Every finding on record at Houston Transitional Care

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 2 residents (Resident#1 and Resident#2) and 1 of 1 staff (Wound Care Nurse) reviewed for infection control. - The facility failed to ensure the Wound Care Nurse washed or sanitized her hands and performed glove changes appropriately while providing wound care to Resident #1 and Resident #2 on 06/24/26. This failure placed residents with wounds or infection at risk for cross contamination and the spread of infection.Record review Resident # 1's face sheet dated 6/24/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included peripheral vascular disease (narrowing of the blood vessels), anemia (having few healthy blood cells), hypertension (high blood pressure), aneurysm of artery of lower extremities (abnormal bulge in the wall of the blood vessels in the leg) and multiple sclerosis (an autoimmune disease that affects the central nervous system). Record review of Resident #1's baseline care plan dated 6/17/2026 revealed she was admitted to the facility with a surgical incision to left groin. Record review of Resident #1's care plan initiated 6/17/2024 revealed the followingFocus: Surgical incision to R- groin and is at risk for dehiscence, delayed healing, infection and pain.Goal: Pain will be alleviated with appropriate interventions. Surgical incision will heal without complications. Will show signs of healing.Interventions: Administer medications as ordered. Administer treatments as ordered. Assess for signs and symptoms of infection, notify physician if observed. Follow up with surgeon as indicated. Labs as ordered, report abnormal findings to physicians. Surgical wound care as ordered. Utilize Enhanced Barrier Precautions (EBP) during high-contact resident care. Record review of physician's order dated 6/17/2026 for treatment to right groin/post-surgical: Clean with normal saline, pat dry, cover with dry gauze, ABD pad and cover with bordered gauze dressing or secure with tape QD and prn until resolved. Observation on 6/24/2026 at 11:05am of wound care for Resident #1 revealed the Wound Care Nurse removing the solid dressing from Resident #1 wound to the right groin and disposed of it in a red bag. She changed her gloves and washed her hands and put on clean gloves. She then cleaned Resident#1's wound to the groin area and disposed of the gauze in the red bag. Without changing her gloves or washing her hands she applied the clean dressing to the wound and covered the wound and dated it. She then changed the gloves and washed her hands. Record review Resident # 2's face sheet dated 6/24/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included sepsis (the body's extreme life-threatening response to an infection), hypertension (high blood pressure), benign prostate hyperplasia without lower urinary tract infection (the prostate has grown large but not compressing the urethra enough to cause urinary issues like urgency to urinate. Record review Resident #2's MDS dated [DATE] revealed the resident was coded has having a BIMS score of 14 indicating the resident was cognitively aware for decision making. For bowel and bladder, he was coded as incontinent. For skin condition he was coded as having one unhealed pressure sore. Record review of physician's order dated 6/18/2026 for treatment to right heel, clean with normal saline, pat dry, apply xeroform and cover with dry bordered gauze dressing QD and prn until resolved every day shift, and as needed. Observation on 6/24/2026 at 11:30 am revealed Wound Care Nurse providing treatment for Resident #2. The Wound Care Nurse washed her hands and put gloves on and removed the soiled dressing form Resident#2's right heel and disposed of it in the red bag. She then washed her hands and put clean gloves on and cleaned the resident's right heel. Without changing gloves or washing her hands, she then dry, the heel and applied dressing and covered and dated the bandage. She then pulled the cover over Resident #2 and took an alcohol swab and wiped the marker and then changed her gloves. In an interview on 6/24/2026 at 11:44 am with the Wound Care Nurse in reference to changing her gloves during the treatment she said she should have changed the gloves between cleaning the wound and applying the dressing. She said she was just nervous that was why she did not change her gloves and wash her hands. She said not changing her gloves and washing hands could result in infection or the spread infection. She said moving forward she would ensure she washed her hands and change gloves during wound care between dirty and clean processes. In an interview on 6/24/2026 at 5:30 pm with the Regional Nurse revealed his expectations of the nurses when they were doing wound care was to change gloves and wash hands between dry and clean procedures. He said he will be in-serving the staff about washing hands and changing gloves during wound care. They will also be in-serviced on infection control, and he was going to ensure they follow the infection policies and procedures. Record review of the facility Wound Care Level III documentation dated 2001 read in part. Purpose The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 2. Provide for privacy.3. Perform hand hygiene.4. Establish a clean field on resident's overbed table.5. Place all items to be used during procedure on the clean field.6. Position the residents so they are comfortable.7. Place disposable cloth next to the resident to protect the bed linen and other body sites.8. Put on exam gloves.9. Loosen tape and remove the old dressing.10. Pull one glove over the dressing and discard into appropriate receptacle. Remove the second glove.11. Perform hand hygiene.12. Put on clean gloves. Use additional PPE as indicated by transmission-based precautions.3. Remove gloves and perform hand hygiene. Clean the Wound1. Apply clean gloves.2. Place a piece of gauze over the wound, leaving the margins of intact skin exposed.3. Clean the area around the wound usually covered by the dressing, tape, or gauze with antiseptic or soap and water.4. Remove dry gauze from the wound.5. Clean and apply treatments as ordered.6. Apply appropriate dressing. [NAME] tape with initials, date, and time and apply to dressing.7. Remove the disposable cloth next to the resident and discard into the designated container.8. Discard disposable items into the designated container.9. Place all soiled laundry, linen, towels, and washcloths into the soiled laundry container.10. Remove disposable gloves and discard into designated container.11. Perform hand hygiene.12. Reposition the bed covers.13. Make the resident comfortable. Use supportive devices as instructed.14. Place the call light within easy reach of the resident.15. Use clean field saturated with alcohol to wipe overbed table.16. Return the overbed table to its proper position.17. Wipe reusable supplies with alcohol as indicated (i.e., outsides of containers that were touched by uncleanhands, scissor blades, etc.). Return reusable supplies to residents' drawer in treatment cart.18. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them they may now enter the room.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 residents (Resident #1) reviewed for infection control. 1. The facility failed to ensure CNA A changed gloves and completed hand hygiene when providing care to Resident #1.2. CNA B failed to don appropriate PPE (disposable gown) prior to providing direct care to Resident #1, who was on EBP. These failures could place residents at risk for cross contamination, infections, and unwanted hospitalization.Record review of Resident #1's face sheet, dated 05/28/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included osteomyelitis (infection of the bone) right ankle and foot, muscle weakness, and non-pressure chronic ulcer part of right foot. Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated the resident's cognition was intact. Section GG-Functional Abilities reflected the resident was dependent for personal hygiene. Section H-Bowel and Bladder reflected Resident #1 was frequently incontinent with urine and bowel. Record review of Resident #1's Comprehensive Care Plan, dated 05/05/26, reflected the resident was care planned for Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact care activities due to the presence of indwelling device Permacath (a specialized tunneled catheter used for long-term, high-flow blood treatments) for dialysis. An intervention included utilizing PPE (gown and gloves; face shield as indicated) during high-contact resident care activities (e.g, dressing, bathing/showers, transferring, hygiene, linen changes, brief changes, toilet assistance, device care, and wound care). Record review of Resident #1's Physician Order Summary Report for the month of May 2026 reflected the following orders:-Dated 04/25/26, Resident to receive dialysis 3 times a week Monday, Wednesday, and Friday.-Dated 04/27/26, Enhanced Barrier Precautions during high contact resident care activities secondary to dialysis and wound every shift.Observation on 05/28/26 at 9:46 AM revealed Resident #1 had EBP signage at the door entrance with a plastic bind at the door entrance with PPE (gloves and disposable gowns) inside of it. Observation was made of CNA A coming out of another resident's room across the hall with gloves on going to Resident #1's room to assist CNA B with providing incontinent care for Resident #1. CNA B had washed her hands and placed on gloves prior to CNA A entering Resident #1's room. Both CNA A and CNA B did not place on a disposable gown. Resident #1's brief was not soiled but the staff provided perineal care by cleaning the resident with disposable wipes. During care, CNA A left the room with gloves on and returned to the resident room with gloves on bringing back some pillowcases. When both CNAs completed care for Resident #1, CNA A left the room without removing her gloves or washing her hands, taking the soiled material out of the room. CNA B removed her gloves and washed her hands.Interview on 05/28/26 at 10:05 AM, CNA B said she worked at the facility PRN since February of 2026 on various shifts but normally worked the morning shift. CNA B said initially she did not see a reason to place on a gown. CNA B said she forgot to place on a disposable gown. She said her last in-service on infection control was about 3 months ago. She said by not placing on the correct PPE when providing direct care for residents with wounds, Foley catheters, or intravenous lines, placed the resident at risk for cross contamination and infections. Interview on 05/28/26 at 10:05 AM, CNA A said she had been working at the facility for almost 5 months full time from 7AM-7PM. CNA A said she received in-service on infection control but could not recall if they mentioned enhanced barrier precautions. CNA A said she should not have been going from room to room with gloves on because it placed the resident at risk for infections. Interview on 05/28/26 at 10:26 AM, the DON said she was the Infection Control Preventionist. The DON said residents who were placed on Enhanced Barrier Precautions consisted of residents who had intravenous ports/lines, Foley catheters, or any artificial openings on their body. The DON said the staff should be wearing gloves and disposable gowns when proving direct care for residents on EBP. The DON said staff needed to be practicing hand hygiene prior to and after providing care of a resident and not going from room to room with gloves on. The DON said if the staff did not take these precautions, it would place the residents at risk of infections. Record review of the facility's policy on Handwashing/Hand Hygiene, revised October 2023, reflected in part: .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Hand hygiene is indicated: immediately before touching a resident.after touching a resident; after the resident's environment.immediately after glove removal. Record review of the facility's Infection Control policy, revised October 2018, reflected in part: .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and help prevent and manage transmission of diseases and infections. Record review of the facility's Enhanced Barrier Precaution policy, revised December 2024, reflected in part: .Enhanced barrier precautions are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents.EBPs employ targeted gown and gloves use in addition to standard precautions during high contact resident care activities.

Number of residents sampled: Number of residents cited: Based on interview and record review the facility failed to ensure the residents were given the right to participate in the development and implementation of their plans of care for 2 of 17 residents (Resident #1, Resident #16) reviewed for participating in care planning. The facility did not conduct a meeting nor invite Resident #16 to participate in resident care planning meetings after his quarterly review assessments on 10/9/2024, 1/9/25 and 4/11/25. The facility did not conduct a meeting nor invite Resident #1's responsible party to participate in resident care planning meetings after his quarterly review assessments on 9/5/24, 12/6/24 and 3/8/25 and after a comprehensive review assessment on 6/6/25. This failure could place residents at risk for a loss of independence, psychosocial well-being and the opportunity for them or responsible party to participate in the planning of their care. Findings Included: Resident #16 Record review of Resident #16's admission Record generated on 7/17/25 revealed he was admitted to the facility on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage (bleeding within the brain tissue not caused by an injury), stiffness of left ankle, schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), bipolar disorder (a disorder associated with mood swings ranging from depressive lows to manic highs), major depressive disorder (a mental illness characterized by persistent feelings of sadness, loss of interest in activities and difficulty functioning), occlusion and stenosis of right posterior cerebral artery (blockage or narrowing of the artery), visuospatial deficit (impairments in the ability to understand and interact with the spatial relationships of objects and oneself in the environment) and hemiplegia and hemiparesis affecting left non-dominant side (muscle weakness or partial paralysis on one side of the body). He was [AGE] years of age. Record review of Resident #16's MDS assessments revealed the facility staff completed quarterly assessments on 10/9/24, 1/9/25 and 4/11/25. Record review of Resident #16's quarterly MDS assessment dated [DATE] revealed he had a BIMS score of 15, indicating no cognitive impairment. Record review of Resident #16's care plan generated on 7/16/25 revealed the last care plan review was completed on 5/7/25. The care plan included the following focus' and revision dates: - The focuses of impaired visual function, psychosocial well-being problem, anticoagulant (a medication that helps prevent blood clots) therapy, mood problem, risk of activities of daily living and mobility decline, risk for falls, risk for skin breakdown, bladder incontinence, full-code status, antipsychotic medication use (medications primarily used to manage symptoms of psychosis such as hallucinations and delusions), were revised on 9/10/24. - The focus of psychotropic medication use (a medication that affects a person's mental state) was revised on 9/18/24. - The focus of antidepressant medication use was revised on 11/8/24. - The focus of potential for altered nutrition and hydration status was revised on 5/13/25. - The focus of need for activities that were consistent with abilities and interests was revised on 5/19/25. Record review of Resident #16's Evaluations dated between 7/2/24 to 7/17/25 in his electronic medical record revealed only one IDT Conference Note was listed. The IDT Conference Note was dated 7/9/25 and had a status of 'in progress.' Record review of the IDT Conference Note dated 7/9/25 in Resident #16's electronic health record revealed it was blank. Record review of Resident #16's electronic medical record revealed there was no mention of a care plan meeting or IDT Conference Note between 7/2/24 and 7/8/25. Record review of a handwritten IDT Conference Note dated 7/9/25 revealed the sections pertaining to nursing services, activities and social services/case management was completed. The sections for dietary and therapy services was not complete. The document indicated the Social Services Director, Activity Director and LVN T were present. Under the section for IDT Members who Attended the Conference, someone had written Resident #16's name then (in person). In an interview on 7/15/25 at 9:36am, Resident #16 said he had been at the facility for one year. He said his therapy ended and he wanted more. He said he was interested in talking about his discharge plan, including the possibility of inpatient rehabilitation, moving home with his parents, or going to an apartment. In an interview on 7/16/25 at 2:00pm, the Social Services Director said Resident #16 was at the facility for long-term care. When asked if there were discussions about a discharge plan, she said, He knows he is a long-term patient. She said he wants to go home but could not go home alone. In an interview on 7/16/25 at 11:55am, Resident #16 said he has never had a care plan meeting. He said he would like to have a meeting with the facility staff to discuss therapy and discharge goals. He said he is not sure why he is at the facility if he was not getting therapy. In an interview on 7/16/25 at 12:35pm, the Social Services Director said they held quarterly care plan meetings for long-term residents. She said care plan meeting invitations were not in writing, but verbal. She said Resident #16 had a care plan meeting on 7/9/25 in his room with LVN T and the Activity Director. She said he was not on therapy, so therapy staff do not attend. Resident #1 Record review of Resident #1's admission Record generated on 7/17/25 revealed he was admitted to the facility on [DATE] with diagnoses of traumatic subdural hemorrhage (a type of brain injury where blood collects in the outer membrane covering the brain), hemiplegia (muscle weakness or partial paralysis on one side of the body), anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin to carry oxygen through the body), encephalopathy (a broad term for any brain disease that alters brain function or structure), dysphagia (difficulty swallowing foods of liquids), quadriplegia (a paralysis that affects the ability to voluntarily move the upper and lower body), and fracture of base of skull. He was [AGE] years of age. Record review of Resident #1's MDS assessments revealed the facility staff completed quarterly assessments on 9/5/24, 12/6/24, 3/8/25 and an annual assessment on 6/6/25. Record review of Resident #1's annual MDS assessment dated [DATE] revealed he was rarely/never understood and sometimes understood others. A staff assessment of cognitive patterns revealed he had short-term and long-term memory problems and had moderately impaired cognition skills for daily decision making. The staff assessment of daily and activity preferences revealed the resident preferred for family or significant other involvement in care discussions. Record review of Resident #1's care plan generated on 7/17/25 revealed the last care plan review was completed on 7/15/25. The care plan included the following focus' and revisions: - The focus of alteration in neurological status was revised on 6/27/24.- The focuses of altered respiratory status/difficulty breathing, risk for skin breakdown, altered cognitive performance, impaired communication, risk for allergic reactions, risk for falls, risk for ADL/mobility decline, enhanced barrier precautions (an infection control strategy that uses gloves and gowns during high-contact resident care to reduce the spread of multidrug resistant organisms), bowel and bladder incontinence (involuntary leakage of urine), anticoagulant medication use, seizure disorder, advanced directives, antipsychotic medication use, weight loss and hemiplegia were revised on 11/1/24. - The focus of impaired skin integrity was revised on 2/25/25. - The focus of enteral nutrition and medications was revised on 5/7/25.- The focus of a need for activities that are consistent with abilities and interests was revised on 5/19/25. Record review of Resident #1's Evaluations dated between 5/24/24 to 7/17/25 in his electronic medical record revealed there were no IDT Conference Notes or Care Plan Meeting notes listed. Record review of Resident #1's Progress Notes dated between 7/16/24 to 7/17/25 in his electronic medical record revealed there were no IDT Conference Notes or Care Plan Meeting notes listed. In an observation and attempted interview on 7/15/25 at 9:27am, Resident #1 was lying in bed alert and awake. Surveyor attempted to interview Resident #1 without success. In an interview on 7/16/25 at 12:35pm, the Social Services Director said they held quarterly care plan meetings for long-term residents. She said care plan meeting invitations were not in writing, but verbal. She said they would call the families to schedule care plan meetings. She said the care plan meetings were documented in the electronic health record progress notes. In an interview on 7/17/25 at 1:34pm, Resident #1's Family Member stated she lived in a different state and does not visit often. She said facility staff had not given her an update on his therapy or care since she was there last a few months ago. She said they had not called to schedule a care plan meeting since last year. She said they do not inform her of too much anymore. She said she was not sure if they were getting him out of bed and have not provided an update on his feeding tube. In an interview on 7/17/25 at 2:00pm, LVN T said she assisted the facility with discharge planning and care plan meetings. She said they held care plan meetings for long-term care residents with the families. She said she scheduled them by phone with the family members. She said residents were invited as well. In an interview on 7/17/25 at 4:48pm, the Social Services Director, when asked if it was possible that Resident #1 and Resident #16 did not have quarterly care plan meetings in the past year, she said yes. Record review of the facility's policy for Care Plans, Comprehensive Person-Centered dated March 2022 read in part, .Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate to the development and implementation of his or her plan of care, including the right to: participate in the planning process; identify individuals or roles to be included; request meetings; request revisions to the plan of care; participate in establishing the expected goals and outcomes of care .the resident is informed of his or her right to participate in his or her treatment, and provided advance notice of care planning conferences.The interdisciplinary team reviews and updates the care plan.at least quarterly, in conjunction with the required quarterly MDS assessment.

Number of residents sampled: Number of residents cited: Based on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activity professional for 1 of 1 facility reviewed for Activity Director.The facility Activity Director was not a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place the residents at risk of not having an activities program that meets their assessed activity needs.Findings Include: In an interview on 7/17/25 at 3:56 p.m. the Activities Director said she was the Activities Director but was more like an Activities Assistant because she did not have the activity director training. She said the training consisted of an online class that did not require much but she had not taken it due to life circumstances. She said the Director of Rehab, who was an OT, oversaw her since she started working as the Activities Director in March 2024. She said the Director of Rehab would participate in a certain activity or shadow her, but he was not the Activities Director. She said she was a certified CNA and had previous experience in long term care, home health, and hospitals. She said she previously worked as a CNA at another nursing facility and helped with activities for approximately 6 months. She said the Administrator hired her and provided a handbook. She said the Regional Director of Clinical Services told her around June 2024 that she needed to get a certification but did not say when. She said she had no formal training in her current position and was not qualified to be the Activities Director but could be the assistant. She said training was important so she could do activities to the best of her ability, and with training she could do a lot more. She said she tried to stay in her scope of practice as a CNA and kept activities with the residents simple such as bingo and socials. She said no one verified her trainings. In an interview on 7/17/25 at 4:25 p.m. the Director of Rehab (who was an occupational therapist) said he oversaw the activities department because at that facility OT worked with cognition. He said he did not plan or schedule the activities and was not the Activities Director. He said he would discuss with the Activities Director which residents were appropriate for activities such as bingo, arts, and crafts. He said he did not assist with in room activities. He said the Activities Director was responsible for resident care plans and documentation and he worked with the residents' cognition and physical abilities. In an interview on 7/17/25 at 4:40 p.m. the Administrator said the Activities Director had been in her role for a while now. He said she was previously a CNA and expressed interest in the position and he hired her. He said he was not an expert in the required qualifications but knew the Activities Director needed to finish courses and schoolwork and needed to get her recreational license and certification. He said she was not qualified to be Activities Director. He said her current role was more like an Activities Assistant because she carried out the activities and was a CNA. He said she reported to the Director of Rehab who was also considered to be the Activities Director at the facility. In an interview on 7/17/25 at 4:59 p.m. the Regional Director of Clinical Services said the Director of Rehab, who was an OT, was the activities director and oversaw activities. She said she told the Activities Director (the staff listed as the facility's Activities Director) about different courses needed to become certified but did not remember when. She said she was unsure what qualifications were needed for an Activities Director and would refer to the regulations. Record review of the Activity Director's job description signed by the Activity Director on 3/22/24 read in part, The primary purpose of the Activity Director position is to plan, organize, develop, and direct the overall operation of the Activity Department in accordance with current federal, state, local and corporate standards, regulations, and guidelines to assure that an on-going program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and physical, mental, and psychosocial needs of each resident. Supervisory Requirements: assist with the overall supervision of and management of the activity staff. Qualification: education and/or experience: high school diploma or equivalent. Preferable one year experience in a long term care facility. Certificates, licenses, registrations: Activity Director certification (preferable - overseen by OT).

Based on observation, interview and record review, the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 of 2 medication fridges (West Medication Room Fridge) and 1 of 1 central supply room reviewed for storage. The facility failed to ensure that medication fridges were clean and free of food; and that expired medications were not found in the central supply room and medication fridge. The failure could place residents at risk of contamination of medications or receiving expired medications. Findings included: Observation on 7/15/25 at 1:56 p.m. of the East Medication Room revealed a yellow substance in the bottom of the medication refrigerator and a frozen meal in the freezer. The DON immediately threw the frozen meal in the trash. During interview on 7/15/25 at 1:56 p.m., the DON said that she would have housekeeping come clean the medication fridge in the East Medication Room. Observation on 7/15/25 at 2:07 p.m. of the Central Supply Room revealed over the counter medications that were beyond their expiration dates or best by dates. The following medications were past their expiration date: Vitamin B-6 25 mg (100 count) times 6 bottles with expiration date of 8/24, Daily Vitamin Formula + Iron (100 count) times 1 bottle with expiration date of 2/25, and Folic Acid 800 mg (100 count) times 1 bottle with expiration date of 10/24. The following medications were found to be beyond their best by dates: Melatonin 1 mg (90 count) times 5 bottles with best by date of 3/25, Vitamin B-6 100 mg (100 count) times 2 bottles with by date of 10/24, Oyster Shell Calcium 500 mg (60 count) times four bottles with best by date of 6/25, Iron 27 mg (100 count) with best by date of 4/24. Observation on 7/15/25 at 2:23 p.m. of the [NAME] Medication Room revealed five Cefepime 2 mg 100 ml bags that expired 5/12/25 in the medication refrigerator. During interview on 7/15/25 at 2:23 p.m., the DON said that the Cefepime was trash as the resident was no longer at the facility and removed the Cefepime from the refrigerator. During interview on 7/16/25 at 9:17 a.m., MA G said she obtained over the counter medications from the supply closet when needed and denied having problems with expired medications on the medication carts and said that most of her medications were good through 2026. During interview on 7/16/25 at 11:16 a.m., the Pharmacist said she did not check the supply room for expired medications and checked the medication carts and medication fridges monthly. The DON said that something had leaked in the East Medication Room medication fridge, but she was unsure what had leaked. The Pharmacist said her last visit to the facility was around June 8th. The Pharmacist said during her monthly checks she checked the facility for expired medications, that medications were stored appropriately, and refrigerator temperatures were appropriate. The Pharmacist said she never seen anything soiled or stained but would notify the DON if she did. The Pharmacist said there were no stains in the medication fridges last month. The Pharmacist said the facility staff knew not to put food in the medication fridge and there should not be food in the medication fridge. The Pharmacist said she had not witnessed food in the medication fridge before either and was an anomaly. Observation on 7/16/25 at 3:08 p.m. of the East Medication Room revealed a yellow substance in the bottom of the medication refrigerator. During interview on 7/16/25 at 3:20 p.m., the DON said the night nurses from 10 p.m. to 6 a.m. were responsible for checking the medication fridges and if they notice something like the fridge leaking, they can let maintenance know so adjustments can be made. The DON said the nurse making their rounds in the morning should also check the fridge to make sure the reading was in the appropriate range. The DON said the nurse who checked the medication refrigerators were supposed to check and makes sure there is no food in the fridge and cleanliness of the fridge. The DON said she was not sure regarding potential adverse effects to residents regarding cleanliness of the medication fridge or food being present in the medication fridge and she will have to follow up and come back to me with an answer. The DON said if a resident received an expired medication, they would reach out to the physician to get further orders and reach out to pharmacist and see what we would need to do. The DON said the effect would depend on the medication after they checked with doctor and pharmacist. During an interview on 7/17/25 at 4:42 p.m., the Regional Director of Clinical Services said the staff checked medications for expirations dates when retrieving them from the supply closet and will not use if expired. Record review of facility's policy Storage of Medications with revised date of April 2007 revealed nursing staff shall be responsible for maintaining medication storage in a clean, safe, and sanitary manner. The policy also revealed the facility shall not use discontinued or outdated drugs or biologicals and all such drugs shall be returned to the dispensing pharmacy or destroyed. The policy also stated that medications must be stored separately from food.

Number of residents sampled: Number of residents cited: Based on interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 17 Residents (Resident #16) reviewed for care plans. -The facility failed to develop and implement a care plan regarding Resident #16's history of self-harm and diagnosis of schizophrenia. These failures could place residents at risk of not having their needs met or inability of staff to identify a change of condition. Findings Included: Record review of Resident #16's admission Record generated on 7/17/25 revealed he was admitted to the facility on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage (bleeding within the brain tissue not caused by an injury), stiffness of left ankle, schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), bipolar disorder (a disorder associated with mood swings ranging from depressive lows to manic highs), major depressive disorder (a mental illness characterized by persistent feelings of sadness, loss of interest in activities and difficulty functioning), occlusion and stenosis of right posterior cerebral artery (blockage or narrowing of the artery), visuospatial deficit (impairments in the ability to understand and interact with the spatial relationships of objects and oneself in the environment) and hemiplegia and hemiparesis affecting left non-dominant side (muscle weakness or partial paralysis on one side of the body). He was [AGE] years of age. Record review of Resident #16's Hospital Records found in his electronic health record at the facility dated 5/3/24 read in part, 53 (year old male).who presents after attempting to drill into his skull with a power drill. per report, EMS was called for odd behavior and when EMS arrived, the patient grabbed a power drill and started to drill into his (right) temple. Record review of Resident #16's quarterly MDS assessment dated [DATE] revealed he had a BIMS score of 15, indicating no cognitive impairment. He had a PHQ-9 score of 9, indicating he had mild depression. He had no signs of behaviors. He had functional limitations in his upper and lower extremities and used a wheelchair for ambulation. The MDS assessment indicated he was admitted to the facility from an acute care hospital. Record review of Resident #16's physician progress note dated 6/27/25 revealed MD A stated Resident #1 presented with subarachnoid hemorrhage due to attempting to drill into his skull with a power drill. He further noted he was on Olanzapine (an antipsychotic medication), venlafaxine (an antidepressant medication) and lithium (a mood stabilizer) for managing history of schizophrenia. Record review of Resident #16's care plan generated on 7/16/25 revealed there was no focus to indicate he had a history of self-harm or a diagnosis of schizophrenia. The care plan had a focus of psychotropic medication use related to schizophrenia and bipolar disorder initiated on 9/10/24 and revised on 9/18/24, with interventions listed, including administer medications as ordered, monitor for side effects and effectiveness, consult with MD to consider dosage reduction when clinically appropriate and monitor/record occurrence of target behavior symptoms. In an interview on 7/16/25 at 2:00pm, the Social Services Director said she was unsure of the details but knew Resident #16's injuries were self-inflicted. She said he had no signs of sadness or self-harm ideations while at the facility. In an interview on 7/17/25 at 11:00am, LVN A said she knew Resident #16 was in some type of accident. She said he is on psychotropic medications to help with his mood. She said she has not witnessed him have sadness or self-harm ideations. In an interview on 7/17/25 at 2:16pm, the MDS Coordinator acknowledged she was responsible for care planning. She said she reviewed the resident's hospital clinicals on admission. She said she did not notice Resident #16 had a history of self-harm after reading his admission clinicals. She said if someone had a history of self-harm, they should have a care plan to show staff what to look for to include signs of possible self-harm. In an interview on 7/17/25 at 3:20pm, The DON said if a resident has a history of self-harm, then it should be care planned so staff know to look for signs of suicidal ideations. In an interview on 7/17/25 at 4:17pm, LVN C said she was not aware that Resident #16 had a history of self-harm. She said if a resident had a history of self-harm, they could assess the resident for suicidal ideations, monitor their mood and not allow certain items in the room. Record review of the facility's policy for Care Plans, Comprehensive Person-Centered dated March 2022 read in part, A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.the comprehensive person-centered care plan: .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. reflects currently recognized standards of practice for problem areas and conditions. services provided for or arranged by the facility and outlined in the comprehensive care plan are: provided by qualified persons; culturally competent and trauma-informed.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 2 of 17 residents (Resident #1 and #16) reviewed for ADL care. The facility failed to ensure Residents #1 and #15 received services necessary to maintain grooming, including haircuts based on their preferences. This failure could place residents at risk of not receiving care and services, discomfort, decreased quality of life, and loss of dignity. Findings included: Resident #1 Record review of Resident #1's admission Record generated on 7/17/25 revealed he was admitted to the facility on [DATE] with diagnoses of traumatic subdural hemorrhage (a type of brain injury where blood collects in the outer membrane covering the brain), hemiplegia (muscle weakness or partial paralysis on one side of the body), anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin to carry oxygen through the body), encephalopathy (a broad term for any brain disease that alters brain function or structure), dysphagia (difficulty swallowing foods of liquids), quadriplegia (a paralysis that affects the ability to voluntarily move the upper and lower body), and fracture of base of skull. He was [AGE] years of age. Record review of Resident #1's annual MDS assessment dated [DATE] revealed he was rarely/never understood and sometimes understood others. A staff assessment of cognitive patterns revealed he had short-term and long-term memory problems and had moderately impaired cognition skills for daily decision making. The staff assessment of daily and activity preferences revealed the resident preferred choosing clothes to wear, receiving a bed bath or sponge bath, family or significant other involvement in care discussions. He used a wheelchair for ambulation, was dependent on others for all self-care tasks, required substantial/maximal assistance for bed mobility, and was dependent on others for walking. Record review of Resident #1's Care Plan generated on 7/17/25 revealed a focus of ADL/mobility that was initiated on 5/24/24 and stated that Resident #1 was at risk for ADL/mobility decline and required assistance related to aspiration risk, bed-bound status, cognitive impairment, communication problems, recent hospitalization and weakness. The goal was to ensure Resident #1's needs are anticipated and met by staff. Interventions included assisting with 1 staff for AM and PM care, bed mobility, dressing and hygiene. In an observation on 7/15/25 at 9:27am, Resident #1 was in bed, continuously scratching his head and mustache with his index finger. He was alert and awake. His hair was approximately 3 inches long, the hair was extending down his neck past the base of his head for about an inch. His hair was disheveled and not combed straight. In an interview on 7/17/25 at 1:34pm, Resident #1's Family Member said Resident #1 liked his hair cut close to his head like a buzz cut. She said she gave the staff a hair clipper kit and put it in the closet so they could cut his hair. When asked about having his hair long, he said he probably did not like it that way. Resident #16 Record review of Resident #16's admission Record generated on 7/17/25 revealed he was admitted to the facility on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage (bleeding within the brain tissue not caused by an injury), stiffness of left ankle, schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), bipolar disorder (a disorder associated with mood swings ranging from depressive lows to manic highs), major depressive disorder (a mental illness characterized by persistent feelings of sadness, loss of interest in activities and difficulty functioning), occlusion and stenosis of right posterior cerebral artery (blockage or narrowing of the artery), visuospatial deficit (impairments in the ability to understand and interact with the spatial relationships of objects and oneself in the environment) and hemiplegia and hemiparesis affecting left non-dominant side (muscle weakness or partial paralysis on one side of the body). He was [AGE] years of age. Record review of Resident #16's quarterly MDS assessment dated [DATE] revealed he had a BIMS score of 15, indicating no cognitive impairment. He had functional limitations in his upper and lower extremities and used a wheelchair for ambulation. He required supervision or touching assistance for personal hygiene tasks, including combing hair, shaving, and washing/drying face. Record review of Resident #16's Care Plan generated on 7/16/25 revealed a focus of ADL/mobility that was initiated on 7/3/24 and stated that Resident #1 was at risk for ADL/mobility decline and required assistance related to anticipated declines in condition due to disease process, cognitive impairment and weakness. The goal was to ensure Resident #16's needs are anticipated and met by staff. Interventions included assisting with 1 staff for AM and PM care, bed mobility, dressing and hygiene. In an observation and interview on 7/15/2025 3:55pm, Resident #16 said he would really like a haircut. He said he could not remember when he got one last. He said his family member was supposed to bring in a hairdresser, but they had not visited yet. He said he could not remember when they last discussed it. Observation of his hair revealed it was approximately 3 to 4 inches long on his head, and the hair was growing down his neck approximately an inch below the base of his head. His hair was disheveled and not combed straight. In an interview on 7/16/25 at 2:00pm, the Social Services Director said the salon was not staffed. She said family members or residents could arrange for someone to use the salon if a resident needed a haircut. She said she was not aware if anyone at the facility cut resident's hair. In an interview on 7/17/25 at 11:00am, LVN A said facility staff do not give residents haircuts. She said if a resident needed a haircut based on their preferences, she would reach out to the resident's family member to see if they arrange a haircut. She said the Social Services Director could arrange for a haircut if needed. In an interview on 7/17/25 at 3:20pm, the DON said the facility used to have a charity group that was using the salon to give haircuts, but they had not visited in a while. She could not remember when they stopped coming. She said they were looking for a new barber/hairdresser. She said if a resident's hair was long, they would ask the resident if they were happy with the length of their hair. She said if they wanted a haircut, the Social Services Director would try to get someone in the community to cut it. In an interview on 7/17/25 at 3:55pm, CNA U said if he noticed a resident's hair was long, he would ask the resident about their hair and preferences. He said if they needed a haircut, he would notify the nurse. He said he would not cut anyone's hair. In an interview 7/17/25 at 4:10pm, CNA E said the facility did not allow CNAs to cut resident's hair. She said if a resident needed a haircut, she would report it to the nurse. She said they would follow the resident's preferences. She said Resident #1's hair was a little long. Record review of the facility's policy regarding Activities of Daily Living, Supporting dated March 2018 read in part, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care).

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for 1 of 17 residents (Resident #1) reviewed for activities. This facility failed to implement an ongoing resident centered activities program for Resident #1 that incorporated the residents' interests, hobbies and cultural preferences. This failure could put residents at risk for a decrease quality of life. Findings included: Record review of Resident #1's admission Record generated on 7/17/25 revealed he was admitted to the facility on [DATE] with diagnoses of traumatic subdural hemorrhage (a type of brain injury where blood collects in the outer membrane covering the brain), hemiplegia (muscle weakness or partial paralysis on one side of the body), anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin to carry oxygen through the body), encephalopathy (a broad term for any brain disease that alters brain function or structure), dysphagia (difficulty swallowing foods of liquids), quadriplegia (a paralysis that affects the ability to voluntarily move the upper and lower body), and fracture of base of skull. He was [AGE] years of age. Record review of Resident #1's admission activity assessment dated [DATE] revealed the Activity Director completed the assessment. She indicated that an interview for Daily Activity Preferences was conducted with Resident #1's family member. The following items were selected as very important for the resident: take care of personal belongings, have family or close friend involved in discussion about your care, a place to lock your things to keep them safe, listen to music he likes, keep up with the news and do his favorite activities. Record review of Resident #1's annual MDS assessment dated [DATE] revealed he was rarely/never understood and sometimes understood others. A staff assessment of cognitive patterns revealed he had short-term and long-term memory problems and had moderately impaired cognition skills for daily decision making. A staff assessment of resident mood indicated his PHQ-9 was 12, indicating he had moderate depression. The staff assessment of daily and activity preferences revealed the resident preferred choosing clothes to wear, caring for personal belongings, receiving a bed bath or sponge bath, family or significant other involvement in care discussions, listening to music, being around animals such as pets, participating in favorite activities and spending time outdoors. He used a wheelchair for ambulation, was dependent on others for all self-care tasks, required substantial/maximal assistance for bed mobility, and was dependent on others for walking. Record review of Resident #1's Care Plan generated on 7/17/25 revealed the following focuses, goals, and interventions: - Focus: Resident #1 had impaired communication related to aphasia, impaired verbal communication. The focus was initiated on 8/15/24. The goal was for Resident #1 to have his needs met. Interventions included us hand signals and gestures to assist with communication as needed and use simple direct communication such as yes and no questions. - Focus: Resident #1 had cognitive loss related to altered cognitive performance with low BIMS score and traumatic brain injury. The focus was initiated on 8/15/24. The goal was for the resident to avoid complications related to cognitive deficits and to have daily needs met. Interventions included anticipating needs, explaining all care before providing, provide medications as ordered, monitor for changes in cognitive status, reduce noise/distractions to provide a calm environment, and speech therapy referral for cognitive management. - Focus: Resident #1 had a need for activities that were consistent with abilities and interests, and enjoyable, meaningful activities to the resident include, but are not limited to massage therapy, news, one-on-one visits, preferred individual activities versus group activities, prefers spending time in room, television. The focus was initiated on 5/26/23 and revised on 5/19/25. The goal was for the resident to have a positive response to one-to-one activity, have daily socialization, and continue to pursue independent activities of choice, group programs, and accepting one-on-one visits to promote socialization and mental stimulation, encouragement and prevent episodes of depression to the extent possible. Interventions included assisting with in-room activities as needed, encourage socialization, provide activity calendar in room, and room visits one-on-one for socialization if needed. In an interview on 7/16/25 at 3:50pm, the Activity Director said she provided activities to the residents. She said her other job duties included working as a CNA and passing snack/drinks on the hydration cart. She said she liked to work as a CNA because she got to interact with the residents and visit with them. She said she provided one-to-one activities to Resident #1, but stated, we don't do much because he is a little quiet. She said she documented her one-to-one activities in the electronic medical record. Record review of Resident #1's Follow-up Question Report dated June 2025 revealed the following on-on-one visits were conducted by the Activity Director: - 6/4/25- response- not applicable. - 6/10/25- response- resident refused. - 6/18/25- response- resident refused. - 6/23/25- response- music. - 6/27/25- response- grooming, phone conversation. - 6/30/25- response- brushing hair, grooming. Record review of Resident #1's Follow-Up Question Report dated June 2025 revealed the following self-directed/independent activities were documented by the Activity Director: - 6/3/25- response- independent leisure, resting/relaxing. - 6/6/25- response- resting/relaxing, watching TV. - 6/9/25- response- socializing with staff, watching TV. - 6/11/25- response- watching TV. - 6/17/25- response- resting/relaxing, watching TV. - 6/18/25- response- watching TV. - 6/23/25- response- watching TV. - 6/25/25- response- watching TV. Record review of Resident #1's Task Report dated July 2025 revealed he participated in no group activities, participated in a self-directed/independent activity on 7/7/25, and participated in on-on-one visits on 7/1/25 and 7/16/25. In an observation and attempted interview on 7/15/25 at 9:27am, Resident #1 was lying in bed alert and awake. He was repeatedly scratching his head and mustache with his finger. His curtains were pulled shut so he could not see outside, and his room was dark. The TV was showing an old black and white movie. Surveyor attempted to interview Resident #1 without success. In an observation on 7/15/25 at 3:50pm, Resident #1 was lying in bed, alert and awake. His curtains were pulled shut so he could not see outside, and his room was dark. The TV was showing an old black and white movie. In an observation on 7/16/25 at 11:25am, Resident #1 was lying in bed, asleep. His curtains were pulled shut so he could not see outside, and his room was dark. The TV was showing an old black and white movie. In an observation on 7/16/25 at 3:19pm, Resident #1 was lying in bed, awake and alert. His curtains were pulled shut so he could not see outside, and his room was dark. The TV was showing an old black and white movie. Record review of the facility's activity calendar dated June 2025 and July 2025 revealed in-room activities were scheduled daily Monday through Friday at 10:00am, except for 7/4/25. In an observation and interview on 7/16/25 at 4:52pm, CNA R entered Resident #1's room and opened the curtains so he could look outside. She said he liked to look outside. She said he liked to watch racecars and old western movies on TV. In an interview on 7/17/25 at 1:34pm, Resident #1's Family Member said Resident #1 loved music because he used to be a drummer, could play saxophone and sing. She said he played in a band. She said he also loved to fish and hunt. She said he liked watching football, baseball and car racing. She stated she lived in a different state and does not visit often. Record review of the facility policy regarding Activity Programs dated June 2018 read in part, Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. 'Activities' are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs.

Based on observation, interview and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 6.25% based on 2 errors out of 32 opportunities, which involved 1 of 3 residents (Resident #17) and 1 of 1 staff (MA G) observed during medication administration reviewed for medication error. 1. The facility failed to ensure Resident #17's Ferrous Gluconate 324 mg was administered as ordered as FeroSul (Ferrous Sulfate) 325 mg was administered on 7/16/25 at 8:58 a.m. 2. The facility failed to ensure Resident #17's Lidocaine 4% patch was administered as ordered as order stated patch was to be placed on sacrum (base of the spine) and was placed on right shoulder on 7/16/25 at 8:58 a.m. The failure could place residents at risk of not receiving therapeutic dosages and/or effects of medications. Findings included: Record review of Resident #17's face sheet dated 7/19/2025, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy (change in brain function caused by systemic metabolic disturbances) and Anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues). Record review of Resident #17's quarterly MDS dated [DATE], section C revealed a BIMS score of 9 that indicated moderate cognitive impairment. Record review of Resident #17's Order Summary Report with active orders as of 7/16/25 revealed doctor's orders for Ferrous Gluconate Oral Tablet 324 (38 Fe) mg to be given one time a day for iron supplement and Lidocaine External Patch 4% to be applied to sacrum (base of the spine) topically one time a day for pain and removed per schedule. Record review of Resident #17's July 2025 MAR revealed documentation of Ferrous Gluconate 325 mg and Lidocaine External Patch 4% were administered on 7/16/25. Observation on 7/16/25 at 8:58 a.m. revealed MA G administered FeroSul (Ferrous Sulfate) 325 mg orally to Resident #17 and placed Lidocaine 4% patch to Resident #17's right shoulder. Resident #17 said he had pain to his right shoulder and said he wanted the Lidocaine patch to his right shoulder. During interview on 7/16/25 at 9:17 a.m., MA G said an adverse reaction a resident can have from a medication error was that potentially a resident could die, and she tried to be super cautious. During interview on 7/16/25 at 11:16 a.m., the Pharmacist said there was only a different in salt between Ferrous Sulfate and Ferrous Gluconate and ordering was usually a preference. The Pharmacist said the activity of the drug referring to Ferrous Sulfate and Ferrous Gluconate did not affect the iron level in the blood regarding the difference between the two medications. The Pharmacist said there was not an advantage in one over the other referring to Ferrous Sulfate and Ferrous Gluconate but what was given should be what was prescribed. The Pharmacist said that there were no adverse effects regarding a Lidocaine patch not being placed where ordered but if there was a location specified in the order that should be followed. The Pharmacist said they should get the doctor or NP to clarify the order to the shoulder for the lidocaine patch, but the medication would still be distributed transdermally (absorbed through the skin into the bloodstream). The Pharmacist said orders like for lidocaine patch should have a specific area for the order to be placed. During interview on 7/17/25 at 1:24 p.m., MA G said the Pharmacist said to make sure to order the Ferrous Gluconate yesterday and they got the new bottle this morning. MA G said residents mostly always have the 325 mg for Ferrous ordered. MA G said Resident #17 had been refusing the Lidocaine patch until yesterday for many months and will ask for patch in different spots but originally was ordered for his sacrum a couple months ago. MA G said medication training included online training that consisted of two online programs. MA G said the Pharmacist will educate us when she sees issues and the DON will come to us with changes as they happen. Record review of facility's policy Administering Medications revised December 2012 revealed medications shall be administered as prescribed.

Number of residents sampled: Number of residents cited: 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 and communicable disease and infections for 1 of 17 residents (Resident #5) reviewed for infection control in that: Resident #5's urinary catheter tubing was observed touching the floor twice on 7/15/2025. This failure placed residents at risk for infections and decrease in quality of life. Findings included: Record review of Resident #5's admission Record generated on 7/17/25 revealed she was admitted to the facility on [DATE] with diagnoses of traumatic subdural hemorrhage (a type of brain injury where blood collects in the outer membrane covering the brain), seizures (uncontrolled jerking, loss of consciousness or blank stares caused by abnormal electrical activity in the brain), dysphagia (difficulty swallowing foods or liquids), diabetes type II (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), obesity, cardiac arrest (sudden, unexpected loss of heart function, breathing and consciousness) and acute kidney failure. She was [AGE] years of age. Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed she was dependent on staff for personal hygiene, transfers and bed mobility tasks. She had urinary incontinence and used an indwelling catheter (a thin, flexible tube inserted into the blader to drain urine and is left in place for a period of time). Record review of Resident #5's physician orders revealed she had orders for the following: - Indwelling catheter to promote wound closure, monitor for signs and symptoms of infection, with an order date of 6/13/25. - Enhanced barrier precautions during high contact resident care activities secondary to wound, g-tube (a small, flexible tube inserted through the abdomen and stomach wall to deliver nutrition, fluids and medications directly into the stomach) and foley catheter use, with an order date of 6/23/25. Record review of Resident #5's Medication Administration Record dated July 2025 revealed facility nurses, including LVN A and LVN C, were ensuring Resident #5's indwelling urinary catheter was in a privacy bag and the leg strap was in place during each shift three times daily from 7/1/25-7/17/25. In an observation on 7/15/25 at 10:51am, Resident #5 was lying in bed. Her bed was in a low position. Her catheter drainage bag was lying flat on the floor on the left side of her bed. The drainage bag was uncovered, and a hook was on top of the bag. In an observation on 7/15/25 4:13pm, Resident #5 was lying in bed. Her bed was in a low position. Her catheter drainage bag was touching the floor on the left side of her bed. The drainage bag was uncovered. In an interview on 7/16/25 at 3:20pm, LVN C said Resident #5's catheter drainage bag is supposed to be hung on the bed, so it did not touch the floor. She said the purpose of it being off the floor was to avoid infections. In an interview on 7/17/25 at 11:00am, LVN A said Resident #5's catheter drainage bag was usually hung on the side of her bed with a hook. She said the bag could fall off or slip off when repositioning or moving the bed. She said the resident was at risk for infections if the drainage bag was touching the floor. In an interview on 7/17/25 at 3:20pm, The DON said nurses completed rounds every 2 hours and should check for catheter placement every shift. She said a catheter drainage bag could fall on the floor if the hook was loose, the resident was repositioned, or if the bag was not hooked on completely. She said if a catheter drainage bag was on the floor, it could cause an infection by climbing up the tubing. Record review of the facility's policy regarding Catheter Care, Urinary dated September 2014 read in part, The purpose of this procedure is to prevent catheter-associated urinary tract infections. infection control. be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 4 of 5 staff (CNA K, Wound care nurse, CMA N, and Laundry aide A ) and one(linen closet W) out of two clean linen closet observed for infection control. 1. The facility failed to ensure CNA K followed proper infection control and hand washing procedure during incontinent care for Resident #24. wound care. 2. CMA N did not sanitize the plastic medication container after using to administer medication for Resident #20 3. CMA N did not wash her hands prior to administering eye drops for Resident #24. 4. The facility failed to ensure to ensure clean item was not stored on the floor in the west clean linen closet. 5. The facility failed to ensure laundry aide A followed proper hand washing technique and infection control procedure when she demonstrated hand washing after loading dirty linen in the washing machine. These failures could place the residents at risk for infection. Findings included: 1.Record review of Resident #24 face sheet dated 05/30/24 revealed a [AGE] year-old male was admitted to the facility on [DATE]. Resident [NAME] had diagnoses included: hypertensive heart disease (a group of heart problems that occur when high blood pressure is present over a long period of time), peripheral vascular disease (is a circulatory condition that occur when blood vessels outside of the heart and brain narrow, block blood flow to other parts of the body), diabetes mellitus (a disease of inadequate control of blood levels of glucose), and hemiplegia(paralysis that affects only one side of the body). Record review of Resident 24's quarterly MDS assessment dated [DATE] revealed: Resident [NAME] had BIMS of 14 out of 15 indicated intact cognition. Further review revealed Resident [NAME] was extensive to depended on staff for ADL care. Record review of Resident #24's Physician orders reflected the following order: -Dated 12/29/2022 Dorzolamide-timolol instill 1 (one) drop in both eyes two times a day for glaucoma. Record review of Resident #24's care plan initiated 08/11/21 revealed Resident [NAME] has ADL self-care performance deficit related to disease process CVA with right sided Hemiplegia. Intervention: Toilet use: The resident is not toileted, requiring incontinent episode care with each incontinent episode. Further review of the care plan revealed dated 00/13/23 that resident was being care planned for impaired vision related to glaucoma with intervention to administer eye drop dorzolamide-timolol 1 drop in both eyes two times a day for glaucoma. During an observation on 05/29/24 at 10:30 a.m., CNA K provided incontinent care for Resident #24. CNA K changed her gloves but did not wash or sanitize her hands before she donned other gloves after cleaning the Resident #24 peri area. CNA K used the same gloves she cleaned Resident#24's buttocks and rectum, applied a clean incontinent brief, and repositioned and covered Resident #24. CNA K washed her hands after she provided care for Resident #24, and she used the wet paper towel which was wet and turned off the water faucet. During an interview on 05/29/24 at 10:56 a.m., CNA K said there was no reason for not sanitizing her hand when she changed her gloves after she cleaned Resident #24 peri area. She said she did not have sanitizer with the incontinent care supply on the table. CNA K said hands are sanitized to prevent the spread of germs. CNA K said she forgot to change the gloves after she cleaned Resident #24 buttocks and rectum before she took the clean brief with the dirty gloves and applied the brief on Resident #24. CNA K said she could have transferred the germs from the dirty gloves to the clean brief. CNA K said she was in service on infection control, including PPE and hand washing. CNA K said she used the same paper towel, dried her hands, and turned off the water tap. CNA K said she could have reinfected her hands with the germs. CNA K said if the germs get to the residents, they could get an infection. CNA K said the nurse monitors the aide during care, and she had skills check-off and in-service in providing incontinent care for the residents. During an interview on 05/30/24 at 1:48 p.m., the DON said CNA K should have sanitized her hands when she changed her gloves after she cleaned Resident #24's peri area. The DON said CNA K should have changed her gloves before she took a clean incontinent brief and applied it to Resident #24 before dressing him. The DON said CNA K could have put Resident #24 at risk of infection when she dressed him with dirty gloves. During an interview on 05/31/24 at 9:34 p.m., the DON said he expected CNA K to follow the infection control procedures they were in serviced on monthly, which included hand washing. The DON said he expected CNA K to use a dry paper towel to turn off the water faucet to prevent cross-contamination. 2.Observation on 05/30/2024 at 9:00AM CMA N walked in Resident #24's room with a pair of gloves in hand to administer the medication eye drop dorzolamide-timolol. Resident #24 asked for a soda out of his personal fridge. CMA N got the soda out of the fridge and gave to Resident #24. CMA N proceeded to place the pair of gloves on without washing her hands and proceeded to administer the eye drop 1 drop in each eye. After administering the eye drops, CMA removed her gloves and washed her hands. Interview on 05/30/2024 at 9:08AM CMA N said the reason she had not washed her hands prior to administering eyedrops to both of Resident #24 eyes was because she had already washed her hands earlier in another resident room after administering medications and therefore did not feel she needed to wash her hands again. CMA N said she became nervous and forgot to wash her hands again prior to administering eye drops to Resident #24. Interview on 05/30/24 at 9:35AM the DON said he was the NF Infection Control Nurse and the Infection Control Preventionist. The DON said the staff received in-services monthly on infection control. The DON said when administering eyedrops, one should wash hands prior to administering eyedrops and afterwards for infection control. Record review of the facility policy on Instillation of Eye Drops dated 2001 revealed in part: .The purpose of this procedure is to provide guidelines for installation of eye drops to treat medical conditions, eye infections and dry eyes .wash and dry your hands thoroughly .put on gloves . 4. Record review of Resident #20's face sheet dated 05/01/2024 revealed an 83year old male admitted to the NF on 04/12/2024. Resident diagnoses included the following: type two diabetes mellitus (when the body has difficulty controlling blood sugar and using for energy), dementia (memory loss and judgement), peripheral vascular disease (narrowing of blood vessels causing a decrease in blood flow to the limbs), dysphagia (difficulty swallowing), and muscle weakness. Record review of Resident #20's MDS dated [DATE] revealed that resident had a BIMS score of 10 indicating that resident cognition was moderately impaired. Record review of Resident #20's Physician Orders for the month of May 2024 reflected the following orders: -Aspirin 81mg give 1 (one)tablet by mouth once a day -Plavix 75mg give 1 tablet by mouth once a day -Miralax 17 gm by mouth once a day (mix in 8 ounces of water) -Senna 8.6mg give 1 tablet by mouth once a day -Acetaminophen 500mg give 1 tablet by mouth three time a day -Lidocaine Patch 4% apply to right leg, left leg, and back topically one time a day for pain, remove after 12 hours and remove per schedule Observation on 05/30/24 at 8:12AM CMA N placed Resident #20's medications inside of a clear plastic container and carried into Resident #20's room to administer. CMA N placed the clear plastic container on top of Resident #20's bedside table. When CMA N finished administering the medications, she washed her hands and took the medication container out of the room and placed on top of another medication cart and proceeded to go down the hallway. Interview on 05/30/24 at 8:48AM CMA N said she sanitized the plastic medication bend once a day on her shift but guessed she could have sanitized the plastic container after removing from Resident #20's room. CMA N said the last in-service she received on infection Control was about a year ago regarding CNA as it related to resident care. CMA N said she done this in-service/training online. Interview on 05/30/24 at 9:35AM the DON said when medication containers are taken in a resident room, the container must be sanitized after each use because of infection control. Record review of the facility policy on Instillation of Eye Drops dated 2001 revealed in part: .The purpose of this procedure is to provide guidelines for installation of eye drops to treat medical conditions, eye infections and dry eyes .wash and dry your hands thoroughly .put on gloves . 5. During an observation and interview with the maintenance director on 05/30/24 at 11:27 a.m., it was revealed that a deflated air mattress was in a clear trash bag and on the floor under the rack in the west clean linen room. The Maintenance director said the bag with the air mattress should not be placed on the floor because of infection control. The maintenance director said he did not know who placed it on the floor, and it should not be stored in the clean linen room. 6. During an observation and interview on 05/30/24 at 11:37 a.m., Laundry aide A demonstrated how she would wash her hands after she loaded the washer with dirty linen before she went over to the clean linen. Laundry aide A turned the water faucet off with her wet hand and then dried her. The maintenance director interpreted for laundry aide A, and she said she forgot to dry her hands first before she turned off the water faucet with dry paper. Laundry aide A said she should have turned off the water faucet with a dry paper towel to prevent infection control. Record review of the facility Policy on Handwashing/Hand Hygiene revised October 2023 revealed in part . This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .Indications of hand hygiene .immediately before touching a resident and after touching a resident .Indications for Hand Hygiene . #1Hand hygiene is indicated #1f . before moving from work on a soiled body site to a clean body site on the same resident .#1g .immediately after glove removal . Washing Hand #4 . Use towel to turn off the faucet . 36918

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs to meet the needs for 1 of 9 Residents (#36) reviewed for pharmacy services in that: Register Nurse (RN) A failed to follow medication administration policies resulting in Licensed Vocational Nurse (LVN) A attempting to give Resident #36 a double dose of resident's 8:00 a.m. prescribed medications. RN A failed to document the start date for Resident #36's medications. Failures could place all residents at risk of drug diversion, health decline, and/or death. Findings included: Record review of the Face Sheet for Resident #36 reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: end stage renal disease, dependence on renal dialysis, atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, with a primary diagnosis of hypertension. Record review of Resident #36 Minimum Data Set (MDS) assessment, dated 03/08/2024, reflected a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intake. Record review of Resident #36's Care Plan with a printed date of 05/31/2024, reflected the following: Focus: Cardiac: Resident is at risk for cardiac issues related to atrial fibrillation, coronary artery disease, hypertension Date Initiated: 12/10/2022 Revision on: 3/29/2023. Goals: Resident will be compliant with medication regimen for cardiac health issues through next review Date Initiated: 12/10/2022 Revision on: 01/29/2024 Target Date: 06/26/2024. Resident will not have any symptoms of cardiac distress through next review Date Initiated: 12/10/2022 Revision on: 01/29/2024 Target Date: 06/26/2024. Resident will have blood pressures within the following parameters through next review Date Initiated: 12/10/2022 Revision on: 01/29/2024 Target Date: 06/26/2024. Interventions/Tasks: Monitor vital signs as indicated and Notify Medical Doctor (MD) as needed Date Initiated: 12/10/2022. Notify MD of symptoms of cardiac distress such as chest pain; irregular heart rate; fainting; numbness; pain or tingling in extremities, neck, or upper back; cold sweats; dizziness; increased or decreased blood pressure Date Initiated: 12/10/2022. Observe for edema, weight gain, and adventitious lungs sounds and report to MD when needed date Initiated: 12/10/2022. Observe for side effects or cardiac medications Date Initiated: 12/10/2022. Record review of Resident #36's electronic medication administration record (EMAR) dated 05/31/2024 reflected LVN A administered the following 8:00 a.m. medications: Amlodipine Besylate Oral Tablet 5 MG for high blood pressure. Do not give if systolic is < 120 diastolic <60. Blood Pressure (bp, ): Finasteride Tablet 5 MG for benign prostatic hypertrophy (BPH). Lidoderm External Patch 5 % to relieve the pain. Sertraline HCL tablet 50 mg for depression. Amiodarone HCL tablet 200 mg for arrythmia. Apixaban tablet 5 mg for blood clot prevention. Record review of Resident #36's EMAR creation date 05/31/2024 at 02:11 p.m. reflected Captopril Tablet 25 MG Give 12.5 mg by mouth every 24 hours as needed for elevated bp greater than 170 PRN Administration was: Ineffective. Author RN A. Interview on 05/31/2024 at 10:39 AM Resident #36 stated he had a dialysis chair time of just 6 a.m. on 05/31/2024. He stated just before going to dialysis, RN A gave him his morning meds. He stated around 8:00 a.m., while still in dialysis LVN A attempted to pass him his morning meds again. He stated he denied the meds informing LVN A he had already received them. He stated he feared had he not been alert; he would have received a double dose of medications. Interview on 05/31/2024 at 11:46 a.m. LVN A stated she had been a nurse with the facility for 3-years. She stated that on 05/31/2024 her shift began at 6:00 a.m. but she arrived at 6:30 a.m. and began passing meds. She stated at about 7:00 a.m. she entered the dialysis room and recorded Resident #36's bp from the dialysis machine he was hooked up to and asked resident had he gotten his morning meds. She stated Resident #36 told her he had received his meds from RN A. She stated that the eMAR reflected that Resident #36 had not received his meds. She then signed off on Resident #36's meds. She stated that had not happened before. She stated because she late, RN A covered for her morning med passes until she arrived. Interview on 05/31/2024 at 11:58 a.m. the DON stated that he was not aware that LVN A had signed off on meds administered by RN A. The DON stated the staff that administers medication should be the staff who signed off on medications, to ensure it was giving and to follow the 6th rights of the medication. The DON stated the medication policy stated that meds were to be given 45 minutes before dialysis begins unless it was a bp medication. He stated the EMAR would not allow staff to sign-off on medications passes without adding a resident's bp. He stated Resident #36's bp fluctuates and was often very high and that was the reason resident received his medication prior to dialysis. He stated medication can be passed to dialysis residents before, during or after dialysis and could be nursing judgement. He stated he would check the actual time Resident #36 received dialysis and provide documentation. Interview on 05/31/2024 at 01:35 p.m. the MD stated that because Resident #36's bp runs high it was fine to administer his bp medication prior to dialysis. He stated that enough of the medication would be absorbed to benefit the resident. He stated the resident's medication doses were adjusted to compensate for the dialysis treatments. Interview on 05/31/2024 at 03:17 p.m. Resident #36 stated that most often he takes his morning meds before dialysis. He stated if his bp was below 125, he would hold all meds until after dialysis and if it was higher than 125, he would take all meds. He stated his chair time was at 6am. He stated that the staff get him up in the morning sometime around 5:00 a.m. and to dialysis at 5:30 a.m. Interview on 05/31/2024 at 3:37 p.m. the DON stated that Resident #36 was given his bp meds around 5:00 a.m. on 05/31/2024 just before dialysis because the resident's bp was high. He stated that the resident has a PRN of captopril every shift and as needed. He stated RN A should have informed MD that the resident's bp was high and if the medication did not work, and a progress note was made by RN A 05/31/2024. Interview on 05/31/2024 at 11:06 p.m. RN A stated he had worked at the facility nearly 2-years. He stated that Resident #36 had a 6:00 a.m. dialysis chair time on 05/31/2024. He stated took resident's vitals at 5/5:06 a.m. and resident's bp was 172/80. He stated that resident had a prescription for captopril 12 mgs to be administered prn. He stated that he took the vitals again and after 6am and it was 159/75 and since it was still high, he called the MD who told him to administer all the resident's morning meds. He stated he administered the meds that were normally assigned for the LVN A to administer: He stated he was rushing off shift and forgot to sign off on administering Resident #36' meds or complete the progress note regarding the MD's order to administer the prn medication. He stated the importance of checking off on administering resident's medications was to ensure that the residents do not receive double doses He stated it was all on him that the meds were not signed off and notes not entered regarding the MD's instructions. He stated had an in-service on med administration about 2-weeks ago. Record review of policy Medication Administration Schedule with a revised date of November 2020 reflected: Scheduled medications are administered within one (1) hour of their prescribed time, unless otherwise specified. Record review of policy Medication and Treatment Orders with a revised date of July 2016 reflected: Policy Statement Orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation 7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date, and the time of the order.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #41) reviewed for incontinent care. The facility failed to ensure Resident #41's foley bag was not place on the bed during wound care. This failure could place residents at risk for pain, infection, injury, and hospitalization . Findings included: Record review of Resident #41's face sheet dated 05/30/24 revealed a [AGE] year-old male was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #41 had diagnoses included: hypertension (blood pressure in the blood vessels is too high), cerebral infraction (damage to tissues in the brain due to loss of oxygen to the area), diabetes mellitus (a disease of inadequate control of blood levels of glucose), and atherosclerotic heart disease( thickening or hardening of the arteries). Record review of Resident#41's admission MDS assessment dated [DATE] revealed: Resident #41 had BIMS of 12 out of 15 indicated moderate impaired cognition. Further review revealed Resident #41 had an indwelling foley catheter. Record review of Resident #41's care plan dated 03/2724 revealed Resident #41 has foley catheter. Interventions: Monitor/record/report to MD for s/sx UTI: pain, burning, blood-tinged urine, Record review of Resident #41's physician order dated May 2024 read in part . Indwelling catheter DX: urine retention, Monitor for S/S of Infection, initiated on 03/08/24 . During an observation on 05/29/24 at 2:17 p.m., the wound care nurse placed Resident #41's Foley bag on the bed from 2:18 p.m. to 2:28 p.m. during wound care, and the urine backed up into the Foley tube. During an interview on 05/29/24 at 2:42 p.m., the Wound care nurse said she placed Resident #41's Foley bag on the bed, and it was at the same leave as the bladder. The wound care nurse said the Foley bag should be placed below the bladder for the urine to drain by gravity. The wound care nurse said Resident #41 could have a UTI if the urine flowed back into his bladder. The wound care nurse said she had in service on Foley care, and the DON and ADON monitored the nurses to ensure they were providing care appropriately when they made random checks. During an interview on 05/30/24 at 1:52 p.m., the DON said placing Resident #41's Foley bag on the bed could have caused pressure, urine flow backward, and infection. The DON said the Foley bag should always be below the Resident's bladder. The DON said she and the ADON monitored the nurses when they make random rounds and talk to the residents about care. Record review of the facility policy on catheter care urinary dated 2001 MED - PASS, Inc. read in part . The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections . Maintaining Unobstructed Urine Flow .#3 Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder .

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 2 of 4 residents (Resident #10 and #11) reviewed for respiratory therapy in that: The facility failed to ensure Resident #10 and Resident 11's oxygen was set according to physician orders. This failure could place residents at risk of respiratory distress. The findings were: 1. Record review of Resident #10's face sheet dated 05/30/24 revealed an [AGE] year-old female was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #10 had diagnoses included: respiratory failure (a serious condition that makes it difficult to breathe on your own) and chronic obstructive pulmonary disease (a long - term lung disease that makes it hard to breath. Record review of Resident #10's quarterly MDS assessment dated [DATE] revealed: Resident #10 had BIMS 12 indicated moderately impaired cognition. Further review revealed it was not indicated Resident #10 was on oxygen. Record review of Resident #10's care plan dated 01/29/24 revealed the resident was on oxygen. Intervention: monitor and report signs of hypoxia (cyanosis, tachypnea, dyspnea, confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, increased pulse) to physician Record review of Resident #10 physician order dated May 2024 read in part . O2 @2-3LPM via nasal cannula continuous per concentrator every shift ordered date 5/29/2024 . During an observation on 05/29/24 at 9:20 a.m., it was revealed that Resident #10's oxygen concentrator was set on 4L. Resident #10 did not respond when asked if she knew where the oxygen should be set on the concentrator. During an interview on 05/29/24 at 11:28 a.m., LVN M said he had not checked Resident #10's oxygen setting since he came to work today and needed to know how many liters of oxygen Resident #10 should be on. LVN M said he would guess 2 to 3 Liters because that was what most residents ordered for oxygen. LVN M stated that you must get an order from the physician to increase or decrease the oxygen setting. LVN M said if Resident #10 was having any crisis, the nurse could increase or decrease the oxygen, notify the doctor, and follow the doctor's order. LVN M said the night nurse did not tell him Resident #10 had any crisis or emergency with regrade to respiration. During an interview on 05/30/24 at 1:31 p.m., the DON said LVN M should have checked Resident #10's order to make sure the O2 was set as ordered, and it was the same negative outcome for the resident as the previous resident. The DON said the ADON, ADON, NP, or the doctors monitor the nurses. The DON said they monitor the nurses by checking the EMAR and ETAR to see if the nurses have signed off, and each department head checks on the residents. During an interview on 05/31/24 at 3:40 p.m., the ADON said her expectation was for LVN M was to check Resident #10 oxygen setting upon coming to the shift and check on the setting sparingly through his shift. The ADON said that for Resident #10 to be on oxygen, the resident should have a physician's order and that the setting on the concentrator should match the order. The ADON said it depended on what Resident #10 diagnoses were, and if Resident #10 got more oxygen than required, Resident #10 could have a negative outcome. The ADON did not respond on what type of outcomes. The ADON said the nurse must have a physician order to increase or decrease the oxygen setting. The ADON said the facility had a respiratory therapist who came and educated the nurses, and the DON, ADON, monitored the nurses. 2. Record review of Resident 11's face sheet dated on 05/31/24 revealed a [AGE] year old male was administered to the facility on [DATE]. Resident #11 Resident #11 had diagnoses included: dyspnea(shortness of breath), and chronic obstructive pulmonary disease(a long - term lung disease that makes it hard to breath). Record review of Resident #11's admission MDS dated [DATE] revealed: Resident #11 had a BIMS of 15 which indicated intact cognition. Further review revealed Resident #11 was on oxygen therapy. Record review of Resident 11s care plan dated 03/28/24 read Oxygen: Resident requires the use of oxygen related to chronic obstructive pulmonary disease. Intervention: educate the resident on the importance of keeping oxygen on and at the prescribed setting. O2 @_3_LPM via nasal cannula continuous per concentrator. Record review of Resident 11's physician's order dated May 2024 read in part . O2 @3-4LPM via nasal cannula continuous per concentrator every shift ordered date 5/31/2024 . During an observation on 05/29/24 at 9:46 a.m., Resident #11's oxygen was set at 6 liters on the concentrator. Resident #11 could not verbalize where the oxygen was supposed to be set. During an interview on 05/29/24 at 11:16 a.m., LVN M said the oxygen was set at 6 Liters on the concentrator, but Resident #11's 02 should be set between 3 and 4. LVN M said Resident #11 should have an order if the oxygen would be higher than the previous order. LVN M said Resident #11's friend usually changes the setting, and everybody was aware of it. LVN M said Resident #11 could have a negative out when given more oxygen than ordered. LVN M said he did not report to the DON; he just told the hospice nurse that Resident #11's friend increased the setting on the concentrator. LVN M said the nurse he took over from today did not give him any report that Resident #11 had any issue that would warrant the oxygen to be increased. LVN M said he had not checked Resident #11's oxygen setting since he came to work today and would check the oxygen setting whenever he got to the resident's room because he was the only nurse for 35 residents. During an interview on 05/30/24 at 1:16 p.m., the DON said for Resident #11 to be on oxygen, Resident 11 must have a doctor's order, and when the setting was increased or decreased, the doctor must give an order. The DON said LVN M should know, and the nurse should fix the setting on the concentrator according to the order. The DON said LVN M should make rounds every two hours to check on residents with oxygen and ensure oxygen was in the correct setting. The DON said if Resident #11 had an emergency, the nurse could change the setting to stabilize the resident, and the doctor would be notified as soon as the resident was stabilized and followed the physician's order. The DON said that depending on Resident #11's diagnosis, the resident's health could worsen if the oxygen was set above or below the resident's order. The DON said Resident #11's physician knew the family's increasing O2. The DON said he had to check the physician's statement and get back to the surveyor. Record review of the facility policy on oxygen administration dated 2001 MED - PASS, Inc. revision date October 2010 read in part . The purpose of this procedure is to provide guidelines for safe oxygen administration . Preparation . 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .

Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster door was secured. This failure could place all residents at risk of infections, pests, and rodents from improperly disposed garbage. Findings included: Observation and interview on 05-29-2024 at 8:21 am, revealed the facility's commercial size dumpster 1/4 full of garbage door on the right side was wide open. The [NAME] stated the dumpster door should remain closed at all times to keep the bugs from getting inside. Interview on 05-29-2024 at 08:34 a.m. Dietary Manager (DM) stated the dumpster door should remain closed for infection control issues and to keep the bugs away. Interview on 05-29-2024 at 03:33 p.m. the Administrator stated all the staff do their best to ensure the dumpster remains closed and kept closed. He stated they had systems in place to avoid the door being found opened to include multiple monthly in-services with all departments on infection control and the DM checks the dumpster at the beginning of his shift. He stated there are multiple sources have accesses to the dumpster outside of the facility staff but ultimately it was the facility's responsibility to ensure the dumpster door remained closed. Record review of policy titled Garbage and Refuse Disposal with a revised date of October 2021 revealed: Food-related garbage and refuse are disposed of in accordance with current state laws. Policy Interpretation and Implementation 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

Based on interviews and records reviewed, the facility failed to develop and implement a baseline care plan that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 4 (Residents #92, #210, #212 and CR #93), of 8 residents reviewed for baseline care plans. -The facility failed to complete a baseline care plan within the required 48-hour timeframe for Residents #92, #210, #212, and CR #93. This failure could place residents at risk for not receiving necessary care and services or not having important care needs identified. The findings included: Resident #92 Record review of Resident #92's face sheet dated 05/11/23, revealed an [AGE] year-old female with an admitted [DATE]. Diagnoses included urinary tract infection, site not specified, enterococcus as the cause of disease classified elsewhere (infection usually present around vagina, rectum), hemoglobinuria due to hemolysis from other external causes (presence of hemoglobin in the urine), type 2 diabetes mellitus with hyperglycemia (elevated blood glucose level), moderate protein calorie malnutrition (imbalance of nutrients), and major depressive disorder. Record review of Resident #92's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating cognitive impairment. Functional status revealed resident required one-person physical assist with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Record review of Resident #92's baseline care plan, dated 04/24/2023, revealed Section II. Social Services was incomplete. Resident #210 Record review of Resident #210's face sheet dated 05/11/23, revealed a [AGE] year-old male with an admitted [DATE]. Diagnoses included non-pressure chronic ulcer of other part of right foot with unspecified severity (localized injury to the skin or underlying tissue), syphilis unspecified (sexually transmitted infection), chronic viral hepatitis C (viral infection that causes inflammation to the liver), type 2 diabetes mellitus with hyperglycemia (elevated blood glucose level), hypertensive heart disease with heart failure (heart condition caused by high blood pressure), and chronic ischemic heart disease unspecified (heart problems caused by narrowing heart arteries). Record review of Resident #210's baseline care plan, dated 05/02/2023, revealed Section II. Social Services was incomplete. Resident #212 Record review of Resident #212's face sheet dated 05/11/2023, revealed a [AGE] year-old male with an admitted [DATE]. Diagnoses included encounter for orthopedic aftercare following surgical amputation (removal of limb), acquired absence of left foot, type 2 diabetes mellitus with hyperglycemia (elevated blood glucose level), hypertensive heart disease without heart failure (heart condition caused by high blood pressure), and unspecified atrial fibrillation (irregular heart rhythm). Record review of Resident #212's baseline care plan, dated 05/02/2023 revealed Section II. Social Services was incomplete. CR #93 Record review of CR #93's face sheet dated 05/11/2023, revealed a [AGE] year-old male with an admitted [DATE] and discharge date of [DATE]. Diagnoses included posterior reversible encephalopathy syndrome (condition in which parts of the brain are affected by swelling), muscle weakness generalized, type 2 diabetes mellitus without complications (high blood sugar), alcohol use unspecified with withdrawal unspecified, hypertensive emergency (severe elevation in blood pressure), acute respiratory failure with hypoxia (respiratory failure where the level of oxygen becomes dangerously low), and unspecified abnormalities of gait (walking) and mobility. Record review of CR #93's baseline care plan, dated 03/13/2023, revealed Section II. Social Services was incomplete. During an interview on 05/10/2023 at 10:45 a.m., the Director of Nursing (DON) said the timeframe to have the baseline care plan completed was 24 to 48 hours after the resident was admitted to the facility. He said if it was not completed within the required timeframe, the resident and/or family would not be aware of their baseline care and the evaluations from all the departments at the facility. He said they had a full-time social services assistant who was responsible for completing the social services portion of the baseline care plan. He said the social services portion was usually delayed because she had to see what the resident's discharge plan was. During an interview on 05/10/2023 at 11:30 a.m., the Social Services Assistant said she had been working at the facility for over 2 years. She said she was responsible for completing the social services portion on the baseline care plan. She said the timeframe to have the baseline care plan completed was 24 to 48 hours after the resident was admitted to the facility. Record review of the facility's Care Plans - Baseline undated, read in part: Statement A baseline plan of care should be developed for each resident within forty-eight (48) hours of admission Interpretation and Implementation 1. The baseline care plan should include instructions needed to provide effective person-centered care of the resident which may include the following: a. Initial goals based on admission orders and discussion with the resident representative. b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendation, if applicable.

Based on observation and interview, the facility failed to dispose of garbage and refuse properly for 1 of 1 waste receptacle reviewed for garbage disposal. -The one dumpster contained waste and its two side doors were left open. This failure could place residents at risk for exposure to germs and diseases carried by vermin and rodents. Findings included: Observation on 05/09/2023 at 6:45 a.m. with the Cook revealed the dumpster's two side doors were open. Observation on 05/09/2023 at 3:40 p.m. with the Dietary Manager revealed the dumpster's side door was open. During an interview on 05/09/2023 at 6:46 a.m. the Cook, stated both side doors were left opened. She said the doors should always be closed. During an interview on 05/09/2023 at 3:41 p.m., the Dietary Manager stated one of two side doors was left opened. He said it should have been closed. Record review of the facility's Food-Related Garbage and Refuse Disposal revised date October 2017, read in part: Policy Statement: Food-related garbage and refuse are disposed of in accordance with current state laws. Policy interpretation and implementation 2. All garbage and refuse containers are provided with tight fitting lids or covers and must be kept covered when stored or not in continuous use. 5. Garbage and refuse containing food waste will be stored in a manner that is inaccessible to pests.

Based on observation, interview, and records reviewed, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen, reviewed for proper ice scoop storage in that: -The ice machine scoop was not stored in a covered container. This failure could place residents at risk for cross contamination and food-borne illness. Observation on 05/09/2023 at 3:45 p.m. revealed the ice machine scoop was being stored, uncovered, on the side of the ice machine. During an interview with the Dietary Manager on 05/09/2023 at 3:46 p.m., he said the ice scoop should be stored in an enclosed container. He said the container fell and broke last month. Record review of the facility's Ice Machines and Ice Storage revised date January 2012, read in part: Policy Statement: Ice machines and ice storage distribution containers will be used and maintained to assure a safe and sanitary supply of ice. Policy interpretation and implementation 2. To help prevent contamination of ice machines, ice storage chests/containers or ice, staff shall follow these precautions: e. Keep the ice scoop/bin in a container when not in use.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (LVN C) of 1 staff members reviewed for pharmacy services in that: LVN C stored Resident #44's Dorzolamide-Timolol 2-0.5% eye drops in the 2 West Medication cart uncapped. Resident #44s Dorzolamide-Timolol 2-0.5% eye drops was stored in the 2 West Medication cart without a cap while not in use. These failures could place residents receiving medications at risk for eye infections. Findings Include: Observation and interview on 5/10/2023 at 11:00 am revealed LVN C administering Dorzolamide-Timolol 2-0.5% eye drops to Resident #44's left and right eye. LVN C did not recap the eyedrop bottle. LVN C placed the opened eyedrop bottle in a pill bottle to store it in the 2 West medication cart. After Surveyor intervention, LVN C said if eye drops were not recapped, residents were at risk of getting bacteria leading to eye infections. She said the nursing staff were expected to recap eyedrops properly, using the cap to avoid cross-contamination when eyedrops were not in use. She said if eyedrop bottles were not recapped, the process was to order new eyedrops from the pharmacy. She said the inside of the pill bottle was contaminated so she should have recapped the eye drops to prevent contamination. She could not recall the last time she was in-serviced for infection control. In an interview on 5/10/2023 at 11:28 am with the DON, he said the expectation for storage of eye drops was to seal the eye drops properly by recapping the bottles. He said nursing staff should never administer eye drops to a resident if they discovered the eye drop bottle was not sealed properly with the cap being on because residents could get eye infections. He said the nursing staff were expected to seal eye drops properly, using the cap to avoid cross-contamination when eye drops were not in use. He said the expectation for storing eye drops was to date and recap the bottles. He said if there was no cap on eye drop bottles, the nursing staff were supposed to order new eye drops from the pharmacy. The DON said the nursing staff had been in-serviced for infection control in the month of May 2023. This Surveyor asked the DON why the failure occurred; he looked down. The DON had no response. Record review of facilities policy titled; Instillation of Eye Drops read in part . Recap the medication bottle .

Based on interview and record review, the facility failed to ensure allegations of abuse or neglect was reported immediately, but not later than 24 hours after the incident occurred, to other officials (including to the State Agency) for 1 of 8 residents (Resident #4) record reviewed for reporting. The facility failed to report an incident to the State Survey Agency (HHSC) immediately but not later than 24 hours of an incident of a missing resident on 7/31/22 involving Resident #4. This failure could place residents at risk for incidents involving resident safety not being reported to the State Agency by the facility. Findings included: Record review of the Admission Record for Resident#4 revealed he was [AGE] years old and was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed BIMS score of 09 out of 15 indicating moderately impaired cognitively. He required extensive assistance from one person physical assist with bed mobility, transfer, dressing, toilet use and personal hygiene. Record review Resident #4's comprehensive care plan initiated on 05/25/2022 and revised on 06/10/2022 had no indication Resident #4 was an elopement risk. Record review of P1 intake# 5 read in part: .on 07/31/22, Resident #4 was last seen around noon. Resident #4 eloped and was out of the facility for seven hours. Resident #4 had a medicine at 2:00 pm. It was not administered because the staff didn't find him in his room. The staff didn't report it. The facility didn't bother to look for him until supper time. The facility learned Resident #4 was at the emergency room . A person passing by saw Resident #4 in a wheelchair on the side of the road. The staff had to call the hospitals and found him at [hospital name]. Resident #4 was found around 6:00 pm or 7:00 pm. Administrator didn't want to file the report. He was told he had to by the veteran affairs . Record review of incident intake# 7 received date 08/02/2022 read in part: .Date and Time of the Incident: 7/31/2022 5:00:00 PM. Date facility first learned of Incident? 7/31/2022 4:45:00 PM. The reporter stated this is the first time the resident has eloped. The reporter stated the resident was noted by the front area, like he usually is, around 12:45 pm. The reporter stated the resident was admitted to the hospital at 1:30 pm, after a bystander noticed the resident, who is in a wheelchair, and called police. The police took the resident to the hospital. At the hospital, all vitals were normal and there were no injuries. The resident was noticed missing at dinner time (5:00 pm) and the facility located him at the hospital. The resident did not miss any medications while gone . In a telephone interview on 8/16/22 at 10:44a.m., with complainant, he said on 07/31/22, Resident#4 eloped from the facility. The resident was a veteran and did not have an elopement history at the facility. On 07/31/22, around 5:00 pm, the facility reported the resident had a visitor. The resident was visiting on the porch area. The nurse discovered he was not in the dining room for dinner. Staff began to search for the resident. The facility contacted the police and reported a missing person. The power of attorney/family member, called the facility management and hospitals in the area. On 07/31/22, Resident #4 was located at [hospital name] approximately half a mile away from the facility. On 07/31/22, the resident was admitted to the hospital. The resident's power of attorney/ family member stated the resident was found by a person in the community. He had the potential to be injured or hit by a vehicle. The hospital ran tests and completed lab work. The resident was diagnosed with confusion. He sustained an abrasion to the left big toe and left chin. The x-ray or CT scans (an X-ray image made using a form of tomography in which a computer controls the motion of the X-ray source and detectors, processes the data, and produces the image) results were unknown. Resident was admitted to the hospital. He said he expressed the concern to the administrator. The complainant felt the facility should ensure residents do not have the potential to elope during visitation. The facility should be aware of residents whereabouts at all times. The complainant would like to ensure veterans at the facility were assessed and revaluated to determine the potential for elopement. Should there be a potential for elopement, the facility should find appropriate placement with a secure unit. In an interview and record review on 8/16/22 at 2:03p.m., with the Administrator, he said on Sunday (7/31/22) at 12:45pm Resident #4 was observed by the Receptionist exiting the front patio per regular post-lunch routine to get some sunlight and fresh air. At 2:00pm the nurse attempted to administer the medication, but the resident was not in his room. At 2:45pm nurse reattempted to administer the [MEDICATION(S)] prior to the medication becoming overdue. At 2:50pm nurse was attempting to find the patient on her hallway. At 3:20pm nurse continue searching in common areas on West wing to locate the resident. At 3:45pm initiated a wide search in each room and their corresponding closets. At 4:25pm nurse completed further search on East wing but was unable to locate the resident still. At 5:00pm dinner trays rolled out and the CNA assigned was also unable to locate the resident and notified the nurse. He said it was a Sunday, management was not at the facility and at 5:30pm, the ADON, DON and himself were notified that the resident was missing and initiated a search party to locate the resident. Local police authorities were notified. At 6:00pm all local nearby hospitals were contacted and Resident #4 was found. He said he was responsible for submitting reports to the state agency. He said he used HHSC provider letter PL 19-17 for guidance on reporting. This Surveyor reviewed Long- term care regulatory provider letter PL 19-17 (Replaces PL 17-18) dated 7/10/ 2019 with the Administrator, he said, provider letter for missing resident was not clear if it was supposed to be reported within 24 hours or after 24 hours. In an interview on 8/18/22 at 2:39p.m., with the Administrator, he said Resident#4 left AMA on 7/31/22. He said family, police, physician and the VA were all notified of locating the resident. The VA inquired if this incident was reported to HHSC. The Administrator said he was facility's abuse prohibition coordinator. He said he discussed this with the Regional Director, and it was decided to call it in. He said he reported the incident on Tuesday (8/02/22). Record review of HHSC Long- term care regulatory provider letter PL 19-17 (Replaces PL 17-18) dated 7/10/ 2019 Title: Abuse, Neglect, Exploitation, Misappropriation of Resident property and other incidents that a nursing facility (NF) must report to the Health and Human Services Commission (HHSC) read in part: .An incident that does not result in serious bodily injury and involves: a missing resident. When to Report: Immediately, but not later than 24 hours after the incident occurs or is suspected .

Based on observation, interview and record review, the facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of one resident (Resident #1) of four residents reviewed for medication administration. -The facility failed to ensure Resident #1 received a scheduled dose of an anti-[CONDITION(S)] medication through gastrostomy tube as ordered by the physican. The resident sustained a [CONDITION(S)] [MEDICATION(S)] 10 minutes and was transferred to the hospital while still seizing requiring acute hospital evaluation and treatment. Resident continued seizing at hospital Emergency Department until stabilized. The failure could place residents at risk of medicinal adverse effects, decreased health status, being hospitalized , and possible death. An Immediate Jeopardy (IJ) was identified on 06/28/2022. While the IJ was removed on 06/30/2022, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy due to the need to evaluate the effectiveness of the corrective systems. Findings include: Record review of the Admission Record for Resident #1 revealed she was [AGE] years old, and she was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Transient Cerebral Attack (symptoms similar to a stroke that resolves), elevated white blood cell count, and seizures. Resident #1's physician was identified as the facility's attending physician (Doctor A). Record review of the Baseline Care Plan dated 06/30/2022 revealed it did not address the [CONDITION(S)] disorder . The Baseline Care Plan did not reflect an area to address 'seizures' in the Health and Safety list check boxes, and the box labelled 'Other' was not checked. The Baseline Care Plan did not reflect an area to address 'seizures' in the Goals for Care section check boxes. The check box for 'Other' was not checked. There was no section to address medications. Record review of the Admission Summary written by LVN B dated 06/17/2022 at 5:20 p.m. revealed Resident #1 arrived to the facility from hospital #1. The resident was awake, oriented and alert at that time. Record review of the Order Summary Report dated 06/30/2022 for Resident #1 revealed the resident was to receive [MEDICATION(S)] solution (anticonvulsant/anti-[CONDITION(S)] medication) 100 mg/ml, 20 ml to be administered two times a day via the resident's g-tube. Record review of hospital #1's External Facility Transfer Summary Medication List provided to the facility on [DATE] revealed Resident #1 was to receive [MEDICATION(S)] 100 mg/ml, 20 ml via her g-tube twice daily for 30 days. The list reflected the resident received a dose at 9:00 a.m. on 06/17/2022, and was to receive the next dose at 9:00 p.m. on 06/17/2022. Record review of the pharmacy Proof of Delivery e-mailed to the facility on [DATE] at 3:08 p.m. revealed the [MEDICATION(S)] solution for Resident #1 was delivered to the facility on [DATE] at 11:13 p.m. Record review of the June 2022 MAR for Resident #1 revealed the MAR reflected a start date/time as 06/18/2022 at 8:00 a.m. Resident #1 was not given the [MEDICATION(S)] on 06/17/2022 at 8:00 p.m . (Calculation revealed there was at least 7.5 hours from when the [MEDICATION(S)] arrived at 11:15 p.m. and the next scheduled dose at 8:00 a.m). Record review of the Transfer to Hospital Summary written by LVN C dated 06/18/2022 at 9:45 p.m. revealed Resident #1 had a [CONDITION(S)] that lasted ten minutes. 911 was called, and the resident was still having a [CONDITION(S)] when taken to hospital #2. Record review of the hospital #2 Emergency Department Provider Documentation dated 06/18/2022 at 4:43 p.m. revealed Resident #1 presented to the hospital in status epilepticus. The report reflected the resident's first [CONDITION(S)] occurred at 6:00 a.m., and she had a [CONDITION(S)] at the hospital that had started 45 minutes prior to arrival at the hospital. The resident was administered Versed, [MEDICATION(S)], and [MEDICATION(S)], but there was no alleviation of the [CONDITION(S)]. The resident was subsequentially intubated at 9:55 a.m. The document did not reflect when the [CONDITION(S)] subsided, but an entry at 11:52 a.m. reflected no [CONDITION(S)] activity. Resident #1 was transferred to the Intensive Care Unit in critical condition. Interview on 06/27/2022 at 2:00 p.m. with LVN C revealed she worked on 06/18/2022 from 6:00 a.m. to 10:00 p.m. She said the [MEDICATION(S)] was available for the 8:00 a.m. dose on 06/18/2022, but the resident was having a [CONDITION(S)] at that time, so she was not able to administer the medication. She said the resident was transferred to hospital #2. She said the Transfer to Hospital Summary (see above) dated 06/18/2022 at 9:45 p.m. was written at 9:45 p.m., but the resident was transferred to hospital #2 in the morning. Interview on 06/27/2022 at 2:09 p.m. with LVN B revealed Resident #1 arrived at the facility on 06/17/2022 at 5:20 p.m. She said she called Doctor A and verified the medications. She said she did not tell the doctor the [MEDICATION(S)] was not available. She did not say why the MAR reflected a start date of 06/18/2022 . She said she worked until 10:00 p.m., and the medication was not delivered prior to her leaving the facility. She said she gave the report to her relief nurse (LVN D). Interview on 06/27/2022 at 2:45 p.m. with the Administrator revealed the facility's pharmacy was connected through their computer system, and medication orders were automatically sent to the pharmacy . He said if a resident was admitted after 4:00 p.m., the medications would be delivered between 10:30 p.m. and 11:00 p.m. Observation on 06/27/2022 at 3:00 p.m. revealed two bottles of [MEDICATION(S)] for Resident #1 was in the medication room in the west nursing station. Both appeared to be full. Interview on 06/27/2022 at 3:16 p.m. with the DON revealed LVN D should have called Doctor A when the [MEDICATION(S)] was delivered. Interview on 06/27/2022 at 3:30 p.m. with the Administrator revealed there was an extended time for medications to arrive from the pharmacy, and that the medication may have to be given in the morning . He also said if the medication was in the facility, it was to be administered. At that time, the Administrator was asked if any in-services had been provided to the nurses regarding receipt of medications and notification to the physician. He said he would check. As of time of exit, no in-services dated prior to this time were provided to the surveyors. Interview via telephone on 06/27/2022 at 4:55 p.m. with Doctor A revealed he said he verified the medications for Resident #1 on 06/17/2022 at 5:20 p.m. He said he would also have been the on-call doctor for that night. He said he was not aware the [MEDICATION(S)] was not available when he verified the orders. He said he should have been called when the dose was missed, and also when the medication arrived. He said by the time his NP arrived the morning of 06/18/2022, the resident had already been sent to hospital #2. He said when he verified the orders, he said to continue them. He did not say he told them to start the orders the next day. He said he was not aware until the morning of 06/18/2022, that the resident had not received her medications. He said When the medication arrived, they should have given the medication. He said he was not sure why the [MEDICATION(S)] was not administered. He said it would have been ok to administer the 8:00 p.m. dose late. He said he did not receive any other calls from the facility that night after the 5:20 p.m. call. Record review of the payroll time sheet for LVN D revealed he worked from 10:35 p.m. on 06/17/2022 to 7:18 a.m. on 06/18/2022. Interview via telephone on 06/27/2022 at 6:34 p.m. with LVN D revealed he spoke with a family member of Resident #1, who verbalized concern that Resident #1 had not received her medications. LVN D said he told the family member that as soon as the medications arrived from the pharmacy, he would administer them. LVN D said the medications arrived at 11:30 p.m. (on 06/17/2022). He said he called the doctor and was told to administer the next dose the next morning. When asked which doctor gave the order, he first said he could not remember, then said he may have just spoken with the answering service. There was no documentation to corroborate LVN D's statement. Interview on 06/28/2022 at 2:12 p.m. with the Administrator, DON and Regional Nurse revealed the Regional Nurse called Doctor A and placed him on speaker phone. She told the doctor to tell the surveyors that the facility did not need to call him for a missed dose. Doctor A said that once he approved the medication, he expected them to be given. He said if he had been called at 11:30 p.m., he would have said for the nurse to give the medication. Review of the [MEDICATION(S)] package insert (revised 10/11/2013) for [MEDICATION(S)] (proprietary name for [MEDICATION(S)]) oral solution revealed [MEDICATION(S)] was rapidly absorbed after administration. It reflected Oral absolute bioavailability is close to 100%. Peak plasma concentrations [the highest level of the drug that can be obtained in the blood] are achieved at 1, 3 hours after dosing. Review of a second package insert for [MEDICATION(S)] (revised April 2017) revealed stopping administration of the medication could cause serious problems such as status epilepticus (a [CONDITION(S)] that will not stop). The insert reflected that if a dose was missed, it should be taken as soon as possible, with the exception of .If it is almost time for your next dose, just skip the missed dose. Review of the [CONDITION(S)] Foundation website ([CONDITION(S)].com), under the topic Importance of Medication Schedule revealed [CONDITION(S)] medicines must be taken each and every day as prescribed. If the right amount is not taken at the right time, the medicine may not be able to prevent seizures, or might cause unwanted side effects. Record review of the facility policy Documentation of Medication Administration (revised April 2017) revealed if a medication was not administered, the nurse was to document why the medication was withheld, not administered, or refused. The deficient practice was determined to be an Immediate Jeopardy (IJ) on 06/28/2022. On 06/28/2022 at 1:40 p.m. a meeting was conducted with the Administrator, the Regional Nurse, the DON, and ADON E. The Administrator was notified of the IJ. The Administrator was provided with a copy of the IJ Template at that time. The following Plan of Removal (POR) submitted by the facility was accepted on 06/29/2022 at 8:21 a.m.: Plan of Removal Date: 06/28/2022 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Given that Resident #1 has discharged from the facility, no corrective action can be taken for this resident discharged on [DATE] 2. How other residents having the potential to be affected by the same deficient practice will be identified and what corrective actions will be taken. The Director of Nursing audited the charts for all residents with orders for antiseizure medications. It was determined that no other residents were harmed by this practice. All new admissions orders and medications were reviewed ensuring all medications are available. Audit completed by DON & ADON on 06/28/2022. Facility residents' MARS were reviewed by DON & ADON and no issues were found on 06/28/2022. 3. What Measures will be put into place or what systemic changes will be made to ensure that the same deficient practice does not recur? a. Facility nurses will complete a weekly audit to determine whether medications ordered by the prescriber are available to meet the needs of the residents. Any medication found to be in low supply (i.e. 3 days worth of medication) will be called to the pharmacy for refill. Nurses were trained on reordering on 06/28/2022 with the ADON's oversight to review/audit. If the refill is not provided/delivered by time the medication is due, the physician, DON, and pharmacy will be notified. If medications are delivered after routine administration time then nurse to notify the physician for further instructions on administering or holding. In-services completed on 06/28/2022. Results of these audits will be submitted to the monthly QAPI committee for review. b. On 6/28/2022, DON and ADON in-serviced admissions nurses on the medication reconciliation and medication administration policies and procedures after being revised, specifically highlighting that if a medication is not immediately available for the next scheduled dose, they are to refer to the Automated Medication Dispensing System (Omnicell) for the listed medications. If the medications are not available in the Omnicell the physician will be notified. 4. How will the corrective actions be monitored to ensure the deficient practice will not recur, ie what quality assurance program will be put into place? The Director of Nursing will monitor weekly medication audits to ensure adequate supply of medications are available to meet resident needs. The Director of Nurses will present the results of these audits to the Administrator on a weekly basis, for 3 weeks, or until substantial compliance is determined. This will begin on 06/28/2022 with the pharmacy consultant's review and assistance with training. Starting on 06/28/2022 the IPOC Committee will audit new admission charts in the Interdisciplinary Plan of Care (IPOC) daily meeting to ensure that all medication orders were followed. Monitoring for the implementation of the POR, initiated on 06/29/2022: Interviews with LVN D, LVN F, LVN G, and LVN H revealed they all received in-services regarding verifying medications upon admission, how to obtain medications from the Automated Medication Dispensing System, and when to notify the doctor if a medication was not available or administered (all three shifts were represented). Record review of the in-services dated 06/28/2022 and 06/30/2022 entitled Missed Doses, Omnicell, Medication Re-ordered revealed the nurses were provided guidance on the importance of giving all medication as ordered. If a medication was not available, the nurse was to notify the doctor. Other topics covered included medication reconciliation for new admissions and documentation. Record review of three new admissions, Resident #2, Resident #3, and Resident #4, all admitted after the POR's acceptance, revealed no concerns. The Administrator, DON, ADON, and Regional Nurse were notified the immediacy of the IJ was lowered on 06/30/2022 at 1:15 p.m. The facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent injuries for 1 of 6 residents (Resident #1) reviewed for accidents/supervision in that; -CNA A failed to adequately supervise Resident #1 while completing ADL care resulting in the resident falling out of bed and sustaining an open [MEDICAL CONDITION] distal ulna. This failure could affect residents who require incontinent care and place them at risk of injury, pain, and psychological harm. Findings include: Record review of Resident #1's face sheet revealed, an [AGE] year-old-male originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS dated [DATE] revealed, a 3 documented for Cognitive Skills for Daily Decision Making indicating the resident has Severely Impaired cognitive skills. The resident required total assistance of 2 people for personal hygiene and bathing. Record review of Resident #1's Care plan date initiated: 1/24/20 read in part, Focus: Balance, poor coordination and generalized weakness, Goal: Staff: Date initiated 2/11/20 Revision on: 9/22/20; Interventions: .Bathing/ showering: The resident is totally dependent on (2) staff to provide showers as necessary. Bed mobility: The Resident is totally dependent on (2) staff for repositioning and turning in bed as necessary . Record review of Resident #1's Care plan date initiated 02/04/2020 read in part, Focus: Risk for Falls r/t Deconditioning and Impaired Mobility, Goal: date initiated 2/04/20 Revision on 9/24/20: Falls will be minimized through next review date, Interventions: .Ensure Resident is repositioned and positioned with the assistance of two staff members at all times, Floor Matts x 2 while in bed . Record review of Resident #1's Fall risk observation assessment dated [DATE] revealed, a score of 26 indicating high risk for falls. Record review of Resident #1's nursing progress notes dated 9/21/20 at 10:15am read in part, The nurse aide came and notified that the resident was observed on the floor, when the nurse went there and observed the resident lying the left side of his body floor. Head to toe assessment was done on the floor and noted the lower right hand was broke. No pain was noted, and V/S were done BP126/65, P 99, T 98.1, R 18. DON, NP and the family were notified. Record review of Resident #1's NP progress notes dated 9/21/20 read in part, Summary: I called and talked to patient's (family member) she wants to send the patient out to the hospital as patient has recently found to have a possible fracture to the right wrist .Plan of care. She will call me back, stating that she had talked to the wound care doctor and patient's (family member #2) and they had, with the plan of not sending the patient to the hospital and she does want to keep him comfortable at the facility with conservative management . Further record review of Resident #1's nursing notes dated 9/22/20 read in part, D.O.N AND WRITER SPOKE WITH (family member) TODAY IN REGARDS TO GUEST AND THE FALL FROM HIS BED ON 9/21/20, WIFE IS UPSET GUEST fell AND WANTS TO PREVENT IT FROM HAPPENING AGAIN . FALL MATS HAVE BEEN PLACED AS WELL AS FOAM WEDGES ON EITHER SIDE OF GUEST IN THE BED FOR FALL PREVENTION. Record review of Resident #1's hospital notes dated 10/08/20 read in part, History of Present Illness: The patient is an [AGE] year-old male patient, nursing home resident with past medical history of [REDACTED]. He was treated for [REDACTED].On admission, they had also noted that he had an open fracture of his right ulna, which is from a fall he had suffered at the nursing home. They had Orthopedic surgeon to see him, but his family decided not to pursue surgical intervention Interview on 9/24/20 at 1:03pm with LVN #1, when asked if she was aware of Resident #1's recent fall, she stated she did not work with him that day, but she heard he fell out of bed. She stated she worked the 10p-6am shift that night and called the NP to request a scheduled pain medication stating he only had PRN Tylenol. When asked if the resident was able to turn or reposition himself, she stated no, and said he was on an air mattress. When asked if he had a fall mat on the floor at the time of the fall, she stated as far as she knew he had a fall mat. She stated he had not had any recent falls, stating he had not fallen since she has been here. Interview on 9/24/20 at 1:21pm with CNA A, he stated he was in the room when Resident #1 fell . He said he went into the resident's room to check on his sheets and pillows because he sweat a lot, so he had to change the sheets. He said he went to see if he needed more pillows and to look to see if his brief needed changed. He said he put the HOB flat and lowered the bed, further stating he did not lower the bed all the way down because if it's in the lowest position, it would move. He said he removed the pillows and turned to get the wipes, briefs, and creams. He said when he turned around a co-worker, CNA B came into the room and asked him a question. He said at that time they heard a boom. He stated the resident fell out of bed landing on his left side. He said his feet were under the bed and his head facing the wall. He said he went to get the nurse to assess him and they put the resident back in bed. Further interview on 9/24/20 at 1:21pm with CNA A, when again asked if the bed was in the lowest position, he stated it was not completely to the ground because if it was all the way down, it can move. When asked if there were side rails on the bed, he stated no rails were on the bed. He stated Resident #1 did not have a fall mat. He said the resident was not really a mover, but he did notice he would fidget and shake his legs, stating the right leg would move when he was relaxed. When asked if he is a 1 person or 2 persons assist for ADLs, he stated 1 person can do his ADLs. Interview on 10/30/20 at 10:23am with CNA B, she stated CNA A was at the dresser getting wipes and briefs and getting everything together. She said she was walking into the room and they both heard a boop. She said when she walked in, they both turned around and looked and Resident #1 was on the floor. She said the bed was real low. When asked how the resident was positioned when they turned around and saw him on the floor, she said he was on his left side. When asked if the resident was able to move himself and/or roll over, she said he normally moved his right leg and pushed and moved himself. She said when he fell , they notified the nurse immediately and she came into check everything out. When asked if the resident has fallen out of bed before, she said, No, not that I'm aware of. When asked if the resident had rails on the bed, she stated the two top ¼ rails were up on both sides stating she thinks when he was moving his right leg he had pushed himself out of the bed. When asked if the resident had a fall mat, she said no. She said Resident #1 required total 2 person assist for ADL care. When asked if both CNAs were supposed to be in the room when providing ADL care, she said usually both CNAs were in the room. When asked what the policy regarding ADL care was and having supplies ready, she said normally you would get the supplies first before you start and have them right there so no one had to move. Observation on 10/30/20 at 12:23pm of Resident #1 revealed, the resident lying supine and asleep in bed. The resident was well-groomed, on continuous O2 at 2LPM via NC, resident was non-verbal, contractures to BLE and right UE. There was no fall mat on floor. Interview on 10/30/20 at 12:48pm with the DON, when asked if a resident required 2-person total assist for ADL care, should there be two CNAs present in the room, she said it would depend if they are setting up, turning and repositioning. When asked if the CNA should ever turn his/her back on the resident during ADL care, she stated, That is such a general question. If they are turning to get water or something, it depends on what they are doing. Further interview on 10/30/20 at 12:48pm with the DON, when asked if the Resident #1 was supposed to have a fall mat on the floor, she said initially after the fall he was care planned for the fall mat. She said yes, he should have a fall matt on the floor now. When informed there was no fall mat in the residents' room, she said oh. Further interview on 10/30/20 at 3:03pm with the DON during exit, she stated there was a fall mat in Resident #1's room, stating the nurse had moved it and it was placed back on the floor. Record review of CNA A's statement dated 9/22/20 at 12:26pm e-mailed to the Investigator by the Administrator on 11/02/20 after exit read in part, On September 21 I was assigned to Resident #1. As I start my usual rounds I go into Resident #1's room and start with my routine of checking all his sheets, pillowcases, and linen sheet to see if anything needed to be changed out. I still haven't cleaned or repositioned the resident but gotten an insight on what I needed to do, so I lower his head and feet to make the bed flat and I removed only the soiled pillows from between his legs. Now that I know what I need to do in the room I head to the dresser to collect my brief, wipes, and creams where CNA B comes in the room and while neither one of us is facing the resident we suddenly hear something fall and to our shock, we find the resident had fallen off the bed to be more exact he had fallen off the left side of his bed with his face facing us and his feet underneath the bed. In shock, I remove the rest of the pillows and sheets that were on top of him and I leave CNA B there and I go grab nurse LVN #2, so he can direct us on how to proceed, which he takes over and tells me to pick the resident up with him. I hold his lower body and LVN #2 holds his upper body. We place him safely onto the bed and there is no sign of blood, he seems to just be shaky from the fall but upon that not else's seemed to be wrong with him. Record review of the facility's Perineal Care policy revised February 2018 read in part, .Preparation .2. Assemble the equipment and supplies as needed Steps in the Procedure1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached .

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 for 5 of 9 residents (Resident #2, #3, #4, #5, and #6) reviewed for infection control. - The facility failed to have PPE 'stations' at the entrance of each of the quarantine rooms for staff to don prior to entering the rooms. -The facility failed to ensure staff, who were providing care to both the quarantined and non-quarantined residents wore appropriate PPE when caring for quarantined residents. - Quarantined Residents had no biohazard disposal or laundry bins set up in the rooms. -Staff entered quarantine rooms without an N95 or eye protection. They wore a surgical mask or homemade mask and gloves while caring for all the residents, to include the ones in quarantine. -Staff in the facility wore homemade cloth masks in patient care areas. An Immediate Jeopardy (IJ) was identified on 6/11/2020. While the IJ was lowered on 6/12/20 the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern while they continued to monitor their plan of removal. These failures placed all residents at risk of contracting an infectious disease, COVID-19, cross-contamination, and hospitalization . Findings Include: Resident #2 Record review of the admission sheet for Resident #2 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's Hospital to Post-Acute Care Facility Transfer-COVID -19 assessment dated [DATE], 16 days prior to the resident's admission, read in part: .has patient been laboratory tested for COVID-19? yes, test performed for COVID-19. Negative test result . The test was performed 16 days prior to admission. Record review of Resident #2's physician's orders [REDACTED].) q shift, report any symptoms to md. Record review of Resident #2's comprehensive MDS assessment dated [DATE] revealed a BIMS of 11 out of 15 indicating moderately impaired cognition. She required extensive assistance from staff for dressing, toilet use, personal hygiene, transfers and bed mobility. Resident #2 was always incontinent of bowel and bladder. Record review of Resident #2's Care Plan initiated 05/26/20 and revised on 6/12/20 revealed the following care plan: Focus: COVID-19: At risk for infection and/or significant change of condition related to Novel Coronavirus (COVID-19) cases in the county/community. Goal: Residents' risk for Coronavirus infection will be mitigated daily and potential spread will be prevented. Interventions: creation and implementation of facility action plan/QA on prevention and management of COVID-19 disease. Facility coordination with local health authorities regarding Coronavirus updates. In-servicing staff on infection control preventative measures. Monitor for any distress associated with facility preventative measures (i.e.: restricting visitors from building, additional resident screening measures). Observing residents for respiratory symptoms and notifications of MD as needed. Posting signages about COVID-19 s/sx symptoms for residents and visitors information. Strict handwashing in between resident's care; use of hand sanitizers frequently. Visitors and employees screening for respiratory symptoms; restricting visitors and staff from being at the facility when presenting respiratory symptoms. Wearing of appropriate PPEs as indicated. Record review of the cdc.gov website read in part, .Considerations for new admissions or readmissions to the facility Newly admitted and readmitted residents with confirmed COVID-19 who have not met criteria for discontinuation of Transmission-Based Precautions should go to the designated COVID-19 care unit. Newly admitted and readmitted residents with COVID-19 who have met criteria for discontinuation of Transmission-Based Precautions can go to a regular unit. o If Transmission-Based Precautions have been discontinued, but the resident with COVID-19 remains symptomatic (i.e., persistent symptoms or chronic symptoms above baseline), they can be housed on a regular unit but should remain in a private room until symptoms resolve or return to baseline. These individuals should remain in their rooms to the extent possible during this time period. If they must leave their rooms, facilities should reinforce adherence to universal source control policies and social distancing (e.g., perform frequent hand hygiene, have the resident wear a cloth face covering or facemask (if tolerated) and remain at least 6 feet away from others when outside of their room). Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. o All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. o Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Testing should not be required prior to transfer of a resident from an acute-care facility to a nursing home. New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). Testing at the end of this period could be considered to increase certainty. Observation on 6/2/2020 at 9:32 am reveled Resident #2's door was opened to the hallway with no isolation cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. There was no sign posted on the Resident's room door to indicate the resident was on contact or droplet precautions. Further observation revealed there were no covered isolation or laundry bins in the room to allow for disposal of contaminated items in a controlled manner. Resident #2 was lying in her bed. In an interview on 6/2/20 at 9:41 am with LVN A, she had on a surgical mask. She said residents in this hall, East Hall, had come from the hospital. They were either new admits or re-admits and were on quarantine for 14 days prior to moving to the other hall that had more stable residents. She said staff were monitoring these residents for signs and symptoms of COVID. She said the staff were to wear a mask and gloves while caring for the residents. She said staff were using standard precautions to care for these residents. The Surveyor asked if she had a list of the quarantined residents in this hall. She said no, but she could look at the resident's admitted to determine when they could come out of quarantine. In an interview and observation on 6/2/20 at 10:39 am with CNA C she said she was assigned to work with new admits or readmits. She said Resident #2 required total assistance with ADLs. She said gloves and masks were required to care for these residents. She said only two residents were in isolation on this hall. She said she did not know why those two residents were in isolation. She said she would know the resident was in isolation after seeing the sign posted on the door and PPE set up outside the room. She said she did not know which residents were quarantined. She said once the residents had completed their 14 days, they would be moved to the other wing. She said there were a few residents that had been in this wing past their 14 days. In an interview on 6/2/20 at 11:37 am with CNA A, she said she worked full time during the 6-2 pm shift at this facility. She said residents in this hall, East Hall, had come from the hospital. She said they were in quarantine for 14 days as precaution for COVID signs and symptoms. The Surveyor asked how CNAs knew that the resident had completed their 14 day quarantine. She said the nurses would notify them or the resident would move to a different hall. She said the staff were to wear a mask and gloves while caring for these residents. In an interview on 6/2/20 at 2:34 pm with RN B, she said she had just started her shift and was checking on her residents. RN B had a cloth mask on, which is not PPE. She said the residents in this hall had come from the hospital; they were either new admits or readmits. She said she did not have any residents on [MEDICAL TREATMENT] in this hall. She said these residents were in quarantine for 14 days to monitor for COVID signs and symptoms. She said their vitals were checked once a shift. The surveyor asked if she had a list of the residents that were on quarantine, how they track who has completed their 14 days and how they communicate that information with CNAs. She said she was not given any list from the 6-2 pm nurse during shift change. She said nurses could look at the resident's admitted to figure out how many days they have left in quarantine. She said there were a few residents that have been in this hall past their 14 days. She said staff could wear homemade masks or facility provided surgical masks to care for the quarantined residents. She said she had on her own cloth mask because it was comfortable to breathe in. Observation on 6/2/20 at 2:32 pm of Resident #2 revealed Resident #2 was resting in bed. There was an X-ray technician in the room. The X-ray technician was wearing a surgical mask and gloves, but no other PPE. There was no PPE available at the entrance or inside the room, other than gloves. Resident #2's quarantine room was on the east wing among resident rooms of residents who were not on quarantine. Record review of Resident #2's physician's orders [REDACTED].>Record review of Resident #2's physician's orders [REDACTED]. In an interview on 6/2/20 at 2:35 pm with the MDS nurse, she said the nurse taking care of Resident #2 was in a meeting getting in-serviced. She said she could assist this Surveyor with any questions. This Surveyor asked if she could tell if Resident #2 was in quarantine. The MDS nurse said there was no list that would indicate which resident was on quarantine. She said the nurses would look at the resident's admitted to determine when they were off quarantine. She said she saw an X-ray technician in Resident #2's room getting x-rays. She said the resident was complaining of shortness of breath. She said residents were placed in the East wing post hospitalization for continuity of care and to monitor their vitals each shift. She said standard precautions were used when taking care of these residents as they did not have any type of infection. She said only a mask and gloves were required to care for these residents. She said additional PPE was required depending on the isolation and the resident's condition. Observation on 6/2/20 at 2:45 pm revealed Resident #2's door was open to the hallway. There was no sign posted on the resident's room door with no isolation cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. Further observation revealed Housekeeper A was inside the resident's room with surgical mask and gloves on. Resident #2 was lying in her bed. The resident did not have a mask on while the housekeeper was in the room. In an interview on 6/2/20 at 2:56 pm with Housekeeper A, she said she did not know which residents were quarantined because no one told her. She said she did know there were two residents in isolation because of the signs posted on the resident's doors and PPE setting outside. Record review of Resident #2's physician's orders [REDACTED]. Record review of Resident #2's physician's orders [REDACTED]. Observation and interview on 6/9/20 at 8:15 am revealed RN A had on coveralls and an N95 respirator being worn in a manner that was not covering RN A's nose. At this time the Surveyor asked RN A to fix her mask. RN A said, The mask comes off as it is loose, I need to fix it again. RN A said she was assigned to work during the 7am to 7pm shift in the COVID positive hall. Throughout the interview, the Surveyor asked RN A to fix her N95 twice as it was not covering her nose. Observation and interview on 6/9/20 at 8:21 am revealed a pair of coveralla was hanging on the hook in the donning and doffing area that appeared to be used. In an interview with RN A, she said the coveralls belonged to the nurse that worked 7pm -7am shift. She said the facility was conserving the coveralls. She said the staff were re-using the coveralls for 3 days before they could discard it. In an interview on 6/9/20 at 10:31 am with the DON and the Administrator, the Surveyor shared her observations of having to tell RN A to fix her N95 twice during the interview. The DON said RN A needed a fitted N95. The DON said the facility was conserving coveralls and therefore staff were reusing the coveralls for 3 to 5 days and only discarding if soiled. Record review of CDC.gov website read in part, .The PPE recommended when caring for a patient with known or suspected COVID-19 includes: ·Respirator or Facemask (Cloth face coverings are NOT PPE and should not be worn for the care of patients with known or suspected COVID-19 or other situations where a respirator or facemask is warranted) Put on an N95 respirator (or higher level respirator) or facemask (if a respirator is not available) before entry into the patient room or care area, if not already wearing one as part of extended use or reuse strategies to optimize PPE supply. Higher level respirators include other disposable filtering facepiece respirators, PAPRs, or [MEDICATION NAME] respirators. N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol generating procedure (See Section 4). See appendix for respirator definition. Disposable respirators and facemasks should be removed and discarded after exiting the patient ' s room or care area and closing the door unless implementing extended use or reuse. Perform hand hygiene after removing the respirator or facemask. If reusable respirators (e.g., powered air-purifying respirators (PAPRs)) are used, they must be cleaned and disinfected according to manufacturer ' s reprocessing instructions prior to re-use. *When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19. Those that do not currently have a respiratory protection program, but care for patients with pathogens for which a respirator is recommended, should implement a respiratory protection program. · Eye Protection *Put on eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use or reuse strategies to optimize PPE supply. Personal eyeglasses and contact lenses are NOT considered adequate eye protection. Remove eye protection before leaving the patient room or care area. Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer ' s reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse. ·Gowns Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use. If there are shortages of gowns, they should be prioritized for: *aerosol generating procedures *care activities where splashes and sprays are anticipated *high-contact patient care activities that provide opportunities for transfer of pathogens to the *hands and clothing of HCP. Examples include: *dressing *bathing/showering *transferring *providing hygiene *changing linens *changing briefs or assisting with toileting *device care or use *wound care . 3. Patient Placement . .·If admitted , place a patient with known or suspected COVID-19 in a single-person room with the door closed. ·As a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with known or suspected COVID-19. Dedicated means that HCP are assigned to care only for these patients during their shift. Resident #3 Record review of the admission sheet for Resident #3 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #3's Care Plan initiated on 05/02/20 and revised on 6/2/20 revealed the following care plan: Focus: COVID-19: At risk for infection and/or significant change of condition related to Novel Coronavirus (COVID-19) cases in the county/community. Goal: Residents' risk for Coronavirus infection will be mitigated daily and potential spread will be prevented. Interventions: wearing of appropriate PPEs as indicated. Record review of Resident #3's physician's orders [REDACTED]. Record review of Resident #3's hospital records testing information revealed Resident #3 was noted as having been tested for COVID-19. The form did not have the date when the test was performed at the hospital. Result was marked negative signed and dated 5/26/20 by the hospital staff. Record review of Resident #3's comprehensive MDS assessment dated [DATE] revealed a BIMS of 3 out of 15 indicating severely impaired cognition. She required limited assistance from staff for dressing, toilet use, personal hygiene, transfers and bed mobility. Resident #3 was always incontinent of bowel and bladder. Observation on 6/2/2020 at 9:18 am revealed Resident #3's door was open to the hallway. There was no sign posted on the resident's room door with no isolation cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. Resident #3 was sitting on her wheelchair looking out the window. In an interview and observation on 6/2/20 at 10:25 am with RN A, she had a surgical mask on. She said Resident #3 was a new admit. The resident was on quarantine for 14 days and staff were monitoring for s/sx such as fever, cough, and shortness of breath. She said the incubation period for this virus was 14 days. She said staff kept track of their quarantine days by checking the admitted s. She said there were two residents in isolation in this hall. One resident had E.coli in the urine and the other resident [MEDICAL CONDITION] of a wound. She said residents in this hall had either come from the hospital, were a new admit, were re-admits or were on [MEDICAL TREATMENT]. She said the [MEDICAL TREATMENT] residents were at risk for infection as they were going in and out of the facility three times a week. She said new admits and re-admits were at risk for bringing infection as they had been out of the facility as well. She said the stable patients were on the west side of the building. She said staff had been using universal precautions while caring for these residents. RN A said she did not have a list of residents on quarantine to show the Surveyor. She said there were residents that had been in this hall past their 14 days. Observation on 6/2/20 at 10:20 am revealed Resident #3's door was opened to the hallway. Resident #3 was sitting in her wheelchair. Speech Therapist was in the room within 6 feet of the Resident. The Speech Therapist was wearing a surgical mask. Resident #3 had no mask on while the Speech Therapist was in the room. In an interview on 6/2/20 at 11:45 am with the Speech Therapist, he said he did not know if Resident #3 was on precautions/isolation. He said usually if the resident was in isolation there would be a sign at the door and PPE set up for the staff to gown up outside the door. Observation on 6/2/2020 at 2:04 pm revealed Resident #3's door was open to the hallway. Further observation revealed Housekeeper A was inside the resident's room with surgical mask and gloves on. Resident #3 was sitting on her wheelchair. The resident did not have a mask on while the housekeeper was in the room. During observation and interview on 6/2/20 at 2:25 pm with CNA Z, she had a surgical mask on. The CNA was observed going into Resident #3's room. In an interview with CNA Z she said she had started her shift at 2 pm and was going room to room passing out hydration to the residents. She said Resident #3 was a new admit and was on quarantine for 14 days. She said she would know if the resident completed their 14 days if the resident had moved to the other wing when she came to her next shift. She said only gloves and a mask were required to care for these residents. In an interview on 6/2/20 at 2:56 pm with Housekeeper A, she said she did not know which residents were quarantined because no one told her. She said she did know there were two residents in isolation because of the signs posted on the resident's doors and PPE setting outside. Resident #4 Record review of the admission sheet for Resident #4 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #4's comprehensive MDS assessment dated [DATE] revealed a BIMS of 14 out of 15 indicating intact cognition. He required extensive assistance from staff for dressing, toilet use, personal hygiene, transfers and bed mobility. Resident #4 was occasionally incontinent of bowel and had a external catheter. Record review of Resident #4's Care Plan initiated on 05/02/20 revealed the following care plan: Focus: COVID-19: At risk for infection and/or significant change of condition related to Novel Coronavirus (COVID-19) cases in the county/community. Goal: Residents' risk for Coronavirus infection will be mitigated daily and potential spread will be prevented. Interventions: wearing of appropriate PPEs as indicated. Record review of Resident #4's hospital records testing information revealed Resident #4 was noted as having been tested for COVID-19 on 5/26/20 and the result was negative, which was 3 days prior to admission. Observation on 6/2/2020 at 9:27 am revealed Resident #4's door was open to the hallway. There was no sign posted on the resident's room door with no isolation cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. Resident #4 was lying in bed. Observation on 6/2/2020 at 9:55 am revealed Resident #4's door was open to the hallway. There was no sign posted on the resident's room door with no isolation cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. Further observation revealed Activity Director was inside the resident's room within 6 feet of the resident with surgical mask and gloves on. Resident #4 was lying in his bed with no mask on. During observation and interview on 6/2/20 at 9:57 am with LVN A, she was standing near Resident #4's door with her med cart. LVN A said the Resident was a re-admit, he had come from the hospital and was on quarantine for 14 days. She said the staff were monitoring the resident for signs and symptoms for COVID. She said the staff were to wear a mask and gloves while caring for this resident. She said the Activity Director was in his room now assisting him with face time. Record review of Resident #4's physician's orders [REDACTED].) q shift, report any symptoms to md every shift for cough. Record review of Resident #4's physician's orders [REDACTED]. In an interview on 6/12/20 at 10:42 am with the Activity Director, she said she provided one on one in room activity for Resident #4. She said Resident #4 required assistance when face timing with family and friends. She said Resident #4's family member would usually call and notify when staff needed to assist the resident with his iPad to facetime. She said she would get a census every day and it would mention new admits. She said new admits were on quarantine for 14 days as per CDC. She said a mask and gloves were required while in the resident's rooms. Resident #5 Record review of the admission sheet for Resident #5 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #5's Hospital to Post-Acute Care Facility Transfer-COVID -19 assessment dated [DATE] read in part: .has patient been laboratory tested for COVID-19? NO, test not performed because patient did not meet the CDC testing criteria. May transfer . Record review of Resident #5's Baseline Care Plan dated 5/27/20 presented by the DON on 6/12/20 revealed Resident was not care plan related to COVID-19. Record review of Resident #5's physician's orders [REDACTED]. Record review of Resident #5's comprehensive MDS assessment dated [DATE] revealed a BIMS of 15 out of 15 indicating intact cognition. She required extensive assistance from staff for dressing, toilet use, personal hygiene, transfers and bed mobility. Resident #5 was occasionally incontinent of bowel and bladder. Record review of Resident #5's nurses note dated 6/3/20 written by RN B revealed read in part: . COVID TESTING TO R/T COVID-19 one time only for 1 Day Patient refused test, stated that she did it at the hospital . Record review of Resident #5's nurses note dated 6/9/20 written by LVN B revealed read in part: . Resident moved from Est wing to 148 West. Resident is adjusting well to new room. Resident is up in wheelchair eating lunch. VS stable no pain or distress. Will continue to monitor . Observation on 6/2/20 at 2:25 pm revealed Resident #5's door was opened to the hallway. Resident #5 was resting in bed. RN B was in the room within 6 feet of the resident. RN B was wearing a homemade mask. Resident #5 had no mask on while RN B was in the room. In an interview and observation on 6/2/20 at 2:34 pm with RN B, she said she had just started her shift and was checking on her residents. RN B had a cloth mask on. Observation on 6/2/20 at 3:15 pm revealed Resident #5's door was opened to the hallway. Resident #5 was resting in bed. CNA X was in the room within 6 feet of the resident. CNA X was wearing a surgical mask. Resident #5 had no mask on while the CNA was in the room. In an interview on 6/2/20 at 3:21 pm with CNA X, she said she worked the 2-10 pm shift at this facility. She said she was going room to room taking resident's vital signs. She said residents in her hall were new admits and readmitted residents. She said the facility kept these residents for 14 days on one side of the building to contain infection as they are new to the facility or have come from the hospital. She said a mask and gloves were required to care for these residents. She said she would know if their 14 days were completed when they moved to the other side of the building. Record review of the CDC.gov website read in part: .Recommendation Regarding the Use of Cloth Face Coverings, Especially in Areas of Significant Community-Based Transmission . Use of Cloth Face Coverings to Help Slow the Spread of COVID-19 CDC continues to study the spread and effects of the novel coronavirus across the United States. We now know from recent studies that a significant portion of individuals with coronavirus lack symptoms (asymptomatic) and that even those who eventually develop symptoms (pre-symptomatic) can transmit [MEDICAL CONDITION] to others before showing symptoms. This means that [MEDICAL CONDITION] can spread between people interacting in close proximity-for example, speaking, coughing, or sneezing-even if those people are not exhibiting symptoms. Record review of CDC.gov read in part: .HCP use of homemade masks: In settings where facemasks are not available, HCP might use homemade masks (e.g., bandana, scarf) for care of patients with COVID-19 as a last resort. However, homemade masks are not considered PPE, since their capability to protect HCP is unknown. Caution should be exercised when considering this option. Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face. Resident #6 Record review of the admission sheet for Resident #6 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #6's Hospital to Post-Acute Care Facility Transfer-COVID -19 assessment dated [DATE] read in part: .has patient been laboratory tested for COVID-19? NO, test not performed because patient did not meet the CDC testing criteria. May transfer . which was 8 days prior to admission. Record review of Resident #6's Baseline Care Plan dated 5/28/20 presented by the DON on 6/12/20 revealed Resident was not care planned for quarantine or s/sx related to COVID-19. Record review of Resident #6's comprehensive MDS assessment dated [DATE] revealed her staff assessm (TRUNCATED)