consuming food that was unlabeled and undated. During an interview with the DON on 05/05/26, at 2:30 p.m., the DON confirmed that perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent residents from consuming spoiled food. The DON stated that all nursing staff were responsible for removing undated, unlabeled food items from residents' refrigerators, including assisting families in labeling and dating food items brought in. She added that her charge nurses were responsible for overseeing this task, and her ADONs would be monitored at random. Record review of the facility policy, Food Brought in by Family / Visitors , revised March 2022, revealed: Nursing staff will discard perishable foods before the use by date .

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, for 1 of 3 residents (Resident # 38) reviewed for oxygen : The facility failed to ensure Resident #38's nebulizer tubing was bagged. This failure could place at risk for an increase in respiratory complications. Findings included:Record review of Resident # 38's face sheet dated 5/5/26 revealed an [AGE] year-old female admitted [DATE] diagnoses included: Chronic Obstructive Pulmonary Disease [disease is characterized by breathlessness], Asthma [is a chronic condition that causes the airways in the lungs to be inflamed and narrowed at times], and Atrial fibrillation [irregular heart rhythm with symptoms include fatigue, heart palpitations, trouble breathing and dizziness]. Record review of Resident #38's Quarterly MDS assessment dated [DATE], revealed a BIMS of 13, which indicated intact cognition. Record review of Resident #38's Physician monthly orders dated May 2026 revealed an order start date of 03/09/26: albuterol and ipratropium solution 0.5-2.5 mg / 3ml four times a day/ per nebulizer [COPD medication]. During an observation on 5/05/26 at 10:35 a.m. Resident #38 's nebulizer tubing was unbagged on the bedside table. During an Interview on 5/05/26, at 11:51 a.m., with Resident #38 stated only certain nurses bagged the nebulizer tubing, depending on the nurse. During an Interview with LVN A on 5/05/26, at 12:10 p.m., she stated she was assigned to Resident #38. LVN A stated it was every nurse's responsibility to bag the nebulizer. however, she stated she forgot to bag it this morning after giving Resident #38 her nebulizer treatment. LVN A stated the resident was at risk of possible respiratory infection due to the nebulizer tubing being unbagged. During an Interview with the DON on 5/05/26 at 1:57 p.m., it was revealed that Resident #38 should have had their nebulizer tubing bagged by the day shift nurse . The DON mentioned that she needed to determine why the nebulizer tubing for Resident #38 was not bagged. She also stated that she oversaw this task and assured that she would monitor it for compliance. The DON stressed that Resident #38 was at risk of respiratory infection due to unbagged nebulizer tubing. Record review of the facility's policy titled, Departmental (Respiratory Therapy Prevention of Infection), dated 11/2011, revealed: Store the circuit in a plastic bag, marked with the date and the resident's name, between uses.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 2 of 6 residents (Residents #3 and #11) observed for nursing care: 1.The Facility failed to ensure resident's privacy was provided during care when LVN C did not close Resident #3's room door while providing colostomy care.2 The Facility failed to ensure resident's privacy was provided during care when CNA D did not completely close Resident #11's privacy curtain while providing catheter care for the resident. This failure could place residents at risk for loss of dignityThe findings were: 1.Record review of Resident #3's face sheet, dated 05/08/2026, revealed an admission date of 08/15/2025, and a readmission date of 11/26/2025, with diagnoses that included: Osteomyelitis (infection in a bone), Type 2 diabetes mellitus (high level of sugar in the blood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood) and paraplegia (inability to voluntarily move or control the lower parts of the body) Record review of Resident #3's Quarterly MDS assessment, dated 04/16/2026, revealed the resident had a BIMS score of 15, which indicated no cognitive impairment, and was indicated to have an ostomy (opening (stoma) in the body for the discharge of body wastes) and an indwelling catheter. Record Review of Resident #3's care plan, dated 04/18/2026, revealed a problem of OSTOMY: requires the use of an Ostomy and is at risk for skin break down and ostomy malfunction and an intervention of Provide colostomy care per order During an observation on 05/07/2026 at 1:49 p.m. LVN C provided colostomy care for Resident #3. LVN C did not close the door after entering Resident #3's room and Resident #3 could be seen from the hall while receiving care. During an interview with LVN C on 05/07/2026 at 2:02 p.m., she stated the door was not closed while she provided care for Resident #3 but should have been. LVN C stated she was nervous and forgot to close the door. She stated she received training about resident rights within the year. 2. Record review of Resident #11's face sheet, dated 05/08/2026, revealed an admission date of 04/03/2023, and a readmission date of 05/07/2025, with diagnoses that included: Dysphagia (difficulty swallowing), Type 2 diabetes mellitus (high level of sugar in the blood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Chronic pain, Hypothyroidism (under active thyroid). Record review of Resident #11's Significant change MDS assessment, dated 03/26/2026, revealed the resident had no BIMS score, had memory problems and was severely impaired cognitively. Resident #11 was indicated to have an indwelling catheter and was always incontinent of bowel. Review of Resident #11's care plan, dated 04/19/2023, revealed a problem of has an Indwelling Catheter d/t (due to)hyperplasia, urinary retention, Neuromuscular dysfunction and BPH (Benin prostate hyperplasia) and an intervention of CATHETER: The resident has 18fr/10cc indwelling foley catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Observation on 05/07/2026 at 2:30 p.m. revealed CNA D provided catheter care for Resident #11. CNA D did not close the privacy curtain around the bed of the resident. The room had 3 residents. The resident across from Resident #11 could see resident #11 from his bed. A hospice nurse was providing care to one of the other residents and opened the room's door 3 to 4 times and Resident #11 could be seen from the door. Resident #11 was receiving catheter care and his genitals were exposed. During an interview with CNA D on 05/07/2026 at 2:50 p.m., she stated she got nervous and forgot to close the curtain. She stated they should provide privacy for the resident during care. They stated they received resident rights training within the year. During an in interview with the DON on 05/07/2026 at 3:57 p.m., the DON stated privacy must be provided during nursing care, Resident #3's door should have been closed and Resident #11's privacy curtain should have been closed completely. Resident rights training was provided every year and the staff skills were checked annually and as needed by the DON. Record review of facility's policy titled, Resident Rights, dated January 2036, revealed, Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident rights to: [ .] Privacy and confidentiality.

Based on record review and interviews, the facility failed to maintain spaces of at least 80 square feet per resident for 14 of 15 Resident rooms (Resident rooms #101, 102, 103, 104, 105, 106, 107, 401, 403, 404, 405, 406, 408, and 409) inspected for resident room sufficient space for privacy and comfort, in that: The facility failed to ensure resident rooms #101, 102, 103, 104, 105, 106, 107, 401, 403, 404, 405, 406, 408, and 409 were maintained with at least 80 square feet of space per resident. This failure could place residents at risk of restricting their resident rights for comfort and privacy. The findings were:Record review of the Bed Classification Form 3740 dated 02/13/24 which was filled out by the Administrator indicated the capacity of the facility was 144 beds. In an interview with the Administrator on 02/16/24 at 10:55 a.m., revealed she was not aware of any room waivers for the facility. Review of the measurements provided by LSC, of the bedrooms which were measured and identified by the Maintenance Director indicated as follows:Bedroom # (allocated for 2 Beds as per Form 3740)101 - 76.35 square feet per bed102 - 77.44 square feet per bed103 - 76.49 square feet per bed104 - 76.589 square feet per bed105 - 76.124 square feet per bed106 - 75.675 square feet per bed107 - 76.83 square feet per bed401 - 77.8145 square feet per bed403 - 72.1485 square feet per bed404 - 75.968 square feet per bed405 - 75.40 square feet per bed406 - 76.25 square feet per bed408-77.30 (allocated for 4 beds per the Form 3740)409-78.19 (allocated for 4 beds per the Form 3740) In an interview with the Administrator on 05/11/2026 at 11:46 a.m. the Administrator stated that the Bed Classification Form 3740 which she completed was accurate. The Administrator stated she could not advise that a room waiver request had been submitted by the previous Administrator. The Administrator stated she would like to apply for a room waiver request for the rooms designated by the Life Safety Surveyor as not meeting room space capacity requirements.

Based on observation, interview, and record review, the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 1 of 1 kitchen reviewed for staffing. The facility failed to employ sufficient staff to prepare resident meals resulting in meals not served according to the posted start times for dinner on 9/10/25 and lunch on 9/11/25. This failure could put residents at risk for altered nutritional status and/or weight loss. Findings included: Record review of facility posting Meal Times on 9/10/25, revealed: .Lunch Starts @ 11:00 am Dinner Starts @ 5:00 pm. Record review of facility's grievance logs revealed: 6/10/25 Food was cold 7/15/25 Cold Food Record review of Resident Council Meeting minutes revealed: 5/12/25 .Cold Food.Lunch, Breakfast, Dinner, Always late being served. 6/10/25 .food is cold sometimes. 7/14/25 .food is cold at breakfast. During an interview on 9/10/25 at 2:58 pm, the DM said there was one cook and two dietary aides working (one in each building). The DM further stated the dinner meal was scheduled at 5:00 pm and nurses arrived at the kitchen at 5:00 pm to start distributing meals. At 5:16 pm, [NAME] A was observed serving the first plate. Observation on 9/10/25 beginning at 4:58 pm revealed a nurse arrive at 5:00 pm to the kitchen in the south building to pick up meal trays. At 5:07 pm, a resident was observed pointing out to the state investigator the mealtimes posted outside the kitchen door. At 5:22 pm, the same resident said dinner was late every day. At 5:24 pm, another resident said dinner had been served about 5:15 pm, adding we all want our food at 5 [PM]. At 5:26 pm, another resident said meals were always late and the food had not really been that hot. Further observation revealed meal trays were still being placed on the meal cart at 5:27 pm. Observation on 9/11/25 beginning at 10:54 am revealed [NAME] B preparing the meal service area in the south building. At 11:26 am the first tray was placed on the meal cart. At 11:34 am a resident in the south dining room said she was hungry. At 11:35 am meal trays were delivered to the memory care unit, 35 minutes after scheduled starting time, a resident said I'm very, very, very hungry. Please, I'm very, very, very hungry. At 11:37 am, the same resident said Give me something to eat, please. I'm very hungry, give me something to eat, I need something to eat. At 11:45 am, the meal cart arrived to the 100 hall for residents eating in their rooms, 45 minutes after scheduled starting time. At 11:50 am the meal cart was delivered to the 200 hall, 50 minutes after the scheduled start time and at 11:52 am the meal cart was delivered to the 400 hall, 52 minutes after scheduled start time. At 12:01 pm the first tray was delivered to the dining room, over 1 hour after scheduled start time. At 12:06 pm, meal trays were being delivered on the 600 hall. Observation on 9/11/25 at 12:14 pm, the state investigator received a test tray. The meal received consisted of meatloaf, scalloped potatoes, and carrots. The food looked appealing and was palatable; however, the carrots and meatloaf were at room temperature. During an interview on 9/11/25 at 2:44 pm, a resident said that the meals were normally late. During an interview on 9/11/25 at 3:14 pm, CNA A said the food was usually late. CNA A further stated the residents did complain that the meals were cold or late. During an interview on 9/12/25 at 1:51 pm, a resident said that the food was sometimes cold, and it arrived late pretty often. During an interview on 9/12/25 at 1:59 pm, RN B said she did not know how often meals were served late but knew that breakfast was scheduled for 7:00 am and lunch started at 11:00 am. RN B further stated that staff started preparing trays until 11:00 am for lunch. RN B said she had helped with tray preparation by adding condiments to the meal trays because the facility was short-staffed. During an interview on 9/12/25 at 2:21 pm, [NAME] B said breakfast was scheduled at 7:00 am, lunch at 11:00 am, and dinner at 5:00 pm. [NAME] B said he considered 10-20 minutes beyond the scheduled meal time late service. [NAME] B further stated residents may be affected by late meal service because they may get upset or frustrated because they were hungry. [NAME] B said he did not know why lunch was served late on 9/11/25. [NAME] B further stated he thought he was on time because he could not look at his phone when in the kitchen. [NAME] B said there was a clock in the kitchen that was 2 minutes behind. During an interview on 9/12/25 at 3:18 pm, the DM said meals were scheduled for 7:00 am, 11:00 am, and 5:00 pm. The DM said he currently helped the kitchen staff with meals to ensure they were served on time. The DM said he had received grievances in the past about the food being cold. The DM further stated he considered late service 5 minutes after the posted meal service time. The DM said late meal service may affect residents, especially those that took medications with meals. The DM said meals were served late every time [NAME] A was working but did not know why. The DM further stated he did not know why dinner was served late on 9/10/25 and lunch service was late on 9/11/25 due to the meatloaf not being the correct temperature. During an interview on 9/12/25 at 3:50 pm, the Administrator said the facility had one hour to serve meals and they were typically not late. the Administrator further stated that on 9/11/25 the meatloaf was not fully cooked at service time. The Administrator said late meal service may affect the residents by having to wait for the meal, they might be really hungry. Record review of facility's policy titled, The Dining Experience: Staff Responsibilities dated 2023, revealed: Policy: The dining experience will enhance each individual's quality of life through person-centered dining.3. The director of food and nutrition services will perform meal rounds routinely to determine if the meals are timely.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 7 of 21 residents (Residents #12, #35, #70, #39, #80, #190 and, #198) reviewed for infection control: 1. The facility failed to ensure CNA-D sanitized her hands in between feeding and assisting Residents #35, # 39 and #70 with their meal on 03/18/2025. 2. The facility failed to ensure RN-E followed EBP when administering G-tube medication to Resident #190 on 03/19/2025. 3. The facility failed to ensure MA-F sanitized the blood pressure cuff in between use with Residents #80 and #12 on 03/20/2025. 4. a. The facility failed to ensure CNA A washed or sanitized her hands, before touching resident #198's clean brief and after touching the soiled resident's brief. b. The facility failed to ensure EBP were implemented or used while CNA A and CNA B provided high-contact resident activities, including: catheter care for Resident #198. These failures could place residents at-risk for infection due to improper care practices. The findings included: 1. Observation on 03/18/2025 at 11:40 a.m. in the South Building dining room revealed CNA-D feeding Resident #35 on one side of the dining table, occasionally using the edge of Resident #35's clothing protector to wipe her mouth and bringing her cup to her mouth to assist with drinking. Further observation revealed that in-between feeding Resident #35, CNA-D assisted Resident #70 who was seated immediately to her left at the end of the table, by removing her used food bowls handing her a spoon, putting sugar in her tea and stirring the tea. Then midway through the meal, without sanitizing her hands prior, CNA-D was observed to move her chair to sit next to Resident #39, who was sitting across the table to assist Resident #39 with setting up her utensils and scooping her food. After assisting Resident #39 with set-up and observing that she was scooping her food on her own, CNA-D moved her chair back to sit next to Resident #35, again without sanitizing her hands to finish feeding her the remainder of her meal. Interview on 03/18/2025 at 12:14 p.m. with CNA-D revealed she was agency staff and this was her first day working at the facility. CNA-D stated she had received training in infection control both when she was studying to become a CNA and when she started working for the agency. CNA-D stated she knew she was supposed to sanitize her hands in between working with each resident, but did not have any sanitizer readily available, and stated she should probably carry a bottle of sanitizer with her in her pocket. CNA-D stated that by not sanitizing her hands in between working with each resident, she could spread germs from one resident to the next. During an interview with the DON on 3/20/2025 at 2:40 p.m. the DON stated all staff should be washing or sanitizing their hands in between feeding or assisting each resident, and not doing this could spread infection. The DON stated she had already been made aware of this incident and had already started on in-servicing CNA-D and the rest of the staff on hand hygiene and infection control. 2. Record review of Resident #190's face sheet revealed a [AGE] year old man admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Malignant neoplasm of colon (colon cancer), gastrostomy status (presence of a Gastrostomy tube or G-tube which is a tube inserted through the abdominal wall into the stomach used to provide nutrition and hydration), colostomy status (presence of a colostomy, which is an opening in abdominal wall to divert stool from colon), pressure ulcer of sacral region Stage 4 (full-thickness skin loss exposing underlying tissue- also known as a bedsore- on the bony area of the lower back) and pressure ulcer of left heel. Record review of Resident #190's admission MDS assessment dated [DATE] revealed the resident was moderately impaired for daily decision-making skills and was dependent (helper does all the effort) for transfers and hygiene. Record review of Resident #190's Order Summary Report dated 03/19/2025 revealed the following: - Glucerna 1.5 at 70cc/HR x 22 hours daily via G-Tube every shift for Nutrition related to GASTROSTOMY STATUS. Record review of Resident #190's care plan revealed focus areas which included: resident requires tube feeding. Observation on 03/19/2025 at 03:20p.m. of Resident #190's medication administration via G-tube by RN - E, revealed RN-E did not wear a gown, only gloves when administering Resident #190's medication via his G-tube. Further observation revealed there was no EBP sign or PPE available outside Resident #190's door. During an interview with RN -E on 03/19/2025 at 03:35p.m., RN-E stated she though Enhanced Barrier Precautions was only needed when working with wounds or foley catheters. RN-E stated she thought EBP did not apply for G-tubes. RN-E further stated that the purpose of EBP was to prevent spread of infection when working with in-dwelling devices. RN-E said she has received training in infection control and Enhanced Barrier Precautions. 3. Record review of Resident #80's face sheet dated 03/20/2025 revealed an admitted [DATE] with re-admit on 02/07/2025 and with diagnoses which included: Essential hypertension (condition characterized by persistently high blood pressure without an identifiable underlying cause) Record review of Resident #80's Order Summary dated 03/20/2025 revealed an order for Losartan Potassium Oral Tablet 25MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION. Record review of Resident #12's face sheet revealed an admitted [DATE] with re-admit on 07/31/2022, with diagnoses which included: Essential hypertension (condition characterized by persistently high blood pressure without an identifiable underlying cause) Record review of Resident #12's Order Summary dated 03/20/2022 revealed an order for Carvedilol Tablet 25mg Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION hold for SBP <110 and pulse <50. Observation of medication pass on 03/20/2025 from 07:53 a.m. through 08: 25 a.m. revealed CMA-F checked Resident #80's blood pressure prior to administering her oral medications, and then proceeded to Resident #12's room, where she sanitized her hands, but did not sanitize the blood pressure cuff before checking Resident #12's blood pressure with the same cuff she had checked Resident #80's blood pressure with. During an interview with MA-F on 03/20/2025 at 08:31 a.m., MA-F stated she knew she was supposed to sanitize the blood pressure cuff in between uses with different residents, but just forgot. She stated that by not sanitizing equipment in between uses with different residents it could spread infection. MA-F stated she had received training in infection control. Interview with the DON on 03/20/2025 at 2:40pm revealed all blood pressure cuffs need to be sanitized in between uses with each resident to prevent the spread of infection. The DON further stated that Enhanced Barrier Precautions needed to be used when working directly with any resident who had an indwelling device, and this included G-tubes. The DON stated she will work to ensure each resident who has indwelling devices has an EBP sign placed on their door, and PPE supply outside the door. Record review of the facility policy titled Infection Control Program (undated) revealed In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub for all the following situations: a. Before and after direct contact with residents; .i. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident. 34788 4. Record review of Resident #198's face sheet, dated 03/20/2025, revealed an admitted [DATE], with diagnoses which included: Pneumonia (infection of the lungs), Hypertension (High blood pressure), Urinary tract infection (an infection in any part of the urinary system) and Gastrostomy status (tube inserted in the stomach for feeding). Record review of Resident #198's 5 days MDS assessment, dated 03/03/2025 revealed Resident #198 had a BIMS score of 15, indicating no cognitive impairment. Resident #198 was coded as always incontinent of bowel and had an indwelling catheter. Resident #198 required total care with his ADLs (Resident was completely dependent of the staff for his ADLs). Review of Resident #198's care plan, dated 2/14/2025, revealed a problem of The resident has an indwelling Catheter: Neurogenic bladder(Lack of bladder control due to brain, spinal cord, or nerve problems), with a goal of The resident will be/remain free from catheter-related trauma through review date. a. Observation on 03/20/2025 at 2:22 p.m. revealed while providing incontinent care for Resident #198, CNA A removed the soiled brief from Resident #198 and, without washing or sanitizing her hands, placed and fasten the new clean brief on Resident #198. During an interview with CNA A on 03/20/2025 at 2:37 p.m., CNA A verbally confirmed she did not wash or sanitize her hands, before touching the clean brief and fastening the brief to the resident. CNA A stated she should have washed or sanitized her hands prior to putting new gloves on and placing the new brief on Resident #198. She stated the staff received infection control training regularly. During an interview with the DON on 03/20/2025 at 3:56 p.m., the DON confirmed the CNA should have washed or sanitized her hands between changing her gloves, prior to placing the clean brief under the resident to prevent risk of cross contamination and prevent infection for the resident. She stated the staff received infection control training frequently and their skills were checked yearly. The DON revealed she and her ADONs were doing spot checks to check the skills of the staff. Review of facility's policy, titled Protecting Residents, employees and Visitors from Infectious Diseases, undated, revealed Use an alcohol-based hand rub [ .] before moving from a contaminated body site to a clean body site during resident care. b. Observation on 03/20/2025 at 02:22 p.m. of Resident #198's catheter care provided by CNA A and CNA B, revealed CNA A and CNA B did not wear a gown, only gloves when providing catheter care for Resident #198. Further observation revealed there was no EBP sign or PPE available outside Resident #198's door. During an interview with CNA B on 03/20/2025 at 03:51 p.m., CNA B revealed she was not aware Enhanced Barrier Precautions was needed when working with indwelling catheters. She was not sure she had received training regarding Enhanced Barrier Protection. During an interview with the DON on 03/20/2025 at 3:56 p.m., the DON confirmed EBP should be used for Resident #198 due to his indwelling catheter and Enteral feeding tube. DON further stated that the purpose of EBP was to prevent spread of infection when working with in-dwelling devices. The DON revealed training on EBP was provided to the staff. Record review of the facility policy titled Enhanced Barrier Precautions (undated) revealed EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. Further review revealed EBP are indicated for residents with any of the following: .Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.

Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 2 of 20 residents (Resident #20 and #62) reviewed for advanced directives, in that: 1. Resident #20's DNR was not signed twice by the physician. 2. Resident #62's DNR was not signed twice by the physician. These deficient practices could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings were: 1. Record review of Resident #20's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: fibromyalgia (long-term condition that involves widespread body pain and tiredness), hypothyroidism (condition in which thyroid gland does not produce enough thyroid hormone), and Covid-19. Further review of Resident #20's facesheet revealed, Advance Directive: DNR. Record review of Resident #20's annual MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. Record review of Resident #20's care plan, updated [DATE], revealed, Advance Directive: DNR. Record review of Resident #20's physician orders revealed an order dated [DATE], DNR. Record review of Resident #20's OOH-DNR form revealed it had been signed twice by the resident and two witnesses, but only signed once by the physician. Further review revealed the physician's signature was missing from the bottom of the form which instructions read All persons who have signed above must sign below, acknowledging that this document has been properly completed. 2. Record review of Resident #62's face sheet, dated [DATE] revealed an admitted [DATE] with re-admission on [DATE] and diagnoses which included: Chronic Obstructive Pulmonary Disease with acute Exacerbation (COPD) (a sudden worsening of respiratory symptoms in COPD which is a lung disease that blocks airflow and makes it difficult to breathe); Acute Respiratory Failure; Vascular Dementia (Problems with memory, reasoning, judgement and other though processes caused by brain damage from impaired blood flow to brain). Record review of Resident #62's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Record review of Resident #62's Care Plan revised [DATE] revealed a focus area for code status of DNR, and included intervention to Make sure code status is signed by appropriate parties and in the medical record Record review of Resident #62's Order Summary Report dated [DATE] revealed order for DNR - No CPR dated [DATE]. Record review of Resident #62's OOH-DNR revealed the resident signed the form on [DATE], the two witnesses signed the DNR form on [DATE], and the Physician signed the Physician statement on [DATE], but on the bottom of the form which reads All persons who have signed above must sign below, acknowledging that this document has been properly completed the Physician's signature is missing. During an interview with the Social Work Designee on [DATE] at 12:27 p.m., the Social Work Designee confirmed Resident #20's DNR was not signed twice by the physician and confirmed Resident #62's DNR was not signed twice by the physician. The Social Work Designee further confirmed that the missing signatures invalidated the documents and could result in the residents' end of life wishes being dishonored. Review of the facility policy, DNR, undated, revealed, While we are awaiting all the signature requirements for the OOH DNR . Review of the Texas Department of State Health Services (DSHS) website at https://www.dshs.texas.gov/sites/default/files revealed Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly. 41651

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 6 residents (Resident #42) whose assessments were reviewed, in that: Resident #42's quarterly MDS assessment incorrectly documented the resident as not receiving an antipsychotic medication. This failure could place residents at-risk for inadequate care due to inaccurate assessments. The findings were: Record review of Resident #42's face sheet, dated 03/19/2025, revealed an admitted [DATE] and, a readmitted [DATE] with diagnoses that included: Hemiplegia (Paralysis of one side of the body), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Bipolar disorder (Mental disorder characterized by periods of depression and periods of abnormally elevated mood) and Anxiety disorder (A group of mental illnesses that cause constant fear and worry). Record review of Resident #42's Physician orders and Medication administration record for February 2025 revealed an order for: Seroquel (an antipsychotic) Oral Tablet 200 MG(Quetiapine Fumarate) Give 1 tablet by mouth two times a day related to Bipolar Disorder. Resident #42 had received Seroquel in the month of February 2025. Record review of Resident #42's Quarterly MDS, dated [DATE], revealed the assessment indicated Resident #42 did not receive an antipsychotic. During an interview with the MDS coordinator on 03/21/2025 at 1:21 p.m., the MDS coordinator verbally confirmed Resident #42's quarterly MDS was coded as the resident not receiving an antipsychotic when Resident #42 had received Seroquel (an antipsychotic). The MDS coordinator revealed she did not know why the Seroquel was not coded as an antipsychotic. She verbally confirmed Seroquel was an antipsychotic and should have been coded as an antipsychotic. The MDS coordinator revealed the RAI was used as reference for the MDS and she had access electronically to the RAI on her computer. Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual,Version 1.18.11, October 2023, revealed, N0415A1. Antipsychotic: Check if an antipsychotic medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days)).

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for 1 (Resident #195) of 8 residents reviewed for Medication storage. 1. The facility failed to ensure Resident #195 did not have a jar of mentholated ointment (a topical analgesic and decongestant) at the bedside. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings included: 1. Record review of Resident #195's face sheet dated 03/18/2025 revealed a [AGE] year old man admitted to the facility on [DATE] with diagnoses which included: Congestive Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should); and COPD (Chronic Obstructive Pulmonary Disease; a chronic inflammatory lung disease that causes obstruction of airflow to the lungs with symptoms that include shortness of breath, chronic cough, wheezing and excess mucus production. Record review of Resident #195's Admission MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident #195's Order Summary dated 03/18/2025 revealed there was no order for mentholated ointment and no order stating he could self-medicate. Record review of Resident #195's Care Plan revealed no indication regarding his ability to self-administer his medications. Observation on 03/18/2025 at 11:12 a.m., during initial tour revealed Resident #195, was lying in his bed with a small jar of mentholated ointment in plain view on the resident's pillow. During an observation of Resident #195's room and interview with LVN-G on 03/18/2025 at 11:22 a.m., the jar of mentholated ointment was now in plain sight on Resident #195's bedside table. LVN-G stated that the jar of mentholated ointment should not be on Resident #195's bedside table or pillow, that he was not assessed as being able to self-medicate and the mentholated ointment was not one of his prescribed medications. LVN-G stated she had not seen the mentholated ointment in his room before and did not know where he had obtained it, but stated if it was left out, then either Resident #195 could possibly misuse it by placing it in his eyes or eating it, or another resident could walk by and take it. During an interview with the DON on 03/20/2025 at 2:31p.m., the DON stated that medicated over-the -counter medications should not be left out unsecured where residents could access them, as this could result in Resident #195 possibly misusing the medication or other residents accessing it. The DON stated this was not one of his prescribed medications and did not know how he had gained access to it, possibly his family brought it to him. Record review of the facility policy titled Storage of Medications (undated) revealed The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #195) of 3 residents reviewed for respiratory care. The facility failed to ensure Resident #195's used oxygen tubing and nasal cannula were disposed of and not left in the resident's room. This failure could place residents on respiratory therapy at risk for respiratory compromise and infection. Findings included: Record review of Resident #195's face sheet dated 03/18/2025 revealed a [AGE] year old man admitted to the facility on [DATE] with diagnoses which included: Congestive Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should); and COPD (Chronic Obstructive Pulmonary Disease; a chronic inflammatory lung disease that causes obstruction of airflow to the lungs with symptoms that include shortness of breath, chronic cough, wheezing and excess mucus production Record review of Resident #195's Admission MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident #195's Order Summary dated 03/18/2025 revealed orders including: -Change O2 tubing and humidifier PRN excessive soiling and weekly every night shift every Sun; and -May use oxygen @2L per NC to maintain sats >90% as needed Observation on 03/18/2025 at 11:12 a.m., during initial tour revealed Resident #195 lying in his bed, receiving oxygen via nasal cannula set at 2L. Further observation revealed there was a used humidifier bottle with a small amount of water left inside and connected tubing and nasal cannula sitting out on Resident #195's chest of drawers, with the tubing hanging down towards the floor. During an interview and observation with LVN-G on 03/18/2025 at 11:22 a.m., LVN-G stated that oxygen tubing and humidifier bottles should be changed once a week by night shift Nurses. If tubing and humidifier bottles are not changed regularly it could cause infection. LVN-G also stated that the used oxygen tubing and humidifier bottle should not have been left in Resident #195's room, as it could be a source of infection, but she noted Resident #195 will often become upset when staff try to remove equipment from his room. LVN-G attempted to remove the used oxygen tubing and humidifier bottle from the top of his chest of drawers, but Resident #195 became verbally upset, telling her not to take those items, they belonged to him. Interview with the DON on 03/20/2025 at 2:31p.m. revealed that oxygen tubing and humidifier bottles should be changed weekly and when needed, She stated not changing the tubing and humidifier bottle and properly disposing of the used oxygen tubing and humidifier bottle could result in growth of organisms and risk for infection. Record review of the facility policy titled Oxygen Administration revised 02/13/2007 revealed under the Goals section The resident will be free from infection. Further review revealed Change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to a meet resident's medical, nursing, mental, and psychosocial needs for 1 of 6 residents (Resident #36) reviewed for care plans, in that: The facility failed to develop a comprehensive person-centered care plan to address Resident #36's indwelling catheter care requirements. This deficient practices could affect residents who require an indwelling catheter by not having their needs met and putting them at risk of being inappropriately cared for. The finding were: Record review of Resident #36's face sheet, dated 03/21/2025, revealed the resident was admitted to the facility on [DATE] and, readmitted [DATE] with diagnoses that included: Dementia (decline in cognitive abilities), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hypertension (High blood pressure). Record review of Resident #36's Significant change MDS, dated [DATE], revealed the resident had memory problem and was severely cognitively impaired. The resident required total care with his activities of daily living. Further review revealed Resident #36 was coded as having an indwelling catheter and was always incontinent of bowel. Record review of Resident #36's Care Plan, revised 03/18/2025, revealed the resident was not care planned for indwelling catheter care. Observation on 03/21/2025 at 12:01 p.m. revealed Resident #36 had an indwelling catheter. During an interview with the MDS coordinator on 03/21/2025 at 1:21 p.m., The MDS coordinator confirmed Resident #36 had an indwelling catheter and should have been care planned for indwelling catheter care. She revealed not care planning the indwelling catheter could cause the resident to not receive the care she needed. Record review of the facility's policy titled, Care plan, comprehensive person-centered undated, revealed, A comprehensive, person centered care plan that includes measurable objective and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. [ .] The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 (Residents #188 and #195) of 8 residents reviewed for baseline care plans. 1. The facility failed to include Resident #188's risk for falls and epilepsy in his baseline care plan. 2. The facility failed to include Resident #195's oxygen therapy and wound care in his baseline care plan This failure could result in residents not receiving needed care and treatment. Findings Included: 1. Record review of Resident #188's face sheet dated 03/21/2025 revealed he was a [AGE] year-old man who was admitted to facility on 03/06/2025 with diagnoses which included: Epilepsy (a disorder where nerve cell activity in brain is disturbed causing seizures); alcoholic cirrhosis of liver (chronic liver damage leading the scarring and liver failure) and muscle weakness. Observation on 03/18/2025 at 09:42 a.m. in Hall 600, revealed a female resident coming into the hallway, yelling he fell , and pointing to Resident #188's room. Resident #188 was observed to be sitting on the floor next to his bed resting against the wall, with his wheelchair next to him. Facility staff immediately went to assess. Interview with Resident #188 on 03/18/2025 at 10:08 a.m. revealed that he stated that he fell because he had the wheels on his wheelchair turned wrong, but stated he had locked the brakes and can transfer himself to his wheelchair. He stated he did not use the call light for help because he can transfer by himself. Resident #188 stated that this was his second fall since he arrived at the facility, noting the first time he fell he got caught up in the leg supports of the wheelchair and fell . He stated they did x-rays and nothing was broken. Resident #188 stated he gets seizures sometimes, but that was not why he fell . Resident #188 stated after his first fall they moved his bed, started him on physical therapy and asked him to use his call light. Record review of Resident #188's 5-day MDS assessment dated [DATE] revealed a BIMS score of 14, indicating intact cognition and was assessed as needing partial/moderate assistance (helper does less than half the effort, helping to lift, hold or support trunk or limbs) for transfers and sit to stand. Record review of Resident #188's Care Plan initiated 03/11/2025 revealed there were no focus or problem areas that addressed his risk for falls, actual falls or epilepsy. Record review of the facility incident log revealed Resident #188 had a witnessed fall on 03/08/2025 and an unwitnessed fall on 03/18/2025. Interview on 03/21/2025 at 1:31 p.m. with the MDS Coordinator revealed that she was responsible for completing the initial, quarterly and annual Care Plans, but Nurse management, the DON, was responsible for revising the Care Plan for acute changes, such as falls or changes in health. The MDS Coordinator stated that Resident #188's falls and epilepsy should have been addressed in his Care Plan so that all staff had information on his care, and to coordinate his care. During an interview with ADON-E on 03/21/2025 at 2:11 p.m., ADON-E stated that all resident falls were reviewed and discussed by the team in morning meetings, and remembered Resident #188's falls were discussed by the team, and that they had agreed to have him evaluated by physical therapy, educated him on using his call light to ask for help, to make sure his call light was always in reach, and to provide him with non-slip socks. ADON-E further stated that his risk for falls and actual falls should have been addressed in his Care Plan. She noted that although his baseline care plan was completed before his first fall, it should have been revised to reflect his falls and epilepsy, to reflect changes that occurred prior to the development of his Comprehensive Care Plan. ADON-E stated that the DON was responsible for revising Care Plans for acute changes such as falls, however she noted the DON had just resigned the day before. ADON-E stated that not revising the Care Plan could result in residents not receiving the best possible care. 2. Record review of Resident #195's face sheet dated 03/18/2025 revealed a 77- year- old man admitted to the facility on [DATE] with diagnoses which included: Congestive Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should); and COPD (Chronic Obstructive Pulmonary Disease; a chronic inflammatory lung disease that causes obstruction of airflow to the lungs with symptoms that include shortness of breath, chronic cough, wheezing and excess mucus production Record review of Resident #195's EHR revealed his Admission MDS assessment was still in progress. Record review of Resident #195's Order Summary dated 03/18/2025 revealed orders including: -May use oxygen @2L per NC to maintain sats >90% as needed -Left buttock: Cleanse with dakin's [a wound care solution used to kill bacteria in and on the wound without damaging healing skin], pat dry, skin prep to peri-wound, apply hydrofera blue [an antibacterial wound care dressing], cover with hydrocolloid dressing [type of bandage that protects and promotes wound healing] every day shift every Tues, Thu, Sat - Right buttock: Cleanse with dakin's, pat dry, skin prep to peri-wound, apply hydrofera blue, cover with hydrocolloid dressing. every day shift every Tue, Thu, Sat Record review of Resident #195's Care Plan initiated 3/18/2025 revealed there was only one focus area RESISTANT TO CARE, in which oxygen therapy and wound care were mentioned, but only to the extent that he has a history of refusing wound care and refusing to allow staff to change his oxygen tubing. There were no focus areas regarding his need for oxygen therapy and skin impairment, to include interventions specifically addressing those areas of need. Observation on 03/18/2025 at 11:12 a.m., during initial tour revealed Resident #195 lying in his bed, receiving oxygen via nasal cannula set at 2L. There was no date written on the tubing or humidifier container. Further observation revealed there was a used humidifier bottle with a small amount of water left inside and connected tubing and nasal cannula sitting out on Resident #195's chest of drawers, with the tubing hanging down towards the floor. Interview with LVN-G on 03/18/2025 at 11:22 a.m. revealed Resident #195 had only been at the facility a few weeks, but she stated that he has used oxygen therapy since he arrived and is often resistant to his oxygen tubing and humidifier bottle being changed out and removed from his room. LVN-G further stated Resident #195 was usually compliant with using the oxygen, he just didn't want anything removed from his room. During an interview with the MDS Coordinator on 03/21/2025 at 1:31 p.m., the MDS Coordinator stated Resident #195's Baseline Care Plan was completed within 48-hours and could be found under the assessment tab in EHR, but also stated his Baseline Care Plan did not include his use of oxygen or need for wound care, and stated these needs should have been included in his Baseline Care Plan. The MDS Coordinator stated she did not know how it was missed, but not having these needs addressed in his Care Plan could result in him not having all his minimum health care needs being addressed. Record review of facility policy titled Care Plans-Baseline (undated) revealed The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatment, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician Orders; c. Dietary orders; d. Therapy services, e. Social services .

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. Access to the handwashing sink was blocked by two rolling carts. 2. There was a sand-like substance on top of the dish sanitizing machine. These deficient practices could result in residents consuming meals and/or snacks prepared in an unsanitary manner. The findings were: Observation on 03/18/2025 at 10:25 a.m. revealed that the hand-washing sink in the kitchen was blocked by a rolling cart with plate covers in front of the sink and a rolling cart with food trays next to it. During an interview with the Dietary Manager on 03/18/2025 at 10:27 a.m., the Dietary Manager stated the rolling carts should not have been stored in a manner which blocked access to the handwashing sink. The Dietary Manager further stated that kitchen staff moved the carts prior to washing their hands, and then put the carts back in front of and beside the sink. Observation on 03/21/2025 at 10:28 a.m., revealed the presence of numerous sand-like particles on top of the dish sanitizer machine. Further observation revealed the machine was accessed via a side cover which slid up and down and came into contact with the sand-like particles and could potentially cause the particles to come into contact with dishes and utensils utilized to prepare and serve meals and snacks for residents. During an interview with the Dietary Manager on 03/21/2025 at 10:28 a.m., the Dietary Manager confirmed the presence of numerous sand-like particles on top of the dish sanitizer machine, and confirmed the particles could potentially come into contact with dishes and utensils utilized to prepare and serve meals and snacks for residents. During an interview with the Administrator on 03/21/2025 at 2:50 p.m., the Administrator stated the facility did not have a policy regarding Dietary Services.

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 beauty shop reviewed, in that: The beauty shop was unlocked and contained potentially dangerous materials. This deficient practice could result in residents, staff, and visitors living, working, and visiting in a potentially dangerous environment. The findings were: Observation on 03/21/2025 at 11:28 a.m. revealed the facility beauty shop was unlocked. Further observation revealed a container of liquid labeled [Brand] Disinfectant, Fungicide, Virucide - Danger Keep Out of Reach of Children and an open tube of hair dye labeled Danger Combustible Liquid. Causes severe skin burns and eye damage. Causes serious eye damage on top of a counter in the beautician shop. During an interview with MA C on 03/21/2025 at 11:29 a.m., MA A confirmed the presence of the disinfectant liquid and hair dye and confirmed that materials with warning labels should not be accessible, so that residents, staff, and the public do not come into contact with potentially dangerous materials. During an interview with the Administrator on 03/21/2025 at 2:50 p.m., the Administrator stated it was the responsibility of all staff to ensure the beauty shop was locked and confirmed that materials with warning labels should not be accessible, so that residents, staff, and the public do not come into contact with potentially dangerous materials. During an interview with the Administrator on 03/21/2025 at 2:50 p.m., the Administrator stated the facility did not have a policy regarding Physical Environment.

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents hazards and supervision, in that: On 01/10/2025 Resident #1 was transferred by CNA A using standing pivot transfer x 1 staff instead of a mechanical lift. During transfer Resident #1 was injured resulting in left tibia /fibula fracture. The non-compliance was identified as past non-compliance. The IJ began on 1/10/25 and ended on 1/13/25. The facility had corrected the non-compliance before the survey began. This failure could lead to injury or death to residents. Findings included: Record review of Resident #1's face sheet, dated 01/30/2025, reveled an [AGE] year old female admitted to the facility on [DATE] with diagnoses that included right below the knee amputation (surgical procedure that removes the lower leg below the knee joint), Osteoporosis (a bone disease characterized by a disease in bone mineral density and bone mass, resulting in weak and brittle bones that are more prone to fractures), and Vitamin D deficiency (the state of having inadequate amounts of vitamin D in your body). Record review of Resident #1's Quarterly MDS assessment, dated 10/23/2024, reflected a BIMS of 4 which suggested severe cognition impairment. Section G revealed Resident #1 required extensive assistance with 2 persons for transfers. Record review of Resident #1's Care Plan, dated 05/2/2021 and revised on 06/02/2024, revealed Resident #1 required a mechanical lift X 2 staff assist for all transfers. Record review of the Provider Investigation Report, dated 01/16/2025, related to the facilty's self-report of Resident #1's injury on 01/10/2025, revealed on 01/10/2025 at 2:00 PM, [CNA A] transferred [Resident #1] from the chair to the bed and heard a popping noise. [Resident #1] voiced her leg hurt. Further review revelaed Resident #1 was noted to have an abnormality to the left shin area., and the resident was transferred to the hospital for treatment. Record review of the Investigation Summary revealed, on 1-13-24 the facility found that [Resident #1's] hospital x-ray revealed an acute left mid tibial diaphyseal fracture with significant anteromedial displacement, acute left proximal and distal fibular diaphyseal minimally displaced olbique fractures, segmental. Extensive diffuse bone demineralization by x-ray/osteoporosis and degenerative changes. Records review confirmed that [Resident #1] is care planned for a [mechanical lift] transfer. Staff interivews revealed no issues with [Resident #1] prior to transfer from chair to bed. Interview with [CNA A] revealed that [CNA A] transferred [Resident #1] without the use of a [mechanical lift] and conducted a single person transfer. [CNA A] stated that she had used the [mechanical lift] previously when transferring [Resident #1] and was aware it was on her plan of care. Further review revealed CNA A's employment with the facility was terminated post-investigation. Record review of CNA A's written statement, dated 1/10/25 at 3:00 PM, reflected, I transferred [Resident #1] from her wheelchair to her bed via pivot X 1 staff member, when resident told me her noted abnormality to left shin. Record review of Incident Report, dated 01/10/2025 at 1:56 PM, revealed, This nurse was called into residents' room by Charge Nurse, left lower extremity assessed and [Resident #1] was able to state where pain was and 911 was called. Record review of hospital records for Resident #1, dated 01/11/2025 at 12:01 PM, revealed Resident #1 had a surgical intervention requiring a left tibia intramedullary nail for shaft fracture and closed management with manipulation left fibula fracture. During an Interview with the DON on 01/30/2025 at 10:10 AM, the DON stated CNA A should have transferred Resident #1 using 2 staff members with a mechanical lift as per Resident #1's Care Plan. The DON also stated that by CNA's not following the care plan injury to residents may occur. An interview with CNA A was attempted on 01/30/2025 at 11:12 AM but was not successful. A voicemail was left for call a back. CNA A did not call back. Record review of the facility's policy titled, Assistive Devises and Equipment, undated, revealed, Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the president's plan of care. The Administrator was notified on 01/31/2025 at 12:30 PM, that a past non-compliance IJ situation had been identified due to the above failure and an IJ Template was provided to the Administrator. The facility implemented the following interventions prior to the survey entrance on 01/28/2025. During an interview with the DON on 1/28/25 at 3:20 PM, the DON stated the facility put a system into place for agency staff / PRN (as needed) to review forms prior to their shift to identify the care needs of each resident. Record review of in-service training titled, Always Follow POC (Plan of Care), dated 01/10/2025 to 01/13/2025, revealed 50 of 50 staff members, 1 of 1 agency staff, and 10 of 10 PRN staff (as needed) completed the in-service training. Further revealed the in-service training addressed: CNA's look at Kardex, Hoyer's have to use if indicated 2 person, where to find POC (Plan of Care), competencies and demonstration of mechanical lift transfers. Interviews with 12 staff members on 01/30/25 from 10:00 a.m. to 12:00 p.m. the following staff (MA B, LVN C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, LVN K, LVN L, LVN M) confirmed completion of in services/training: Always Follow POC (Plan of Care), CNA's look at Kardex, mechanical lifts have to use if indicated 2 people, where to find POC (Plan of Care. Staff were able to verbalize understanding and information provided in the in-service/training. During an Interview with the DON on 1/30/25 at 10:20 AM, the DON confirmed CNA A was terminated from employment at the facility on 1/17/25. Observation on 01/31/25 at 7:30 AM confirmed MA B and LVN C transferred Resident #3 using a two-staff mechanical lift transfer. Observation on 1/31/25 at 8:30 AM confirmed MA B and LVN C transferred Resident #4 using a two-staff mechanical lift transfer. The non-compliance was identified as past non-compliance. The IJ began on 1/10/25 and ended on 1/13/25. The facility had corrected the non-compliance before the survey began.

Based on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facilities reviewed for nursing services. The facility did not have RN coverage for 24 days on 10/5/24, 10/12/24, 10/13/24, 10/20/24, 10/26/24, 10/27/24, 11/16/24, 11/17/24, 11/23/24, 11/24/24, 11/30/24, 12/1/24, 12/7/24, 12/8/24, 12/14/24, 12/15/24, 12/21/24, 12/22/24, 12/28/24, 12/29/24, 1/4/25, 1/5/25, 1/18/25, and 1/19/25. This failure could place the residents at risk of not receiving needed care and services. The findings were: Review of the facility RN timesheets revealed there were no RN hours for Saturdays on 10/5/24, 10/12/24, 10/26/24, 11/16/24, 11/23/24, 11/30/24, 12/7/24, 12/14/24, 12/21/24, 12/28/24, 1/4/25, and 1/18/25. Review of the facility RN timesheets revealed there were no RN hours for Sundays on 10/13/24, 10/20/24, 10/27/24, 11/17/24, 11/24/24, 12/1/24, 12/8/24, 12/15/24, 12/22/24, 12/29/24, 1/5/25, and 1/19/25. In an interview on 1/31/25 at 9:58 a.m. the DON stated the facility did not currently have a designated weekend RN but ADON's do cover some shifts on the weekends but not all. The DON was unsure if there was an active job posting for an RN on the weekends. In an interview on 1/31/25 at 5:23 p.m. the DON stated the facility was actively seeking an RN specifically for weekends and the job was posted online. The DON stated the facility did not have any nursing waivers and the possible consequences for not having a weekend RN would be not having the services of an RN onsite on the weekends. In a telephone interview on 1/31/25 at 5:27 p.m. the Administrator stated she was not aware the facility was missing RN coverage for that many days. The Administrator further stated an ADON who was an RN was covering some of the weekend shifts. Review of the facility policy on staffing coverage undated revealed . A Registered Nurse (RN) must be onsite 8 consecutive hours a day, 7 days a week .

Based on interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent elopements for 2 of 5 residents (Residents #1 and #2) reviewed for accidents and supervision, in that: 1. The facility failed to provide adequate supervision to Resident #1. As a result, Resident #1, who had dementia, eloped from the facility on 5/7/2024 and was unaccounted for after approximately 5:45 pm. Resident #1 was discovered to be walking approximately 4 blocks from the facility near a busy street at approximately 6:10 PM. The weather for that day at around that time was in the upper 80s F and Resident #1 was purported to say she was thirsty and lost and was seen to be visibly perspiring. 2. The facility failed to provide adequate supervision to Resident #2. As a result, Resident #2, who had Alzheimer's Disease, eloped from the facility on 5/3/2024 and was unaccounted for after approximately 5:15 PM. The facility was notified by law enforcement on 5/4/2024 the resident was discovered to be with a family member who did not have consent by Resident #2's responsible party to be discharged from the facility. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 5/10/2024 at 5:55 PM. While the immediacy was removed on 5/12/2024 at 5:27 p.m., the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to monitor the implementation of the plan of removal. This failure placed all residents at risk for serious injury, harm, and/or death due to lack of appropriate supervison. Findings included: 1. Record review of Resident #1's face sheet revealed she was admitted on [DATE] and was [AGE] years old. Resident #1's diagnoses included: tachycardia (When you have tachycardia, your heart beats too fast -- more than 100 beats per minute when you're at rest), and dementia. Record review of Resident #1's electronic chart revealed no care plan. Record review of Resident #1's MDS (Entry 5/7/2024) revealed no BIMs score. Record review of Resident #1's electronic chart, under Assessments, revealed a document titled, Elopement Risk - Change of Status, dated 5/7/2024. Further review revealed Resident #1 was at risk for elopement with a score of 12 (High Risk), specifically that she, Verbalizes desire or plan to leave the facility unauthorized/unsupervised (10 pts.), and, Ambulatory (2 pts.) Record review of Resident #1's Progress Note, dated 5/7/2024 at 7:19 PM, stated,**Nurses Note** Note Text: Notified RP and Physician of (Resident #1's) elopement. RP was thankful resident is ok and moving to memory care. Resident and belongings moved to memory care per (ADON K).[sic] Record review of Resident #1's Progress Note, dated 5/7/2024 at 7:57, stated Skin/Wound Note Text: Weekly skin assessment completed. Noted: No current skin concerns noted. Finger nails are clean neat and trimmed. Toe nail are neat, clean and trimmed. Yes pain medication available. [sic] Record review of the facility's Incident's and Accidents report, printed 5/9/2024, revealed no documented incidents related to Resident #1, specific to elopement. Record review of a website, [Name of City] Weather History | Weather Underground (wunderground.com), revealed the temperature for 5/7/2024 at 5:15 PM was approximately 89 F. Observation on 5/9/2024 at 11:28 AM - Hall 100's entry/exit door opened without delay and the alarm did not sound. A photograph and video taken were recorded at this time. Interview and observation on 5/9/2024 at 11:29 AM. the Maintenance Aide confirmed the door on the end of hall 100 readily opened and no alarm sounded. The Maintenance Aide proceeded to depress a switch located at the top of the door frame which successfully armed the door alarm. The Maintenance Aide was asked if he understood the concern and responded that, You wouldn't know when a resident might walk off. The Maintenance Aide was asked why the door alarm was not armed and responded that staff may have been taking out the trash. When asked if any residents had recently left the facility without assistance, the Maintenance Aide responded that he was not aware. Interview on 5/10/2024 at 1:38 PM, the Administrator said some residents do sit on the front patio when accompanied by staff or family members and said the facility now ensures there is always someone at the front desk until the evening when the door locks but said prior to Resident #1's elopement, the front desk staff would take residents to the smoking area during smoke breaks. The Administrator said that her office and several other offices were near the front door as a back up to when the front door monitor would assist during smoke breaks. The administrator said there had been one family member that would shut off a door alarm on occasion and said she has talked to the family member about the concern and has staff checking the daily to ensure the door alarms are armed. Interview on 5/10/2024 at 2:32 PM, Resident #1's Responsible party stated he was not with Resident #1 when she eloped but said she was now in memory care where she belongs. Telephone interview on 5/10/2024 at 2:40 PM, LVN A stated she had just arrived at the facility after Resident #1 had eloped. LVN A stated she was told to do another elopement risk assessment for Resident #1 following her elopement. LVN A said the person who found Resident #1 was an LVN C who had just ended her shift and discovered the resident walking. Interview on 5/10/2024 at 3:50 PM, MA B said it was around 6:00 pm on 5/7/2024 when staff discovered Resident #1 was missing. MA B said LVN K got a phone call and then started pacing around looking out the windows. MA B said she saw Resident #1 walking through the grass in someone's yard approximately 4 blocks away from the facility near a busy street where 18 wheelers travel at a high rate of speed. MA B said Resident #1 recognized her and got in the car with her to go back to the facility. MA B Resident #1 was sweating and looked tired and said she didn't know where she was, that she was lost. Upon returning to the facility, MA B got the Resident #1 a glass of water. MA B said a high school-aged family member of one of the dietary staff the reported she saw Resident #1 depart the facility from the front door after she noticed the resident being returned to the facility. When asked if anyone was monitoring the front door at the time of Resident #1's disappearance, MA B said the front door monitor would take the residents to a different location during their designated smoke break and said that it's always a big hassle. MA B said it was warm that day and that her .car's temperature gauge showed the temperature was 91 F after her shift ended that day. When asked how staff would be informed of the identity of new residents, MA B said she was unsure and that some residents are admitted at random times, and stated that it was difficult to identify newly admitted residents. 2. Record review of Resident #2's facesheet (printed 5/8/2024) revealed she was admitted [DATE] and discharged [DATE] and was [AGE] years of age. Resident #2's diagnoses included: senile degeneration of the brain (also known as Senile dementia is the mental deterioration (loss of intellectual ability), Alzheimer's disease, copd, depression, insomnia, hypertension, gastro-esoph reflux, and an over-active bladder. Record review of Resident #2's electronic chart, MDS (entry), dated 4/29/2024) revealed no BIMs Score. Record review of Resident #2's electronic chart revealed no careplan. Record review of Resident #2's progress note on date, 5/3/2024 at 10:00 AM, stated, Late Entry: Note Text: Received call from (biological family member) of (Resident #2) requesting to speak to and come visit resident at facility. This nurse placed call to RP, spouse, whom gave verbal permission for son to speak to and visit resident inside facility.[sic] Record review of Resident #2's progress note dated, 5/3/2024 at 5:41 PM, stated, Late Entry: Note Text: Notified by staff that they were unable to locate (Resident #2) after dinner. This nurse along with other ADON and staff attempted to locate (Resident #2). Per charge nurse, (Resident #2's biological family member) was in the facility and given permission by RP to visit with (Resident #2) inside facility. Called RP and informed resident was not able to be located. Called number for (Resident #2's biological family member) given by RP. Was informed it was the wrong number. Police notified and in facility. CNA stated she witnessed son in the facility with a bag of (Resident #2's) belongings. All belongings gone from room. Notified by another staff member that she witnessed (Resident #2) walking down the hall hand in hand with (Resident #2's biological family member). All this information given to RP and police officer in facility. Administrator, PCP, and RP updated on current situation. Late Entry: Note Text: (Resident #2) was reported possibly missing at 1715 to this nurse by CNA as she was attempting to serve her dinner. This nurse notified ADON immediately and began checking every room in the north wing. This nurse checked residents closet and clothes were gone. Record review of Resident #2's progress note dated 5/3/2024 at 8:42 PM stated, Note Text: Reported to (RN L) regarding incident with (Resident #2). (RN M) Executive Director called to confirm and asked that this facility f/u with any new information. Record review of Resident #2's progress note dated 5/4/2024 at 2:34 PM, stated: Late Entry: Note Text: At approximately 1:45 PM on 5/4/24 I received a call from (Off N) in regard to (Resident #2). Case # 2400898/ [PHONE NUMBER](phone #). He stated that (Resident #2) is safe and is with (Resident #2's biological family member). (Resident #2) has been checked out by the local EMS personnel and is in good health and spirits. He also stated all missing person's bulletins have been cancelled. There will not be any kidnapping charges filed nor any other charges since she is with (Resident #2's biological family member). Number to Hospice provided per his request. (Off N) stated (Resident #2's biological family member) has already obtained all her medications as well. Record review of a document, titled, Medical Power of Attorney Designation of Healthcare Agent, signed by Resident #2 on 11/15/2023, revealed the Resident #2's (biological family member) was designated as First Alternate Agent. Record review of the facility's Incident's and Accidents report, printed 5/3/2024, revealed no documented incidents related to Resident #2, specific to elopement. Interview on 5/13/2024 at 2:48 PM, the Administrator statedResident #2 was removed from the facility by biological family member 5/3/2024, and was subsequently taken to his home. The Administrator indicated there was an ongoing family dynamic between the biological family of Resident #2 and the non-related children of her husband. The Administrator stated the police were called by the facility when they discovered Resident #2 was missing. The Administrator stated Resident #2 was no longer residing at the facility and her RP was issued a reimbursement. Interview on 5/13/2024 at 3:40 PM, Witness, LVN C said she was at the facility at the time Resident #2 left the facility. LVN C said she was asked by staff if she had seen Resident #2 pass her as Resident #2 was unable to be located. LVN C said she spoke to the a police officer near (Resident #2's biological family member's home) the following day and said Resident #2 had been assessed by EMS and had no injuries, was not in distress, and was with (Resident #2's biological family member) and was safe. LVN C said police informed her the case was cancelled and asked for the Resident #2's hospice information and spoke to her hospice agency. LVN C said on the day of the incident, (Resident #2's biological family member) was visiting. LVN C said Resident #2's dementia was getting progressively worse which was why she was admitted to the facility. When asked why the (Resident #2's biological family member) wasn't on the resident's face sheet as a contact she said it was likely because her (non-biological family members) were involved with placing Resident #2 at the facility. Interview on 5/13/2024 at 3:55 PM, ADON E, stated the facility was contacted by a nurse (name unknown) who said Resident #2 was not in her room and her room was empty. ADON E said staff made all necessary notifications and said one of the staff said they saw Resident #2 walking down the hall, holding hands. ADON E further stated another staff, CNA G, was said to have seen the (Resident #2's biological family member) walking out of the facility with a large bag. Telephone interview on 5/13/2024 at 4:02 PM, Resident #2 Emergency Contact said Resident #2 was taken illegally, and was said to still be residing with (Resident #2's biological family member) Interview on 5/13/2024 at 4:11 PM, CNA G said she saw (Resident #2's biological family member) come into the facility and was visiting the Resident #2. CNA G said she left Resident #2's room to allow them privacy during their visit and said she later saw (Resident #2's biological family member) leaving the facility with a big blue bag but said she did not think anything of it because residents' families would frequently take their clothing home to wash it. The CNA G said Resident #2 was pretty new at the time and said some staff may not have been aware of her identity. Telephone interview on 5/14/2024 at 9:44 AM, (Resident #2's biological family member) confirmed Resident #2 was with him and said she was currently at the hospital because she had blood on her brain, and that doctors are trying to dissolve it. When asked why he took Resident #2 from the nursing home (Resident #2's biological family member) responded, because she didn't want to be there. (Resident #2's biological family member) further stated that Resident #2's RP, .put her in the facility without her (biological family's) consent, and that Resident #2's RP, . took all of her belongings and sold them or gave them away. Interview on 5/14/2024 at 10:47 AM, the Administrator stated Resident #2 was not signed out of the facility prior to her leaving the facility and said Resident #2's RP and non-biological children requested a refund from the facility. Telephone interview on 5/14/2024 at 11:35 AM, Resident #2's Responsible Party revealed he had not talked to Resident #2 since she left the facility with (Resident #2's biological family member) The RP said Resident #2's biological family, .are crazy sons' of bitches. The RP further stated Resident #2 had Alzheimer's disease, that she had, good days and bad days, that they had been married over [AGE] years and, .she is the love of my life. The RP stated Resident #2's hospice agency had filed a report with Adult Protective Services. Interview on 5/14/2024 at 4:30 PM, the facility's Social Worker stated the facility had a protocol for residents leaving the facility which included checking with the charge nurse, documenting the time and who the resident is leaving with, and ensuring authorization with the resident's responsible party. Interview on 5/14/2024 at 4:32 PM, Health Screener (HS) J stated she was monitoring the facility's front door during the time and date of Resident #2's elopement. HS J said her job was to greet and screen individuals entering and exiting the facility. HS J said that during the time of Resident #2's elopement, she was monitoring residents in a different location, the smoking area, and returning them to their rooms afterward. HS J said the front entrance was not being monitored during this time but said there had been recent changes requiring staff to be at the front door at all times while the entrance is unlocked. Interview on 5/14/2024 at 4:50 PM, ADON E was asked why where Resident #2 resided and said Resident #2 was on 500 Hall. When asked why Resident #2 was not in a secured unit given her Elopement Assessment indicated she was at risk, ADON E responded that Resident #2 did not present with a history of exit seeking or wandering behaviors. Record review of website, Elopement in Nursing Homes: Resident Elopement Risks (nursinghomesabuse.org), stated, According to the Alzheimer's Association, elopement or wandering are common issues among the elderly who have conditions such as Alzheimer's disease or other types of dementia. Residents who wander may have mental impairments and be unable to return home once they find themselves outside the facility. They may be confused about where they are or where they are going. For those with Alzheimer's disease, it is predicted that six out of 10 people will wander and become lost. Wandering can happen at any stage of Alzheimer's disease, early, middle, or late. Problematically, since people with Alzheimer's disease, mental impairments, or dementia may be confused about their location or other information, those who are not found within 24 hours are at a high risk of getting hurt or passing away. The Administrator was notified of an IJ on 5/10/2024 at 5:55 PM and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 5/12/2024 at 5:27 PM and included the following: 1. On 5-10-2024 at approximately 5:55pm (This Nursing Facility) was notified by an HHSC employee the facility was in Immediate Jeopardy (IJ) with an allegation of Supervision (F689) noncompliance. The surveyor provided an Immediate Jeopardy (IJ) Template notification via email that the Regulatory Services has determined that Immediate action is required to ensure residents are safe and provided correct supervision. Action: R1 was immediately assessed on 5/10/24, currently resides in the secure unit, elopement assessment reflects high risk and BIMs was completed on 5/10/24. 2. On 5/10/24 Maintenance checked all facility alarms for proper functioning, all alarms working at this time. 3. Residents that reside outside in the general population not the secure unit with diagnosis of Dementia were immediately assessed to make sure they were not an elopement risk and Elopement assessment completion. One was identified as being a potential for elopement, ADON immediately called physician and RP for consent to move to secure unit for safety and supervision. 4. On 5-10-24 the Administrator / or designee immediately in-serviced staff on Elopement policy those staff that did not attend in person or via phone for in-service will be in-service before the start of the next assigned shift. 5. On 5/10/24 Administrator in-service staff on door alarms in the secure unit and non-secure unit to make sure the staff know how to identify if they are properly working and the sound of the alarm when someone opens the door and attempts to exit, main front door, times were revised when they are locked and unlocked for safety. 6. When the receptionist goes on break or leaves the front check another team member will sit and monitor the entrance/ exit during business hours. After hours, the front doors are locked through a maglock system. All residents will be identified using the Electronic Health Record (EHR) face sheets that include a photo, it will be updated by activities staff. Visitors will be requested to sign in and out for staff to verify and monitor who comes in and out of the facility. 7. On 5/10/24 Social services designee and admission nurses were in-service by Administrator on completing BIMS once a new resident admits to the facility. Observations, interviews, and record reviews (5/11/2024-5/12/2024) included: Observation on 05/11/2024 at 9:00 AM revelaed no residents were seen outside of the facility or in the parking lot, no residents were seen in the back of the facility or in the bridge area between the two building, and the front door was locked and the Receptionist were seen behind desk. Further observation revealed the Receptionist opened the door, and one resident was seen in the dining room, listening to music. Observation on 05/12/2024 at 9:30 AM revealed no residents were seen outside. Futher observation around the facility outside did not reveal any resident outside without supervision. Interview with the Administrator on 05/12/2024 at 9:45 AM, the Administrator stated all the doors were alarm and the staff were doing the rounds every shift to check there alarms were working. The Administrator stated, all BIMS have been audited as well as elopement risk and one resident who was previously in the locked unit was moved back in the locked unit as a preventive measure and the family agreed. Everybody who has been on shift since the elopement has been in-serviced Some were in-serviced by phone. Some they are still trying to get in the facility or reach by phone to in-serviced them. Record review of Resident #1's electronic medical record revealed a Brief Interview for Mental Status (BIMS) was commpleted with the resident's family member on 5/10/2024 and the score was 1, which indicated severe cognitive impairment, with inattention fluctuating. Further review revealed an elopement risk assessment was completed on 05/07/2024 with a score of 12, which indicated high risk for elopement. Resident located in 300 hall which is the locked unit. Record review of the facility's alarm door log revealed: - 5/10/24 at 3:50 PM Maintenance Director checked a total of 8 doors on North unit that require alarms. All 8 doors were armed and working status - 5/10/24 at 4:20PM Maintenance director checked 9 doors in south building with alarms and 2 outside gate with Maglocks and all alarms were working. Both gates were armed and locked. Rounds have been made since then q shift and at night to insure alarms are on. Per Administrator she is planning to change all the exiting alarms to alarms with keys. The keys will stay on the nurses key ring. That is for all doors that should not be used as exit. Everybody would then have to always exit by the front. Observation on 05/12/2024 at 11:30 AM, during a tour of the facility, revealed no residents were seen outside without supervision, alarms were working when doors were opened, all doors to the outside were alarmed and those alarms were working, and the fenced area had maglocks in place and locked. Further observation revealed the Receptionist was seen making visitors sign in and out, and a resident who was going on pass with family was not let out before their family was present. Interview with Health Sceener J on 05/12/2024 at 12:49 PM, Health Screener J stated she had received the in-service training on 5/10/2024 which included that statff had to greet the guest and make them sign and out, use face sheet with picture to identify staff, and to never leave the desk without someone to take their place. Health Screener J stated when their shift was done at 8:00 PM they were to tell the nurse they were living and lock the door and engage maglock and alarm. Interview with CNA/RNA M on 05/12/2024 at 12:55 PM, CNA/RNA M stated she was to tell a nurse if any seeking behaviors were noted from residents, to make sure all alarms were always working and doors were closed, and to be aware of alarms going off and to go see why an alarm was going off. CNA/RNA M was able to verbalize what to do to prevent elopement and what to do when someone was missing. Interview with with CNA N on 05/12/2024 at 1:00 PM, CNA N stated she was in-serviced to be aware of residents with seeking behaviors and alert the charge nurse if someone trying to get out, and to be aware of alarms and go see why an alarm was ringing. CNA N stated she was also traing to make sure alarms were working and door were closed. Interview with with HC M on 05/12/2024 at 1:10 PM, HC M stated she received in-service training regarding elopement procedures, including elopement prevention and what to do if somebody elopes, and door alarms, including checking the door alarms and answering them. HC M was asked about any resident, not in the locked unit, they may suspect to be at risk for elopement or exit seeking and no resident was named. HC M stated all of the at risk residents were in the locked unit. HC M revealed they knew to report to their nurse about any resident trying to exit the building, and they knew the residents had to sign in and out if they were going on pass or appointment. Interview with with HC N on 05/12/2024 at 1:15 PM, HC N stated she received in-service training regarding elopement procedures, including elopement prevention and what to do if somebody elopes, and door alarms, including checking the door alarms and answering them. HC N was asked about any resident, not in the locked unit, they may suspect to be at risk for elopement or exit seeking and no resident was named. HC N stated all of the at risk residents were in the locked unit. HC N revealed they knew to report to their nurse about any resident trying to exit the building, and they knew the residents had to sign in and out if they were going on pass or appointment. Interview with with KA O on 05/12/2024 at 1:25 PM, KA O stated he received in-service training regarding elopement procedures, including elopement prevention and what to do if somebody elopes, and door alarms, including checking the door alarms and answering them. KA O was asked about any resident, not in the locked unit, they may suspect to be at risk for elopement or exit seeking and no resident was named. KA O stated all of the at risk residents were in the locked unit. KA O revealed they knew to report to their nurse about any resident trying to exit the building, and they knew the residents had to sign in and out if they were going on pass or appointment. Interview with with DA P on 05/12/2024 at 1:30 PM, DA P stated she received in-service training regarding elopement procedures, including elopement prevention and what to do if somebody elopes, and door alarms, including checking the door alarms and answering them. DA P was asked about any resident, not in the locked unit, they may suspect to be at risk for elopement or exit seeking and no resident was named. DA P stated all of the at risk residents were in the locked unit. DA P revealed they knew to report to their nurse about any resident trying to exit the building, and they knew the residents had to sign in and out if they were going on pass or appointment. Interview with with DA Q on 05/12/2024 at 1:32 PM, DA Q stated she received in-service training regarding elopement procedures, including elopement prevention and what to do if somebody elopes, and door alarms, including checking the door alarms and answering them. DA Q was asked about any resident, not in the locked unit, they may suspect to be at risk for elopement or exit seeking and no resident was named. DA Q stated all of the at risk residents were in the locked unit. DA Q revealed they knew to report to their nurse about any resident trying to exit the building, and they knew the residents had to sign in and out if they were going on pass or appointment. Interview with with PHT R on 05/12/2024 at 1:35 PM, PHT R stated he received in-service training by phone on 05/11/2024 which was regarding elopement procedures, including elopement prevention and what to do if somebody elopes, and door alarms, including checking the door alarms and answering them. PHT R was asked about any resident, not in the locked unit, they may suspect to be at risk for elopement or exit seeking and no resident was named. PHT R stated all of the at risk residents were in the locked unit. PHT R revealed they knew to report to their nurse about any resident trying to exit the building, and they knew the residents had to sign in and out if they were going on pass or appointment. Interview with with LVN K on 05/12/2024 at 1:40 PM, LVN K stated she received in-service training regarding elopement procedures, including elopement prevention and what to do if somebody elopes, and door alarms, including checking the door alarms and answering them. LVN K was asked about any resident, not in the locked unit, they may suspect to be at risk for elopement or exit seeking and no resident was named. LVN K stated all of the at risk residents were in the locked unit. LVN K revealed they knew to report to their nurse about any resident trying to exit the building, and they knew the residents had to sign in and out if they were going on pass or appointment. LVN K further stated they had received in-service training for new admissions BIMS as well as elopement and alarms. Interview with with CNA S on 05/12/2024 at 1:50 PM, CNA S stated she received in-service training regarding elopement procedures, including elopement prevention and what to do if somebody elopes, and door alarms, including checking the door alarms and answering them. CNA S was asked about any resident, not in the locked unit, they may suspect to be at risk for elopement or exit seeking and no resident was named. CNA S stated all of the at risk residents were in the locked unit. CNA S revealed they knew to report to their nurse about any resident trying to exit the building, and they knew the residents had to sign in and out if they were going on pass or appointment. Interview with with DA T on 05/12/2024 at 1:55 PM, DA T stated she received in-service training regarding elopement procedures, including elopement prevention and what to do if somebody elopes, and door alarms, including checking the door alarms and answering them. DA T was asked about any resident, not in the locked unit, they may suspect to be at risk for elopement or exit seeking and no resident was named. DA T stated all of the at risk residents were in the locked unit. DA T revealed they knew to report to their nurse about any resident trying to exit the building, and they knew the residents had to sign in and out if they were going on pass or appointment. Record review of the in-services log for BIMS assessed at admission 100 revealed all residents were assessed. Interview with with CNA U on 05/12/2024 at 2:02 PM, CNA U stated she received in-service training regarding elopement procedures, including elopement prevention and what to do if somebody elopes, and door alarms, including checking the door alarms and answering them. CNA U was asked about any resident, not in the locked unit, they may suspect to be at risk for elopement or exit seeking and no resident was named. CNA U stated all of the at risk residents were in the locked unit. CNA U revealed they knew to report to their nurse about any resident trying to exit the building, and they knew the residents had to sign in and out if they were going on pass or appointment. Interview with with CNA V on 05/12/2024 at 2:08 PM, CNA V stated she received in-service training regarding elopement procedures, including elopement prevention and what to do if somebody elopes, and door alarms, including checking the door alarms and answering them. CNA V was asked about any resident, not in the locked unit, they may suspect to be at risk for elopement or exit seeking and no resident was named. CNA V stated all of the at risk residents were in the locked unit. CNA V revealed they knew to report to their nurse about any resident trying to exit the building, and they knew the residents had to sign in and out if they were going on pass or appointment. Interview with with HC W on 05/12/2024 at 2:14 PM, HC W stated he received in-service training regarding elopement procedures, including elopement prevention and what to do if somebody elopes, and door alarms, including checking the door alarms and answering them. HC W was asked about any resident, not in the locked unit, they may suspect to be at risk for elopement or exit seeking and no resident was named. HC W stated all of the at risk residents were in the locked unit. HC W revealed they knew to report to their nurse about any resident trying to exit the building, and they knew the residents had to sign in and out if they were goi [TRUNCATED]

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections including COVID-19 for 6 of 8 residents (Residents #1, #2, #3, #4, #5, and #6) reviewed for infection control, in that: The facility placed COVID-19 negative residents in the same rooms as COVID-19 positive residents. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 01/28/2021. While the IJ was removed on 02/02/2021 the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not IJ identified as pattern due to the facility's need to evaluate the effectiveness of their plan of removal. These failures could result in residents at risk of infectious disease and exposure to COVID-19 resulting in illnesses, hospitalization , or death. Findings included: Record review of Resident #1's admission record, dated 02/02/2021, revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's COVID-19 test result on 01/25/2021 revealed Resident #1 was positive for COVID-19. Record review of Resident #2's admission record, dated 02/02/2021, revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's COVID-19 test result on 01/25/2021 and 01/27/2021 revealed Resident #2 was negative for COVID-19. Record review of Resident #3's admission record, dated 02/02/2021, revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's COVID-19 test result on 01/25/2021 and 01/27/2021 revealed Resident #3 was negative for COVID-19. Record review of Resident #4's admission record, dated 02/02/2021, revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's COVID-19 test result on 01/25/2021 revealed Resident #4 was positive for COVID-19. Record review of Resident #5's admission record, dated on 02/02/2021, revealed an admitted on 01/16/2020 with [DIAGNOSES REDACTED]. Record review of Resident #5's COVID-19 test result on 01/27/2021 revealed Resident #5 was negative for COVID-19. Record review of Resident #5's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making. Record review of Resident #6's admission record, dated 02/02/2021, revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's COVID-19 test result on 01/27/2021 revealed Resident #6 was positive for COVID-19. During an interview with the DON on 01/28/2021 at 10:19 AM, the DON stated COVID-19 negative residents and COVID-19 positive residents resided in the same rooms. The DON stated, I don't have anywhere to move them. Observation with the DON on 01/28/2021 at 10:20 AM revealed Residents #5 and #6 shared the same room. During an interview with the DON on 01/28/2021 at 10:20 AM, the DON confirmed Resident #6 was COVID-19 positive and Resident #5 was COVID-19 negative. Observation with the DON on 01/28/2021 at 10:21 AM revealed Residents #1 and #2 shared the same room. During an interview with the DON on 01/28/2021 at 10:21 AM, the DON confirmed Resident #1 was COVID-19 positive and Resident #2 was COVID-19 negative. Observation with the DON on 01/28/2021 at 10:22 AM revealed Residents #3 and #4 shared the same room. During an interview with the DON on 01/28/2021 at 10:22 AM, the DON confirmed Resident #3 was COVID-19 negative and Resident #4 was COVID-19 positive. Observation on 01/28/2021 at 1:37 PM revealed Resident #3 and Resident #4 was resided in the same room and were both sleeping. During an interview with the DON on 01/28/2021 at 2:25 PM, the DON confirmed Resident #4 tested positive for COVID on 1/25/2021 and Resident #3 (Resident #4's roommate) tested negative for COVID on 1/25/2021. The DON confirmed the facility tested Resident #3 again on 01/27/2021 with negative result. The DON confirmed Resident #3 and Resident #4 were still in the same room together since 01/25/2021 and stated this was because the facility did not have any rooms to move anybody. Observation on 01/28/2021 at 1:40 PM revealed Residents #1 and # 2 resided in the same room without privacy curtain separated between them. Further observation revealed Residents #1 and #2 did not wear masks. Resident #1 wheeled herself to her bathroom and Resident #3 was resting in bed. During an interview with the DON on 01/28/2021 at 2:25 PM, the DON confirmed Resident #1 tested positive for COVID-19 on 01/25/2021 and Resident #2 tested negative for COVID-19 on 01/25/2021. The DON confirmed the facility tested Resident #2 again on 01/27/2021 and still negative. The DON confirmed Resident #1 remained in the same room with Resident #2 because there was no room to move. Observation on 01/28/2021 at 1:44 PM revealed Resident #5 was sitting at her bedside table and doing cross-word, and Resident #6 was sleeping on her recliner. Further observation revealed there was no privacy curtain separated between Resident #5 and #6, and the residents were not wearing masks while staying in the same room. During an interview with Resident #5 on 01/28/2021 at 1:45 PM, Resident #5 stated she did not have any signs and symptoms of COVID-19. Resident #5 stated, my temperature was fine. Resident #5 stated she had concerns about staying in the same room with Resident #6 because Resident #6 was tested positive for COVID-19. Resident #5 stated, I am worried getting [MEDICAL CONDITION] because she (Resident #6) was right next to me. Resident #5 stated she told staff about her concern, but staff told Resident #5 not to worry. During an interview with the DON on 01/28/2021 at 2:25 PM, the DON confirmed Resident #5 and Resident #6 tested on [DATE] and Resident #5 was negative and Resident #6 was positive. The DON stated the facility did not transfer positive COVID-19 residents to another facility because she only knew facility A to transfer positive COVID-19 residents. The DON stated she reached out to facility A on Monday, 01/25/2021, but facility A was full and was not able to take any positive COVID-19 residents. The DON stated there were so many positive residents on both halls (500 and 600-hallway) there was no way for her to move positive residents on one side and negative residents on another side. During an interview with the Executive Director on 01/28/2021 at 8:45 PM, the Executive Director confirmed the facility had COVID-19 negative Resident and COVID-19 positive Resident stay in the same room. The Executive Director said some COVID-19 negative residents had not separated from their roommates who were COVID-19 positive since Monday (1/25/2020) because the facility needed to have a designated area to move negative residents, and the rooms needed to be deep clean. The Executive Director also said the facility was not ready to move negative COVID-19 residents from the North side of the building to the South side of the building where Residents tested negative for COVID-19 because the facility did not want to spread COVID to South building. During an interview with the DON and the Executive Director on 02/02/2021 at 3:25 PM, the DON and the Executive Director stated there was accumulation of several components that staff had a sense of no urgency to move the residents in the morning, and timing with rooms needed deep cleaning, notifying family and time to serve lunch. The DON and the Executive Director stated staff could not do housekeeping while lunch was being served and residents moving did not happen until after lunch which end up with opportunity cross contaminating from the nurse and the CNA. The DON stated she was confused with CDC's suggestion that should not move the resident who exposed to positive COVID-19 roommate. The DON stated the facility did not separate two negative Residents from their roommates who were positive COVID-19 since 1/25/2021 because the facility did not have rooms to move the negative COVID-19 residents until 1/28/2021. The DON confirmed the facility did not reach full capacity before 01/28/2021. The DON stated the facility had rooms available on South unit, and she should have moved negative residents to South unit, regardless. Record review of the facility's policy titled, Limiting the Transmission of COVID-19, version 16 updated 12/24/2020, revealed, Suspected case of COVID in the facility - A confirmed or suspected case of COVID 19 will be considered an outbreak: Once a case of COVID-19 is identified in the facility, immediate action will be taken to isolate the resident away from other residents, notify the resident's physician as well as the local public health authorities . Due to PPE limited availability, this facility will have HCP remove only gloves and gown (if used) and performed hand hygiene between residents with the same diagnosis (e.g., confirmed COVID-19) while continuing to wear the same eye protection and respirator or facemask (i.e., extended use) . Any roommates should be moved and monitored for fever and symptoms each shift for 14 days. Room-sharing might be necessary if there are multiple residents with known or suspected COVID-19 in the facility. If a resident with COVID-19 has another infectious disease that requires transmission-based precautions, they need to be in a single occupancy room. As roommates of symptomatic residents might already exposed, it is generally not recommended to separate them per the HHSC COVID Guidelines, Version 2.2. Record review of HHSC's COVID-19 Response for Nursing Facilities Version 3.7, dated 12/16/2020, revealed, Control measure for Residents: . Isolation - Once a case of COVID-19 is identified in the facility, immediate action must be taken to isolate the residents. Any roommate should be moved and monitored for fever and symptoms twice daily for 14 days. Room-sharing might be necessary if there are multiple residents with known or probable COVID-19 in the facility. Public health authorities can assist with a decision about resident placement. Create a plan for cohorting residents with symptoms of respiratory infection and COVID-19, including dedicating HCW to work only on affected units. Record review of, Responding to Coronavirus (COVID-19) in Nursing Homes: Considerations for the Public Health Response to COVID-19 in Nursing Homes, by the CDC, dated 04/30/2020, revealed, Resident with new-onset suspected or confirmed COVID-19: if the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. Roommates of residents with COVI-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was move to the COVID-19 care unit). Exposed resident may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. Retrieved on 02/09/2020 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html On 01/28/2021 at 8:55 PM, the Executive Director and the DON were notified the facility had an IJ for the above failures. The Executive Director and the DON was provided with the IJ template and a Plan of Removal was requested. The facility's Plan of Removal was accepted on 01/30/2021 at 7:58 AM. (Facility's) Plan to remove immediate jeopardy The facility has six (6) residents that tested negative and have the potential of being affected by COVID-19 positive residents. The residents that tested negative are no longer cohorting with the residents that tested positive for COVID-19. The CNA (certified nurse aides) who took care of the residents was identified and is being provided training on the following areas: proper donning and doffing of PPE (personal protective equipment), proper handwashing, the symptoms of COVID-19 virus, and the risk of cross contamination. In-services have been provided by the DON (Director of Nursing) on 1/28/21. The nurses who took care of the residents were identified and are being provided training on the following areas: proper donning and doffing of PPE, proper handwashing, the symptoms of COVID-19 virus, and the risk of cross contamination. In-services have been provided by the DON (Director of Nursing) on 1/28/21. All residents that are COVID-19 negative have the potential to be affected by the alleged deficient practice. The building audit was initiated on 01/28/21 to ensure proper separation of positive verses negative staff eliminate cross contamination. In-services of donning and doffing PPE and handwashing are being conducted by the DON and ADON (assistant director of nursing) and will be complete with staff in person or via phone on 1/29/21. The DON will cross reference the staff roster with in-service sign in logs. Staff members are completing the competency checks. The following policies and procedures were reviewed and revised on 01/29/21, by the DON, Administrator and Medical Director: Separation of positive verses patient under investigation residents with designated staff, proper donning and doffing of PPE, proper handwashing, the symptoms of COVID-19 virus, and the risk of cross contamination. The DON will cross reference the staff roster with in-service sign in logs. Staff members are completing the competence checks. On 01/28/2021, the DON and the ADON initiated training to the staff on proper donning and doffing of PPE, proper handwashing, the symptoms of COVID-19 virus, and the risk of cross contamination. All in-services will be completed on 01/29/21. The in-service trainings for positive residents entail educating the staff members on PPE requirements, proper donning and doffing of PPE, proper handwashing, the symptoms of COVID-19 virus, and the risk of cross contamination. The in-service trainings for negative residents entail educating the staff members on wearing N95 mask, proper handwashing, the symptoms of COVID-19 virus, and the risk of cross contamination. Potentially affected residents that tested negative for COVID-19 will be monitored every two hours for respiratory screening starting 01/28/21 and nursing staff continue monitoring residents for symptoms of COVID-19 and report to nurse immediately any change in condition. The screenings monitor for fever, cough, shortness of breath, diarrhea, nausea, vomiting, chills, headache, loss of taste and smell, dizziness, muscle, or body aches. The screening also will entail temperature checks. Staff were reeducated on the different signage of the positive and negative. The residents however that were negative have been moved to the warm zone, so color coding to signage is no longer necessary to determine positive and negative residents. Residents that tested positive for COVID-19 will be monitored every four hours and full vitals every shift. The nursing staff continue monitoring residents for symptoms of COVID-19 and report to nurse immediately any change in condition. The screenings monitor for fever, cough, shortness of breath, diarrhea, nausea, vomiting, chills, headache, loss of taste and smell, dizziness, muscle, or body aches. Nursing will complete the screening and the ADON will ensure the charge nurse documents in the Assessment tab in Point Click Care. The Medical Director was notified of the immediate jeopardy level on 01/28/21. A QAPI meeting is scheduled for 02/15/21 to review the alleged deficiency and infection control procedures. The medical director will be involved with the review. Monitoring for POR as follow: Observation on 01/30/2021 at 12:10 PM revealed a warm unit (an area used to monitor residents probable of COVID-19 infection) cohorted residents tested negative and residents tested negative and exposed to the roommates who tested positive. There was a separate entrance from the facility to go in the warm unit. There was a plastic barrier separated the COVID-19 unit where all positive residents from negatives residents in the warm unit. Observed LVN D and CNA B wore face shield, N95, gown, and gloves while working in the warm unit. Observed the facility cohorted Resident #2 and Resident #3 who tested negative and exposed to positive COVID Residents. Resident #9 and Resident #10 who tested negative shared the same room. Resident #8 was in a private room, and Resident #5 was in a private room. Observation on 01/30/2021 at 2:10 PM revealed CNA I entered the warm unit with N95 mask on; CNA I entered the donning room, sanitized hands, put on gown, face shield, hair cover and shoe cover; CNA I sanitized hands and exited donning room to hallways. Observation on 01/30/2021 from 5:11 PM to 5:27 PM revealed RN E - ADON, 2 CNAs and 1 nurse aide delivered meal trays for COVID-19 positive residents revealed they wore full PPE and performed hand hygiene in between each resident's meal tray delivery. Observation on 01/30/2021 from 5:11 PM to 7:07 PM revealed there was no staff went back and forth between COVID-19 unit and warm unit. During interviews on 01/30/2021 from 11:23 AM to 6:25 PM with 5 CNAs and 2 Nurse Aides, they confirmed they received and understood in-service: hand washing and don/doff PPE; confirmed did returned demonstration on handwashing and don/doff PPE; able to verbalize sign/symptoms of COVID-19 to report to the nurses. During interviews on 01/30/2021 from 11:05 AM to 6:18 PM interviewed 5 LVNs, they confirmed they received and understood in-service: hand washing and don/doff PPE. Check residents' temperature and COVID-19 sign and symptoms every 4 hours and documented under respiratory screening on computer. Check residents' full vitals sign and COVID-19 sign and symptoms one per shift. During an interview with LVN D on 01/30/2021 at 12:27 PM, LVN D confirmed she worked in the warm unit during the 6:00 AM to 6:00 PM shift. LVN D confirmed she did respiratory screening every 2 hours by checking resident temperature and respiratory sign and symptoms such as shortness of breath, coughing and running nose, and further confirmed COVID assessment included full vital sign and COVID -19 sign and symptoms on each shift. During interviews on 01/30/2021 from 6:03 PM to 6:13 PM with 2 LVNs who worked in COVID unit. Two LVNs confirmed check residents' temperature and COVID-19 sign and symptoms every 4 hours and documented under respiratory screen on the computer and checked residents' vitals sign and COVID sign and symptoms one per shift. During an interview on 02/01/2021 at 8: 48 AM with RN E - ADON, she confirmed she did in-service with staff. RN E said she had staff demonstrated back to ensure they understood the training in-service. RN E also stated she manually assess to computer to check and ensure nursing staff complete the respiratory screening. RN F said respiratory screening needed to be done for negative resident every 2 hours and positive resident every 4 hours. Record review in-service training report with topic: Hand hygiene, dated 01/29/2021, revealed 45 of 103 staff signed as received in-service. Record review in-service training report with topic: donning/doffing PPE, dated 01/28/2021 and 01/29/2021, revealed 75 of 103 staff signed as received in-service. Record review in-service training report with topic: Applying and removing Respirator appropriately, dated 01/28/2021 and 01/29/2021, revealed 74 of 103 staff signed as received in-service. Record review in-service training report with topic: Symptoms of COVID-19 and prevention, dated 01/28/2021, revealed 56 of 103 staff signed as received in-service. Record review in-service training report with topic: Plan to remove Immediate Jeopardy, dated 01/29/2021 revealed, 18 of 103 staff signed as received in-service. Record review of, Hand Hygiene Competency Validation, dated 01/29/2020, revealed 31 of 103 staff completed the competency. Record review of, Personal Protective Equipment (PPE) Competency Validation: donning and doffing, revealed 42 of 103 staff completed the competency. The Executive Director and DON were notified the IJ was lifted on 2/2/21 at 2:40 PM. While the IJ was lifted, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not IJ, and a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness.