Every finding on record at Hurst Plaza Nursing and Rehab

Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for 1 of 1 kitchen (Kitchen 1) reviewed for dietary services. 1. The facility failed to ensure residents did not receive cold food.2. The facility failed to ensure residents who received puree texture were served food that looked and tasted good.These failures could place residents at risk of weight loss, altered nutritional status and a diminished quality of life.Findings include:Observation and interview on 05/20/26 at 1:01 PM, three state surveyors and the Dietary Manager tasted a regular texture and pureed texture lunch. The puree tray had turkey with gravy, bread, brussels sprouts and polenta. The puree tray was unappealing in appearance and lacked color. The polenta was white, the brussels sprouts were pale yellow, the turkey was light pink with brown gravy and the bread was light brown. The turkey tasted overly salty and the food was cold. The Dietary Manager stated the plate should have more color, the polenta was cold and the gravy and turkey was salty. She said the turkey came prepared and the cook should have used chicken broth to prepare the puree turkey . The Dietary Manager stated she sometimes received complaints that eggs were cold and she would go talk to the residents personally after receiving a complaint. She stated kitchen staff tried to push the food out as fast as they could and last week she started texting the nursing staff when each hall cart was ready to go out so it was not sitting in the hallway. Observation and interview on 05/20/26 at 1:13 PM, [NAME] F tasted the puree tray and said the turkey was salty. She said she did not taste it before serving. [NAME] F said the residents might find the food overly salty. The Dietary Manager stated [NAME] F mixed chicken base paste with water and added that to the turkey. During a confidential resident group interview on an undisclosed date at an undisclosed time, revealed residents had complaints of cold food being served. Interview on 05/20/26 at 1:39 PM, the Dietary Manager provided the recipe for the puree turkey. She stated she trained staff to follow the recipe and they usually used the gravy off the meat when they prepared the puree mixture. She stated she preferred staff to use the chicken paste instead of water and would retrain [NAME] F not to use so much of the paste. She said it should be half a teaspoon of chicken base mixed with 8 ounces of liquid. She stated they did not have a policy related to food being served cold and if a resident received cold food, kitchen staff would provide a new plate off the steam line, and a grievance would be filed . Interview on 05/20/26 at 3:22 PM, the Administrator stated they did not have a policy on food palatability. Record review of the recipe for Pureed Turkey Rotisserie Style revealed the following .Measure desired # of servings into food processor. Blend until smooth.Add small amounts of gravy, sauce, vegetable juice, water, fruit juice, milk or half & half to meet desired consistency.Record review of the facility's grievances revealed the following:-On 01/30/26, Resident states food is always cold when she gets it.Record review of resident council minutes, dated from 05/19/25 to 04/22/26, revealed the following: -On 05/19/25, .Dietary.Food cold most of the time.-On 06/23/25, .Dietary.Food cold.-On 09/18/25, .Dietary.Eggs cold.-On 10/22/25, .Dietary.Eggs cold.-On 11/20/25, .Dietary.Scrambled eggs are cold.-On 02/25/26, .Dietary.Scrambled eggs are cold often.Wish they had heated trays like they have in the hospital.-On 03/24/26, .Dietary.my breakfast is usually cold; I eat breakfast in my room.-On 04/22/26, .Dietary.my food is too cold.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen (Kitchen 1) reviewed for food and nutrition services.The facility failed to ensure fans used in the kitchen were free of grease and dust. This failure could place residents at risk of food contamination and foodborne illness.Findings include:Observation on 05/18/26 at 5:53 PM in the kitchen, revealed a fan placed on the floor that was running and had grease and dust accumulated on the front grille of the fan. Another fan mounted on the wall in the dry storage area was observed running with dust build up. A third fan, mounted on the wall near the refrigerators and freezers, was running and pointed towards the steam table had grease and dust built up on the front grille. Interview on 05/20/26 at 1:51 PM, the Dietary Manager stated she had removed the fan that was on the ground because it was a trip hazard. She stated the ones hanging were wiped off and she told evening shift to clean the fans and to remove the cover to clean the inside of the blades. The Dietary Manager stated the dietary aide was responsible for cleaning the fans and they should be cleaned weekly. She said the last time they were cleaned was probably 3 weeks ago. She stated if they were not cleaned, dust could possibly contaminate the food. Record review of facility's, undated, policy titled, Sanitation Inspection revealed .1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects.

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 3 residents (Resident #2) reviewed for infection control.The facility failed to ensure Resident #2's catheter bag was not on the floor.These failures could place residents at risk of infections. Findings included:Record review of Resident #2's Significant Change MDS assessment, dated 02/19/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Diabetes Mellitus (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), renal insufficiency (a decline in kidney function over months or years), and dementia (loss of memory, language and thinking that interfere with daily life). Resident #2's BIMS score was 00, which indicated severe cognitive impairment. Section H revealed Resident #2 had an indwelling catheter.Record review of Resident #2's care plan revealed the following:- Alteration in elimination of bowel r/t incontinence and bladder r/t foley.secondary to neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord or nerve condition). Date initiated 08/20/2024. Record review of Resident #2's physician orders summary revealed the following:- Foley Catheter Care Q Shift, cleanse with soap and water or peri -wash Record Output q shift.Start date 10/07/25.- Enhanced Barrier Precautions r/t indwelling medical device: FOLEY CATHETER.Start date 05/17/26- Ensure foley bag are in basin and not touching the floor when bed is in the lowest position.Start date 05/20/26Observation on 05/19/26 at 12:08 PM, revealed Resident #2 was lying in bed and the Foley catheter bag was hanging on the side of the bed with the bag touching the floor. Resident #2 was not interviewable.Observation on 05/20/26 at 9:40 AM, revealed Resident #2 was in bed and the Foley catheter bag was hanging on the side of the bed and the bag was touching the floor . Interview on 05/20/26 at 11:53 AM, CNA C stated the aides were responsible for making sure the catheter bags were in a privacy bag or off the floor because it could be cross contamination. Observation and interview on 05/20/26 at 12:13 PM with CNA C in Resident #2's room, revealed Resident #2 lying in bed and the catheter bag was touching the floor. CNA C stated the bag should not touch the floor and should be placed in a basin or position off the floor. She stated the risk to the resident was contamination.Record review of Resident #42's order summary report, dated 05/20/26 , revealed:1. Foley catheter with 18cc balloon. Change every month and as needed. Change the drainage bag every 15th of the month and as needed every night shift starting on the 15th and ending on the 16th every month for infection control monitoring/foley catheter use. Active Order date 05/06/26 start date 05/15/262. Foley catheter with 18cc balloon. Change every month and as needed. Change the drainage bag every 15th of the month and as needed every night shift starting on the 1st and ending on the 2nd every month for infection control monitoring/foley catheter use. Active Order date 05/06/26 start date 06/01/263. Foley Catheter care every shift, cleanse with soap and water or peri-wash. Record Output every shift. Active Order date 06/14/26 start date 06/14/264. Ciprofloxacin HCI Oral Tablet 250 MG (Ciprofloxacin HCI) Give 1 tablet by mouth one time a day for Prophylaxis due to history of Urinary Tract Infection related to Sepsis Due to Escherichia Coli (a group of bacteria that can cause infections); Urinary Tract Infection (Infection in the urinary tract). Active Order date 02/24/26 start date 02/25/26.Observation and interview on 05/18/2026 at 7:52 PM revealed Resident #42 was in his room, laid in bed. Observation of the catheter bag revealed the bottom of the bag was touching the floor at the foot of the bed with a catheter cover. Resident #42 stated he was not aware his catheter bag was touching the floor. Resident #42 could not recall if he had issues with the catheter or catheter care. Observation on 05/19/2026 at 9:45 AM revealed Resident #42's bottom of the catheter bag was touching the floor.Observation on 05/20/2026 at 9:35 AM revealed Resident #42's catheter bag laid flat on the floor.Interview on 05/20/26 at 12:21 PM with CNA E revealed she was new to the floor and working with Resident #42. to CNA E she was aware Resident #42 had a catheter, because when she arrived at the beginning of her shift and rounded, she observed the catheter bag on the floor. According to CNA E, she picked it up at that time and hung it at the lowest part of his bed. CNA E stated she rounded maybe every 1.5 hours to ensure the bag did not need to be drained and checked for placement. CNA E stated all staff were responsible for ensuring catheter bags were not touching the floor, not doing so placed residents at risk of contamination. Interview on 05/20/26 at 12:25 PM with LVN D revealed usually resident catheter bags were not supposed to touch the floor, it was the responsibility of all staff to ensure the bags were not touching the floor. LVN D stated Resident #42 was a fall risk, his bed was lowered to the ground which may allow the bag to touch the floor. LVN D stated Resident #42 should have had a basin which should be utilized to keep the catheter bag from touching the floor, or if it fell it, would not touch the floor. According to LVN D, allowing the resident's catheters to touch or fall to the floor placed residents at risk of contamination and urinary tract infections. Interview on 05/20/26 at 12:57 PM with the DON revealed it was not okay to allow resident catheter bags to touch the floor. The DON further stated nothing that touched the resident should touch the floor because it created an infection control issue. The DON stated all staff which included CNAs, nurses and the ADONs were responsible for checking the bags to ensure they were not touching the floor.Record review of the facility's policy titled Indwelling Catheter Use and Removal, revised 06/06/25, revealed in part: .If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with currently professional standards of practice and resident care policies and procedures that include but are not limited to:.d. Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures.Record review of the facility's policy titled Infection Prevention and Control Program, revised 04/02/2025, revealed This facility has established and maintains 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 as per accepted national standards and guidelines.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 medication carts (Hall 2 East nurses' medication cart) reviewed for pharmacy services .The facility failed to ensure expired medications were removed from the Hall 2 East nurses' medication cart. This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction. Findings included:Observation on 05/19/2026 at 1:04 PM, of the Hall 2 East nurses' medication cart with LVN G revealed 3 boxes of Loperamide 2mgs (used to control and relieve the symptoms of acute diarrhea) with an expiry date of 04/2026, one pen Toujeo Solostar insulin (used to control blood sugar) with an open date of 3/20/26 and expiry date of 56 days from open date. It was due for discard on 05/15/26 and one pen Lantus (insulin glargine) (used to control blood sugar) with an open date of 3/21/26 with an expiry date of 28 days from open date and due for discard on 04/18/26. Interview on 05/19/2026 at 1:53 PM, LVN G stated she was responsible for checking the cart for expired medications. She stated she checked her cart for expired medications that morning, and she missed the expired medication. LVN G stated she checked her cart daily for expired medication and expiry dates. LVN G said failing to remove the expired medication could result in the medications being administered which could cause the residents not to get the required therapy. She stated the risk of having expired medication if administered was, it will not be effective. She stated she had done training on cart audit, but she could not recall when.Interview on 05/21/2026 at 2:02 PM, the ADON revealed her expectation was for nurses to check their cart for expired medications every week. She stated the ADON's were responsible for checking behind the nurses weekly. She stated she was supposed to audit the carts on 05/18/26, but she was off. She said the last time she audited the cart was a week prior to the date she was off and she also missed the expired medications. She stated the risk of having expired medications on the cart was it being administered, and they would not be effective.Interview on 05/21/2026 at 3:13 PM, the DON stated her expectation was all nurses were responsible for checking the carts daily, to ensure expired medications were removed from the carts. She stated it was the responsibility of the ADON and the DON to go behind the nurses weekly and ensure expired medications were being removed from the carts. She stated she last checked the carts on 05/18/26 and she missed the expired medications. She stated if expired medications were administered, it could place residents at risk of having side effects.Record review of the facility's Medication Administration/medication errors on policy , dated 05/09/25, reflected: . 13. Identify expiration date. If expired, do not administer and notify pharmacy for replacement.

Based on observations, interviews, and record review, the facility failed to store food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure semi-thawed meat was stored properly, which caused the liquid contents of the meat drip onto the freezer floor. 2. The facility failed to ensure dry storage food was stored properly and off the floor. The failures could place all residents at risk for food-borne illness. Findings included: Observation on 04/01/2025 at 9:20 AM of the reach in freezer revealed, a plastic bag containing raw chicken parts placed on the wired shelf. The liquid contents of the bag were observed dripping from the bag onto the flooring of the freezer. The bag was immediately removed from the freezer by [NAME] A and placed in a metal bowl, then placed in the sink. Observation of [NAME] A cleaning the freezer flooring and the wired shelf. The other items in the freezer were frozen solid to touch. Observation on 04/01/2025 at 9:22 AM in the facility's only dry storage area revealed a 50 lb. bag of onions labeled and dated, placed on the floor. Observation on 04/01/2025 at 12:15 PM of meal pass revealed, no chicken being served to residents. Interview on 04/03/2025 at 10:44 AM with the DON revealed, no residents have presented with GI concerns (vomiting or diarrhea) within the last 24 hours. Interview on 04/03/2025 at 1:45 PM with the Dietary Manager revealed, she did not realize [NAME] A put the bag of raw chicken parts into the freezer. She noticed the food debris on the flooring of the freezer. She stated it was not proper thawing procedure to place food that was thawed (or in the process of thawing) to be placed back into the freezer. She stated that the risk was food borne illness and residents could become sick. She stated food that was for consumption should not be placed on the floor. She stated when food was received from delivery it should be placed up off the floor. The risk was the chance for food borne illness. Interview on 04/03/2025 at 1:55 PM with [NAME] A revealed, she took the chicken out of the freezer to thaw as an alternate for lunch. She stated the chicken was placed in the sink under running water to thaw. She stated the DM advised them State was in the building and to make sure the kitchen was clean. She stated she panicked and grabbed the bag of raw chicken parts and threw it into the freezer (she thought it was the refrigerator) to make sure the kitchen appeared clean. She stated in her panic she thought the freezer was the refrigerator. She stated that it was not in there for long. She stated she knew it was not proper procedure to re-freeze meat because it could get bacteria and create food borne illnesses. She stated she threw the chicken away. Interview on 04/03/2025 at 03:12 PM with the Administrator revealed, his expectation was everything to be thawed appropriately, and nothing was re-frozen. The risk was food borne illness, serious injury that could lead to death. The follow up was to have dietary staff conduct a re-education on proper food storage and have the DM follow up with the staff. Dry goods should be up off the floor when delivered and properly labeled and dated. The risk was pest control issues. Record review of the facility policy Food Receiving and Storage revised October 2017 revealed: Foods shall be received and stored in a manner that complies with safe food handling practices. 6. Food in designated dry storage areas should be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. 13. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods. Review of the U.S. Public Health Service Food Code, dated 2017, reflected: .3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below, separating raw animal foods during storage, preparation, holding, and display from: (a) Raw ready-to-eat food including other raw animal food such as fish for sushi or molluscan shellfish or other raw ready-to-eat food such as fruits and vegetables, (b) Cooked ready-to-eat, and (c) Fruits and vegetables before they are washed; (d) Frozen, commercially processed and packaged raw animal food may be stored or displayed with or above frozen, commercially processed and packaged, ready-to-eat food. (2) Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display .

Based on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care were provided care, consistent with professional standards of practices for 5 of 7 residents reviewed for respiratory care (Residents #3, #4, #5, #6 and #7). 1. The facility staff failed to ensure Resident #3, #4, #6, and #7's nasal annular oxygen tubing was changed per the facility's policy and Physician orders on Sunday during the 10:00 PM to 6:00 PM shift and the following shifts by the nurse on 09/15/24, 09/17/24, and 09/18/24. 2. The facility staff failed to ensure Resident #3, #4, #5, #6, and #7's nasal annular oxygen tubing was dated per facility policy on 09/17/24 and 09/18/24. 3. The facility staff failed to ensure Resident #3, and #5's Sleep Apnea mask was bagged and dated when not in use per facility policy on 09/17/24 and 09/18/24. 4. The facility staff failed to ensure Resident #5's nebulizer mask was changed per the facility's policy. 5. The facility staff failed to ensure Resident #6's and Resident #7's portable NC oxygen tubing that was attached to their wheelchair was changed and dated per the facility's policy and Physician orders on 09/17/24 and 09/18/24. 6. RN P failed to ensure Resident #3's nasal annular that was attached to her portable oxygen and w/c was changed when found on the floor on 09/19/24. 7. The facility failed to ensure Resident #7's physician's order dated 07/08/24 was updated for continuous oxygen at the time of re-admission for respite on 09/15/24 nor addressed the tubing maintenance. These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress. Findings: Resident #3 In an observation of Resident #3's room on 09/17/24 at 12:30 PM revealed NC lying on the floor behind the oxygen concentrator and humidifier bottled dated 09/10/24. In an interview with Resident #3 on 09/17/24 at 12:30 PM she stated that the nurse checks her oxygen tubing daily, and she had some difficulty breathing at times. She does not remember when the last time her NC tubing was changed on her wheelchair or room concentrator. Observation of NC tubing revealed oxygen setting on 2 L and NC tubing was not dated. In an observation on 9/18/243 at 1:00 PM revealed Resident #3's revealed the oxygen setting on 2 L and her NC tubing was not dated. In an observation of Resident # 3 on 9/19/24 at 9:45 AM revealed resident lying on bed with oxygen NC in her nose and dated with white tape 09/18/24. In an observation on 09/19/24 at 9:49 AM of Resident #3's wheelchair located in the hallway revealed the NC nostril prongs, and tubing lying on the ground unbagged and undated. This Surveyor walked to obtain assistance from a nurse and returned and discovered RN P. RN P accompanied this surveyor to Resident #3's wheelchair and observed a new piece of white tape dated 09/18/24, and the tubing was still on the ground. Record review of Resident #3's face sheet dated 09/19/24 revealed she was an [AGE] year-old female with an initial admitted [DATE] and readmission 08/07/24. DX included: Acute posthemorrhagic anemia (a low amount of hemoglobin in your red blood cells. Hemoglobin is a protein that helps red blood cells carry oxygen throughout your body.) Chronic Obstructive Pulmonary Disease (progressive lung disease), Asthma (inflammation of the airways to the lungs), Dependence on supplemental oxygen (Supplemental oxygen therapy helps people with COPD, and other breathing problems get enough oxygen to function and stay well.) Record review of Resident #3's QA MDS dated [DATE] with a BIMS score of 14 indicating she was cognitively intact. Section GG Functional abilities revealed she was independent with eating and required set up and clean up for hygiene. Substantial assistance for showers, toileting hygiene, dressing and personal hygiene. Section J reflected other conditions including SOB, with exertion and when lying flat. Section O reflected Resident #3 receives treatment for continuous oxygen therapy. Record review of Resident #3's care plan dated 6/25/24 reflected, Focus: Resident requires supplemental oxygen for respiratory status r/t Cardiac (heart) Diagnosis, COPD intervention to monitor for complications r/t oxygen use (ears, nose, dry mucous membranes) follow with MD and preventative measures as ordered Oxygen per nasal annular at 2 or more Liters/Min; Oxygen to be administered intermittently/Constantly to keep SA O2 > 90% ; Oxygen tubing changed per facility protocol. Focus: the resident has Alteration in Respiratory Status Due to Asthma, oxygen dependent. Interventions treatments Administer oxygen as needed per Physician order. Monitor oxygen saturations on room air and/or oxygen. Monitor oxygen flow rate and response .Elevate HOB to alleviate shortness of breath .Observe for changes in level of consciousness, restlessness, confusion . Record review of Resident #3's MD order dated 01/31/24 reflected an order document SP O2 and Temperature q shift for safety Change Oxygen tubing weekly and PRN every night shift every Sun for Oxygen uses. Record review of Resident #3's progress note dated 9/16/24 at 2:28 AM reflected a note from Skilled Status note Resident sleeping in bed with eyes closed. HOB up to 30%. 02 in place at 2 LPM/NC. Respirations even and unlabored. 02 Sat at 96%. No coughing or c/o dyspnea. No new s/s of bleeding/ no new bruising or bleeding. No reports of dark colored stools. No c/o palpations or chest discomfort. Remains Skilled. Record review of Resident #3's September 2024 TAR reflected that LVN C changed oxygen tubing. Additional TAR record review of nursing task to take and monitor vitals on the following dates 09/16/24, 09/17/24, and 09/18/24 were completed by RN P. In an interview with RN P on 09/18/24 at 9:55 AM, she said that she placed the white tape on NC tubing after the surveyor finished the observations. RN P stated that during her application of the tape she had not noticed the NC tubing on the floor. She stated that she would remove old tubing and change and date the [NAME] immediately. RN P stated that resident tubing should be changed weekly and as needed. She said tubing found undated or on the floor should be discarded immediately to prevent infection. Resident #4 In an observation and interview with Resident #4 on 09/17/24 at 10:40 AM revealed that his NC oxygen tubing not dated. NC in nose no complaints of breathing did not appear to be having any trouble breathing. Resident #4 said he does not remember when his oxygen tubing was last changed. Record review of Resident #4's face sheet dated 09/19/24 revealed he was a [AGE] year-old male admitted on [DATE]. DX included Acute Respiratory Failure, Diabetes Mellitus 2 (abnormal blood sugar levels). Record review of Resident #4's QA MDS dated [DATE], reflected he had a BIMS score of 03 indicating he was severely impaired cognitively. He required set up and clean up assistance for eating, he required partial staff assistance for oral hygiene, dependent on staff for toileting hygiene, dressing, bating and personal hygiene. Resident #4's oxygen was addressed in his MDS and DX of respiratory failure. Record review of Resident #4's Care plan dated 07/30/24 reflected Resident has alteration in Respiratory Status Due to Chronic Obstructive Pulmonary Disease, respiratory failure, pulmonary edema (excessive fluid accumulation in the tissue of the lungs interventions: Observe and document vital signs, specifically respiratory pattern, rate, rhythm, observe for changes .Observe for shortness of breath. Focus: Resident requires supplemental oxygen for respiratory status Hypoxemia (low level of oxygen in the blood.) Record review of Resident #4's MD orders dated 11/17/23 reflected Change Oxygen tubing weekly and PRN 10/21/23 Oxygen per nasal annular at 3 L/min to keep SA O2 > 90% No directions specified for order. 11/17/23 .Change O2 Tubing and Date every Sunday Night. Every Sunday dated 11/19/24 Anticoagulant medication - monitor for discolored urine, black tarry stools, sudden severe headache, N/V, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and / or v/s, sob, nose bleeds. Document n if monitored and none of the above observed. y if monitored and any of the above was observed, select chart Other/see nurses notes,' and enter findings in progress note. Monitor every shift for monitoring and safety, dated 11/17/2023 10:00 PM. Resident #5 In an observation of Resident #5 on 09/17/24 at 10:55 AM revealed resident nebulizer mask unbagged face down on a chair next to her bed. In an interview with Resident #5 on 09/17/24 at 10:55 AM revealed she does not remember if her oxygen mask was changed or if she had a bag. Resident was not interviewable based on her answers and inattentive to questions. In an observation of Resident #5 on 09/18/24 at 9:48 AM revealed resident nebulizer mask unbagged face down on top of her nightstand. Record review of Resident #5's face sheet revealed she was an [AGE] year-old female admitted on [DATE] DX Dementia (cognitive memory loss), Sleep apnea (sleep related breathing disorder). Record review of Resident #5's QA MDS type (none of the above) dated 07/15/24, reflected a BIMS score of 8 indicating moderate cognitive impairment. Section GG resident requires setup and clean up assistance supervision for oral hygiene and substantial/maximal assistance with toileting hygiene, showers, and dressing. Section O did not address oxygen therapy Bi-PAP or C-PAP. Record review of Resident #5's care plan dated 08/05/24 reflected Potential for sleep disturbance alteration r/t insomnia .intervention Medications as ordered if interventions not effective, reduce environmental distractions (e.g., close door to client's room; use night light rather than overhead light whenever possible; Record review of Resident #5's MD orders dated 09/12/24 ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML 3 ml inhale orally every 6 hours as needed for SOB or Wheezing via nebulizer. Obtain vital signs BP, HR, RR, SP O2%, and temperature weekly .1 time every 7 days for safety and monitoring. Record review of Resident #5's September 2024 MAR reflected documentation of resident vitals being checked on 09/16/24. Record review of Resident #5's September 2024 MAR reflected documentation for MD order Albuterol treatment was documented as follows: 09/13/24 at 6:00 PM. 09/15/24 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. 09/16/24 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. 09/17/24 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. 09/18/24, 12:00 PM, and 6:00 PM. 09/19/24, 12:00 AM, 6:00 AM Resident #6 In an observation with Resident #6 on 09/17/24 at 10:30 AM she was lying in bed on her back with NC properly positioned in her nose with her eyes closed. Resident #6's oxygen NC tubing was not dated and touching the floor. In an attempted interview with Resident #6 on 09/17/24 at 10:30 AM and 09/18/24 at 9:30 AM revealed she was not interviewable due to confusion. Record Review of Resident #6's face sheet revealed she was a [AGE] year-old female with an admitted [DATE]. DX included: Peripheral Vascular Disease (a vascular (vessel) disorder that causes abnormal narrowing of the parties) and vascular dementia (progressive loss of intellectual functions), cerebral atherosclerosis (hardening of your arteries, chronic kidney disease (failing kidney function). Record Review of Resident #6's QA MDS assessment MDS 07/12/24 BIMS 5, oxygen not addressed on MDS, hospice addressed. Anti-anxiety and anti-psychotic, pain. There was no Significant Change MDS found in resident's records. Resident #6 requires assistance from staff for all care needs. Record Review of Resident #6's care plan reflected she had a physical functioning deficit related to: Mobility impairment, Self-care impairment, risk of falls, related to a history of poor safety awareness, medication side effects, and attempts to ambulate without assistance/walker. Bed mobility assistance, call light in reach. Increased confusion. Hospice care with Vitas Hospice related to cerebral atherosclerosis There were no revisions to address the fall on 09/09/24, order for oxygen, and hospitalization . Record Review of Resident #6's MD orders dated 07/17/24 reflected Monitor and record Temperature and 02 sats once daily, Monitor for the following: Fever [greater] than 99.0 F, Cough, Chest pain, Runny nose, SOB, Chills, Muscle pain, Headache, Loss of smell or taste, diarrhea and loss of appetite, or sore throat. If source of symptoms has not yet been determined or treatment implemented, follow up with MD for any positive findings Change Oxygen tubing weekly and PRN every night shifts every Sat for Oxygen use -dated 06/22/24 10:00 PM. Monitor for fatigue, weight gain, loss of consciousness Notify MD as needed .Admit to hospice dated 03/12/24. Record Review of Resident #6's physician orders revealed an order on 03/12/24 stating admit to nursing facility under Hospice for routine care with a diagnosis of hypertensive heart disease with heart failure. Record Review of Resident #6's Progress note 09/09/24 6:04 PM by LVN J reflected Nurses Note [HN] came and evaluated the resident no new orders at this time and continue with Neuro checks as protocol. Record Review of Resident #6's fall incident report by RN Y dated 09/9/2024 4:00 PM completed Event Initial Note Event Type: Unwitnessed fall Date of Event: 09/09/24 Time of event : 4:00 PM Detailed description of event (how, when, where, vitals, symptoms): Resident was found on the floor in her room by the nurses on duty, the resident was lying on the left side between the bed and the closet, and she has S/T on the left side of her left eye close to the eyelash and bump on the same side, resident is c/o of pain ( headache)Tylenol given, head to toe assessment completed and the nurses and the CNA put the resident back on the bed, S/T was cleaned and dressing was placed. Patients' description of event: I was trying to go to the bathroom, and I lost balance and fell MD Notification (Date, Time, Method of communication): MD and HMD were notified on Hospice on 09/09/24 at 4:15 PM. Full Range of Motion Assessment findings: WNL. Responsible Party Notification: on 09/09/24 at 4:15 PM. Interventions (any interventions what we can do as staff to prevent this event from happening again): Head to Toe assessment completed. Educated the resident to use the call light for assistance. Bed in a low position. Floor mat paced. W/c on reach. MD, DON, Hospice, and family notified over the phone. The resident was lying on the left side when found. Resident #7 Record review of Resident #7's face sheet reflected he was a [AGE] year-old male with an initial admission on 05/31/24 and readmitted d on 09/15/24 for respite care. DX included: Chronic Obstructive Pulmonary Disease COPD (lung disease), Anemia (blood disorder that decreased ability to carry oxygen to the lower extremities), Morbid obesity (severely overweight), Sleep Anemia, and Atrial Fibrillation (abnormal heartbeat rhythm.) Record review of Resident #7's Admissions MDS dated [DATE] reflected BIMS of 15 indicating he was cognitively intact DX of COPD, Sleep Apnea, respiratory illness, and Morbid obesity was addressed in MDS. respiratory illness. Oxygen treatments and BiBap (B-ilevel positive airway pressure machine that helps you breathe by delivering air through a mask) was addressed. Resident #7 requires assistant with toileting, hygiene care, transferring and bed mobility. Record review of Resident #7's baseline care plan dated 09/16/24 reflected he has a physical deficit functioning. Interventions he needs assistance with dressing, toileting, bed mobility, keep call bell in reach. He was at risk of falls, interventions assess for pain, bed in low position, clear and monitor environment obstacles (tubes, cord), and encourage resident to wear footwear to prevent slipping. Record review of Resident #7's MD orders reflected an active written order dated 07/07/24 Admit to facility for Respite stay: 07/13/24 .order date 07/08/24 Head of bed elevated 30-45 degrees at all times every shift for SOB while lying flat . verbal order date 07/09/24 Document findings in PN. Notify MD of change in condition as needed .obtain vital signs: BP, HR, RR, SPO 2%, temperature weekly enter in weights and vitals. One time a day every 7 day(s) for monitoring and safety .written order date order date 09/15/24 by phone Monitor and record Temperature and 02 sats once daily, Monitor for the following: Fever >99.0, Cough, Chest pain, Runny nose, SOB, Chills, Muscle pain, Headache, Loss of smell or taste, Nausea or diarrhea and loss of appetite, or sore throat. If source of symptoms has not yet been determined or treatment Implemented, follow up with MD for any positive findings. one time a day . order date 09/16/24 Observe for sis of resp illness-fever (>100 F), SOB, Phone cough, sputum production. Sore throat, rhinorrhea, chills, myalgias, fatigue, headache, N/DN, new loss of taste or smell, & mental status changes. Resident #7's MD order dated 07/08/24 revealed that his oxygen order was not updated at the time of his admission on 09/15/24. Resident #7's oxygen orders did not address tubing maintenance and change for sanitary respiratory care. Record review of Resident #7's September 2024 TAR did not reflect nursing administration documentation of oxygen tubing. Record review of Resident #7's progress note dated 09/15/24 10:20 PM by LVN T reflected Patient admitted (per report) to facility under RESPITE care for one week. Patient is on 1.5 liters of O2 which was changed in 2030. Patient A/O X 3-4 Lungs clear. Patient experiences SOB r/t CHF. O2 continuous. HR reg. BS X 4 Edema (swelling fluid retention) X 2 lower extremities. Patient is on is type 1 DM and is on Lantus as ordered. Meds Cap minus 3. PEARL (Pupils (Are) Equal, Round, And Reactive (To) Light and Accommodation) verified with MD H and medications have been ordered and awaiting pharmacy delivery. Patient did not bring own meds and has been informed that meds will not be delivered until night run. Resident #7's admission PN documentation Patient is on 1.5 liters of O2 which was changed in 2030. Therefore, it was unclear in the Resident's documentation if orders were changed from 07/08/24 to 3 L. This may have been entered in error [2030] on 09/15/24. Record review of Resident #7's progress note dated 09/15/24 by LVN C at 11:43 PM reflected Resident with DX: COPD (an ongoing lung condition caused by damage to the lungs.) DM Type II (Type 2 diabetes is a chronic disease. It is characterized by high levels of sugar in the blood. Anemia (a condition in which the body does not have enough healthy red blood cells.) Sleep Apnea (A sleep disorder that is marked by pauses in breathing of 10 seconds or more during sleep and causes unrestful sleep.) A-Fib (an irregular and often very rapid heart rhythm) Hypertension (high blood pressure) Resident admitted at 1:15 PM today. Resident is here for seven days of Respite. Resident is AAOx3 (refers to the patient being alert and oriented to person, place and time) C-PAP (machine used to keep breathing airways open while you sleep) in use at this time/ wears O2 (oxygen) at 2 L (liter metric unit equal to volume of water) P (Pulse the rhythmic contraction and dilation of the arteries resulting from the beating of the heart), M (Meter a base unit of length)/NC (Nasal annular a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help.) (Continuous. Abdomen obese with Bowel sounds active X (times) 4. Uses urinal (male urine collection container. At this time resident is sleeping with C-PAP (machine used to keep breathing airways open while you sleep) in place/ respirations even and unlabored. Call Bell/urinal/ and fluids within easy reach. Resident oriented to surroundings. Encouraged to have someone present during transfers. Stable. In in an interview with RN P 09/19 /24 at 9:45 AM admitted to placing the white tape on Resident #3's oxygen tubing that was still on the floor. She said she would change and date. Dating prevents overuse. In in an interview with the MDS Coordinator on 09/19/24 at 11:00 AM she stated the MDS significant change or decline in 2 areas of care treatment and changes in services to the patient. She would be notified by the IDT team in the weekly morning meeting. She said in the meeting discussion, Resident #6 had not had a change in her medical needs. She stated that Resident #6 had fallen last week (she did not know the exact date.) MDS coordinator said that Resident #6 was ordered PRN oxygen last week. She said this did not warrant a significant change in MDS assessment. She did not answer the risk to residents. MDS consultant stated she was not directed to complete a significant change for Resident #6 in the IDT meeting. In an interview on 09/19/24 at 02:15 PM with ADON she stated that she expects the 10:00 PM to 6:00 AM to change and date tubing weekly on Sunday's, and the 6:00 AM to 2:00 PM staff were responsible for auditing tubing for dates during their care rounds and checking vitals. She stated it was the ADON and DON responsibility to monitor nursing task. The ADON said the risk of not dating resident tubing can result in respiratory infections and illnesses. In interview on 09/19/24 at 2:25 PM, the DON stated the charge nurses were responsible for changing the oxygen tubing and humidifier bottles weekly. He stated by not doing so could cause oxygen delivery issues or infections. The DON said he and the ADON was responsible for ensuring processes are in place. During an interview on 09/19/24 at 2:335 PM, the Administrator said nursing was responsible for, changing the tubing and bottles every Sunday, and as needed. He said the DON was to oversee that the nursing staff were following the respiratory care policy and expected respiratory equipment to be cleaned and changed weekly. He said the residents could be at risk for infections. Record Review of facility in-serviced dated 09/18/24 by DON reflected Topics: 02 and Nebulizer Infection Control of Tubing and Masks for oxygen and nebulizer's MUST be changed q 7 days and labeled with the date that the new tubing/mask is placed in use .02 concentrators and their filters MUST be sanitized q 7 days Nebulizer's MUST be sanitized q 7 days. Humidifier containers MUST be replaced q 7 days and PRN Nasal annular's, masks, nebulizer administration sets Must be bagged and labeled when not being used. ALL nurses, no matter which shift you are working, MUST pay attention to these points whenever you enter a resident's room, and MUST correct any issues as you find them. Please read the attached policy and print and sign your name on last page acknowledging understanding what is expected of you regarding this matter. The facility's ADM did not provide the policy for respiratory care was requested on 09/18/24 and 09/19/24 and was not provided at the time of exit.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, reviewed for 1 (Resident #7) of 3 Residents reviewed for baseline care plan in that: The facility failed to update Resident #7's baseline care plan dated 09/15/24 which did not include his oxygen treatment, sleep apnea treatment, and need for assessments of O2 sats every shift. This deficient practice could result in newly admitted residents receiving improper care. The findings included: In an observation and interview with Resident #7 on 09/18/24 at 10:35 AM revealed his portable nasal canula tubing was in use but not dated. Resident #7 stated that he was admitted with his oxygen due to COPD and difficulty breathing. In an observation and interview with Resident #7 on 09/18/24 at 10:35 AM revealed the resident sitting in a power electric wheelchair moving to through the facility. No concerns observed. In an interview Resident #7 stated that he was admitted with his oxygen due to COPD and difficulty breathing. Record review of Resident #7's face sheet reflected he was a [AGE] year-old male with an initial admission on 05/31/24 and readmitted d on 09/15/24. MDS dated [DATE] reflected BIMS of 15 indicating he was cognitively intact, power wc, respiratory illness. Resident #7's DX included: Chronic Obstructive Pulmonary Disease COPD (lung disease), Anemia (blood disorder that decreased ability to carry oxygen to the lower extremities), Morbid obesity (severely overweight), Sleep Anemia, and Atrial Fibrillation (abnormal heartbeat rhythm.) Record review of Resident #7's MDS dated [DATE] reflected BIMS of 15 indicating he was cognitively intact DX of COPD, Sleep Apnea, and Morbid obesity addressed in MDS. respiratory illness. Oxygen treatments and Bi-PAP (Bi-level positive airway pressure machine that helps you breathe by delivering air through a mask) was addressed. Resident #7 requires assistant with toileting, hygiene care, transferring and bed mobility. Record review of Resident #7's baseline care plan dated 9/16/24 reflected he has a physical deficit functioning. Interventions he needed included assistance with dressing, toileting, bed mobility, keep call bell in reach. He was at risk of falls, interventions assess for pain, bed in low position, clear and monitor environment obstacles (tubes, cord), and encourage resident to wear footwear to prevent slipping. Resident #7's oxygen and sleep apnea treatments were not addressed. Record review of Resident #7's MD orders dated 7/8/24 reflected a prescription Oxygen: Oxygen at 3 L/HR every shift related To Chronic Obstructive Pulmonary Disease, Unspecified (J44.9). MD order dated 07/08/24 obtain vital signs: BP, HR, RR, SPO 2%, temp weekly. Enter in weights and vitals .one time a day every 7 day(s) for monitoring and safety. MD order dated 09/16/24 PRN Observe for s/s of resp illness-fever (>100 F), SOB, cough, sputum (mucus) production, sore throat, rhinorrhea (runny nose), chills (feeling cold), myalgias (muscle pain), fatigue, headache, new loss of taste or smell, & mental status changes. Document findings in PN. Notify MD of change in condition. Record review of Resident #7's progress note dated 09/15/24 by LVN T reflected the patient was on 1.5 liters of O2. Record review of Resident #7's progress note dated 09/15/24 by LVN C at 11:46 PM reflected Resident with Dx: COPD. DM Type II, Anemia/Sleep Apnea C-Pap in use at this time/ wears O2 at 2 L/P/M/NC continuous resident sleeping with C-Pap in place/ respirations even and unlabored. In an observation and interview with Resident #7 on 09/18/24 at 10:35 AM revealed the resident sitting in a power electric wheelchair moving to through the facility. No concerns observed. He stated that his medication did not arrive on time after his admission on 09/15/24. During an interview with the ADON on 09/19/2024 at 2:30 PM, she stated the baseline care plan includes and shows staff what needs to happen until a comprehensive [care plan] was provided. The nurse conducting admission assessment was responsible for documenting resident care needs, and the ADON and DON were responsible for ensuring the task was completed timely and correctly to address the resident needs. During an interview with the DON on 09/19/2024 at 2:40 PM the DON stated baseline care plan provides the resident care needs for the staff providing skilled care. The risk of not providing all needs could result in resident not receiving care and a decline in health. He stated that the ADON and DON were responsible for monitoring the admission care plan and resident needs. Record review of the facility policy, Care Plans - Baseline, was not provided.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 8 residents (Resident #7) reviewed for quality of care. The facility failed to document Resident #7 diagnosis of COPD and oxygen orders on the care program. This failure could place residents at a risk of being receiving incorrect treatment. Findings included: Record review of Resident #7's face sheet reflected he was a [AGE] year-old male with an initial admission on 05/31/24 and readmission for respite dated on 09/15/24. Record review of Resident #7's MDS dated [DATE] reflected BIMS of 15 indicating he was cognitively intact. Resident #7 requires staff assistant with toileting, hygiene care, transferring and bed mobility. Record review of Resident #7's care plan dated 09/16/24 reflected he has a physical deficit functioning. Interventions he needs assistance with dressing, toileting, bed mobility, keep call bell in reach. He was at risk of falls, interventions assess for pain, bed in low position, clear and monitor environment obstacles (tubes, cord), and encourage resident to wear footwear to prevent slipping. Record review of Resident #7's MD orders dated 07/8/24 reflected a prescription Oxygen: Oxygen at 3 L/HR (liters per hour) every shift related To Chronic Obstructive Pulmonary Disease, Unspecified (J44.9). MD order dated 07/08/24 obtain vital signs: BP, HR., RR, SPO (see acronyms) 2%, temperature weekly. Enter in weights and vitals .one time a day every 7 day(s) for monitoring and safety. MD order dated 09/16/24 PRN Observe for s/s of resp illness-fever (>100 F), SOB, cough, sputum (mucus) production, sore throat, rhinorrhea (runny nose), chills (feeling cold), myalgias (muscle pain), fatigue, headache, new loss of taste or smell, & mental status changes. Document findings in PN. Notify MD of change in condition. Record review of Resident #7's September 2024 TAR did not reflect nursing administration documentation of oxygen tubing. Record review of Resident #7's progress note dated 09/15/24 10:20 PM by LVN T reflected Note Text: Patient admitted (per report) to facility under RESPITE care for one week. Patient is on 1.5 liters of O2 which was changed in 2030. Patient A/O X 3-4 Lungs clear. Patient experiences SOB r/t CHF. O2 continuous. HR reg. BS X 4 Edema (swelling fluid retention) X 2 lower extremities. Patient is on is type 1 DM and is on Lantus as ordered. Meds Cap minus 3. PEARL (Pupils (Are) Equal, Round, And Reactive (To) Light and Accommodation) verified with MD H and medications have been ordered and awaiting pharmacy delivery. Patient did not bring own meds and has been informed that meds will not be delivered until night run. Record review of Resident #7's progress note dated 09/15/24 by LVN C at 11:43 PM reflected Resident with Dx: COPD (.an ongoing lung condition caused by damage to the lungs.) DM Type II (Type 2 diabetes is a chronic disease. It is characterized by high levels of sugar in the blood. Anemia (a condition in which the body does not have enough healthy red blood cells.) Sleep Apnea (A sleep disorder that is marked by pauses in breathing of 10 seconds or more during sleep and causes unrestful sleep.) A-Fib (an irregular and often very rapid heart rhythm) Hypertension (high blood pressure) Resident admitted at 1:15 PM today. Resident is here for seven days of Respite. Resident is AAOx3 (refers to the patient being alert and oriented to person, place and time) C-PAP (machine used to keep breathing airways open while you sleep) in use at this time/ wears O2 (oxygen) at 2 L (liter metric unit equal to volume of water) P (Pulse the rhythmic contraction and dilation of the arteries resulting from the beating of the heart), M (Meter a base unit of length)/NC (Nasal cannula a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help.) (Continuous. Abdomen obese with Bowel sounds active X (times) 4. Uses urinal (male urine collection container. At this time resident is sleeping with C-PAP (machine used to keep breathing airways open while you sleep) in place/ respirations even and unlabored. Call Bell/urinal/ and fluids within easy reach. Resident oriented to surroundings. Encouraged to have someone present during transfers. Stable. Interview on 09/19/24 at 2:33 PM, the ADM who stated that he expected the nursing staff to follow admissions policy and protocol for new admission physician orders. He said the risk to residents could result in services and orders not being followed. Interview on 09/19/24 at 2:25 PM, the DON who stated the admitting nurse was responsible for entering all orders for the attending physician to review orders and change them as needed. The DON stated there should be no reason for the admitting nurse omitting the O2 oxygen orders. The DON stated he did not know at the time which nurse completed the admitting The DON stated that it was his expectation for nursing staff to consult with MD admission orders and submit for resident care. He said the risk to residents could result in services and orders not being followed. Review of the facility's policy dated March 2017 titled Admissions admissions - From the Community Policy Statement Residents from the community who's medical and nursing care needs can be adequately met may be admitted to this facility. 1. Policy Interpretation and Implementation resident may be admitted directly from the community to the facility upon the written order of the resident's primary healthcare provider. 2. Prior to, or at the time of admission, a resident admitted from the community to the facility will have the following information available to assure that the immediate care needs of the resident can be met: admitting diagnosis and prognosis; Current medical status; Physician orders for immediate care; and Others as necessary or appropriate. A physical examination will be made within forty-eight (48) hours of the resident's admission unless a physical examination was completed not more than five (5) days prior to the resident's admission. 3. A copy of the physical examination must be provided to the facility and filed in the resident's admission record. 4 .A summary of the resident's prior treatment(s) and his or her rehabilitative potential (long-term and short- term) will be provided to the facility within forty-eight (48) hours of the resident's admission.

Based on observation, interview and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area for 2 of 14 residents (Residents #41 and #62) reviewed for physical environment. The facility failed to ensure Residents #41's and #62's call lights were accessible. This failure could place residents at risk of not having their needs met. Findings included: Record review of Resident #41's face sheet, dated 02/22/2024, reflected an original admitted [DATE] and readmitted on [DATE]. Resident #41's diagnoses included Cerebral Infarction (stroke; occurs when a clot blocks a blood vessel that feeds the brain), Unspecified; Unspecified Dementia (dementia without a specific diagnosis, also known as mild or mixed dementia); Type 2 Diabetes Mellitus Without Complications (long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels); Chronic Obstructive Pulmonary Disease; Acute Kidney Failure; Abdominal Aortic Aneurysm, (enlargement of the aorta, the main blood vessel that delivers blood to the body, at the level of the abdomen) Without Rupture, Unspecified; Dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus), Oropharyngeal Phase; Difficulty In Walking, Not Elsewhere Classified; Muscle Wasting And Atrophy; Other Abnormalities Of Gait And Mobility; Cognitive Communication Deficit; Heart Failure, Unspecified; Altered Mental Status, Unspecified. Record review of Resident #41's most recent quarterly MDS assessment, dated 11/26/2023, revealed a BIMS score of 03, indicating severe cognitive impairment. Review of the MDS, dated [DATE], reflected Resident #41 was totally dependent with two-person assist for toilet use, dressing, hygiene, and transfers. Resident #41 utilized a manual wheelchair for mobility. Observation and interview in Resident #41's room area on 02/22/2024 at 8:55 AM revealed the call light along the bedframe between the mattress and the grab bar with the call light button on the floor. Resident was in bed, bed was in a mid-height position, wearing casual clothing, and eating breakfast. When asked, Resident #41 said he did not know where his call light was. Observation on 02/23/2024 of Resident #41's room area revealed resident in bed asleep, bed was in the lowest position, and the call light was again in the same position between the bedframe, mattress, and grab bar with the call light button on the floor. Record review of Resident #62's face sheet, dated 02/22/2024, reflected an original admitted [DATE] and readmitted [DATE]. Resident #62's diagnoses included Unspecified Dementia (dementia without a specific diagnosis, also known as mild or mixed dementia), Acute Kidney Failure, Muscle Weakness (Generalized), Other Lack of Coordination, Cognitive Communication Deficit (difficulty with thinking and how someone uses language). Resident #62 was not a native English speaker. Record review of resident #62's most recent quarterly MDS assessment, dated 12/29/2023, revealed a BIMS score could not be obtained due to a language barrier. Resident #62's MDS showed a Staff Assessment for Mental Status indicated this resident was Severely Impaired for Cognitive Skills for Daily Decision Making. Resident #62 was documented to be totally dependent with two-person assist for showering/bathing, needing supervision for tub/shower transfer. Observation on 02/21/2024 at 10:35 AM of Resident #62's room area revealed resident in bed asleep, bed in lowest position, room area clear of any hazards, and the call light was on the roommate's bed between the grab bars and mattress along the bedframe with the call light button on the floor. Observation of Resident #62's room area on 02/22/2024 revealed the call light was in the same position as the previous day between the roommate's grab bar and mattress along the bedframe with the call light button on the floor. Interview on 02/23/2024 at 9:55 AM, CNA B stated that call lights should be on the beds of each resident within reach of the resident if they were in bed. CNA B stated that everybody was responsible to check the call lights as a resident could have a fall or a need and not be able to let anyone know. The call lights were tested weekly by the nursing staff and routinely by maintenance to ensure they were working according to CNA B. CNA B stated the call light, even if functioning properly, is no good if not in easy reach of the resident when they need it. Interview on 02/23/2024 at 10:21 AM with LVN D revealed this was the LVN's second day working at the facility. LVN D stated that at the start of a shift rounding and looking at each room, looking for any hazards, and checking for call light placement was a high priority task for each staff member. LVN D stated that if a staff member saw a call light on, they should ask the resident who they were to make sure it is the correct patient in the bed or room area, ask how they were doing and what the need was, converse with the resident, and make sure the call light was within reach by placing it on the chest or in the hand of the resident, then take care of their need. LVN D stated that call lights are to be checked by any staff that sees it activated; all are responsible for checking no matter what their position was. Interview on 02/23/2024 at 10:39 AM, the ADON stated that call lights are everyone's responsibility. The ADON expects that at any time a staff member was in a resident's room they were to look for call light placement and move it to an appropriate area if not already. The ADON shared that the nurses are responsible to go behind the CNAs to look for call light placement, hazards in the room, and anything that may be out of place or not functioning properly when conducting rounds at the beginning of and throughout their shift. The ADON and DON stagger their shift time to ensure one was always available for any issue that may arise. The ADON stated she expects for a call light to be within reach of a resident if they were in their room because without the call light nearby a resident could lose their balance and fall if not able to call for help. A resident could need help with repositioning, transferring to a wheelchair, need water/hydration, or have an inability to get what they need when they need it if the call light is not functioning or within reach which could cause an injury. Interview on 02/23/2024 at 11:19 AM, the ADM stated the expectation of all staff was to answer any call light in a timely manner, and the facility goal is for call lights to be answered in less than 10 minutes in busy times. Staff are expected to be sure to acknowledge all call lights and to communicate with the resident and any other staff in the area who will address the resident's need and if a delay is anticipated to advise the resident of why. All call light buttons are to be in reach of a resident when that resident was in or near their bed, call light buttons should be easy for the resident to get to, and the call light button should always be within reach of the resident. The ADM stated that it is the responsibility of anyone who goes into a resident room to check for call light placement. Interview on 02/23/2024 at 11:30 AM, the DON stated the expectation of any staff going into a resident's room should be to check that each call light was in reach and working for each bed, each resident had a drink in reach on the bedside table, and the bed was in the correct position in the room. Record review of facility policy titled, Answering the Call Light (C)2001 (Revised July 2023), revealed The purpose of this policy is to ensure timely response to the resident's requests and needs. General Guideline #1 stated Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident. General Guideline #4 stated Be sure the call light is plugged in and functioning at all times. General Guideline #5 stated Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on observations, interviews, and record reviews the facility failed to review the risks and benefits of bed rails and enabler/grab bars (smaller bars used by the person in bed to reposition themselves), with the resident or resident representative and obtain informed consent prior to installation for one (Resident #40) of 3 resident rooms observed and reviewed for bed rails/enabler bars. The facility failed to have evidence of informed consent, assessment of the resident for risk of entrapment, or a physician's order for the quarter bed rails/enabler bars for Resident #40. This failure could affect residents who used bed rails/enabler bars at risk of the resident/responsible party not being aware of the risks, informed consent not being obtained from the resident or responsible party, physician not being aware of use of the enabler/grab bars, and care plan not being properly documented. Findings included: 1. Record review of Resident #40's face sheet, dated 02/23/2024 revealed resident was originally admitted on [DATE] with diagnoses of Unspecified Dementia (dementia without a specific diagnosis, also known as mild or mixed dementia), Insomnia, unspecified (difficulty initiating or maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakening), Unsteadiness on Feet, Generalized Anxiety Disorder (worrying constantly and cannot control the worrying), Muscle Weakness (Generalized), Difficulty in Walking, not elsewhere classified, Cognitive Communication Deficit (difficulty thinking and with how someone uses language), Mild Neurocognitive Disorder Due to Known Physiological Condition Without Behavioral Disturbance (condition in which people have more memory or thinking problems than others their age), Other Specified Disorders of the Brain, Arthropathy (surgical procedure to restore function to a joint), unspecified, Per the face sheet, Resident #40's responsible party was a family member. Review of Resident #40's MDS assessment (quarterly), dated 01/17/2024, and signed by RN A as assessment coordinator verifying assessment completion, revealed the resident had a BIMS (Brief Interview for Mental Status; assessment of cognitive functioning that is performance-based) score of 03 (a score of 0-7 indicates severe cognitive impairment), is noted to have wandering tendencies 4 to 6 days of the week, is dependent for showering/bathing, and tub/shower transfer. Resident #40 uses a manual wheelchair for mobility. Resident #40's assessment indicated no assistance needed with bed mobility, oral hygiene, meals, dressing, toileting, and personal hygiene. Record review of Resident #40's Care Plan, dated 1/18/2024 as reviewed, revealed no indication of bed rail or enabler bar discussion of risks and benefits with Resident or responsible party. Resident #40's Care Plan has no reference to an assessment that was completed for bed rails or enabler bars. Review of Medical record of Resident #40 revealed no written Physician Order for quarter bed rails/enabler bars for mobility and positioning. No assessment for use of enabler bars or bed rails was located in the medical record for Resident #40. Review of Medical Record of Resident #40 revealed no Physical Device Acknowledgement form (bed rail/enabler bar consent) for the quarter bed rails/enabler bars signed by the resident or resident's responsible party or noted to have verbal permission for the enabler bars. Observations on 02/21/2024 at 10:40 AM, 02/22/2024 at 9:05 AM, and 02/23/2024 at 9:35 AM revealed Resident #40's room had the resident's bed with quarter bed rails/enabler bars raised on both sides of the bed with the call light wrapped around the enabler bars. Resident #40 was not observed in the bed as he had already been assisted with getting ready for the day and was in the activity room with other residents. In an interview on 02/23/2024 at 11:19 AM, the ADM reviewed the facility process for bed rail and grab bar use. The ADM stated the bed rails/grab bars were used for residents for positioning and comfort. The ADM stated that a resident is to be assessed for appropriateness for use and if safety can be maintained. Consent must be received from the resident or responsible party for use of bed rail/grab bars, and orders from the doctor must be received and documented in the resident's chart. Maintenance will fit the appropriate bar to the bedframe once the correct assessments and consents have been placed in the chart and the work order has been placed. The ADM was able to discuss some of the hazards of grab bars being inappropriately placed, such as the resident feeling restrained, and potential for entrapment resulting in bruising, skin tears, or limbs being broken. ADM stated the nursing staff as directed by the DON are responsible for ensuring the assessment is completed, and consent and orders are received before the bars are added to the resident's bed. In an interview with the DON on 02/23/2024 at 11:30 AM, it was expressed that the expectation for grab bars or any type of bed rail was for evaluation of the resident appropriateness with the bed rail/grab bar in place, resident ability to safely utilize the bed rail/grab bar safely, consent from the resident or responsible party based on understanding of hazards and risks of the bed rail/grab bar placed on the resident's bed, care planning of the bed rail/grab bar and what the specific use is for and goal of the bed rail/grab bar, and provider orders. DON was able to speak to the hazard of bed rails/grab bars to a resident included resident getting hung up in the bed rail/grab bar with potential for injury such as bone fracture, skin tears, and bruising, resident who required assistance getting out of bed attempting to do so unassisted resulting in injury, the resident viewing the bed rail/grab bar as a restraint or not understanding the use of the devices. DON stated the nursing staff should make sure each resident has been deemed appropriate for use of bed rails/grab bars and have correct documentation in the electronic health record. DON stated that he didn't think there were any residents in the secure unit with grab bars however other residents had the consents, assessments, and care planning completed. Interview with ADON on 2/23/2024 at 10:39 AM was completed about bed rail or grab bar use in the facility. ADON stated that residents should have been evaluated for use of bed rails/grab bars to make sure the resident can be safe. ADON stated that there must also be a consent on file from either the resident or responsible party, a doctor's order, and therapy evaluation. ADON recognized hazards of bed rails/grab bars as entrapment, balance issues if resident is not appropriate, and injury from a false sense of helping during care by using bars without being cued or asked. Interview with CNA B on 02/23/2024 at 09:55 AM revealed that inappropriate use of bed rails/grab bars could result in resident injury including entrapment, broken arms or legs, or suffocation if a resident were to become trapped between the bar and mattress. CNA B stated that bed rails are not used in the facility and that use of grab bars is determined when a resident is admitted by the IDT. Record review of the facility's provided Bed Safety and Bed Rails, (C)2001 (Revised August 2022), revealed the policy statement Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bedrails is prohibited unless the criteria for use of bed rails have been met. Policy Interpretation and Implementation item #1 states The resident's sleeping environment is evaluated by the interdisciplinary team. Policy Interpretation and Implementation item #2 states Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. Policy Interpretation and Implementation item #10 states additional safety measures are implemented for residents who have been identified as having a higher than usual risk for injury including bed entrapment (e.g., altered mental status, restlessness, etc.). Under the Use of Bed Rails section item #1 states . For the purpose of this policy bed rails include: a. Side rails; b. Safety rails; and c. Grab/assist bars Use of Bed Rails section item #3 states The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Use of Bed Rails section item #5 states If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes: a. an evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs; b. the resident's risk associated with the use of bed rails; c. input from the resident and/or representative; and d. consultation with the attending physician. Use of Bed Rails section item #8 states Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c. The alternatives that were attempted but failed to meet the resident's needs; and d. The alternatives that were considered but not attempted and the reasons.

Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions for storage of drugs and biologicals for 1of 2 medication rooms reviewed for storage and labeling. The facility failed to ensure Influenza (flu) and Tuberculosis (TB) vaccines were dated with an open date. This failure could cause resident to receive less effective and or less strength vaccines. Finding included: Observation and interview with DON on [DATE] at 11:14 AM revealed two medication refrigerators. One refrigerator had 1 open vial of Tuberculosis (TB) vaccines with no open date. The vaccine read House Account, Tubersol 5T/ UINT [unit]/0.1 ML VIAL, for house use ON [DATE]. Discard 30 days after opening. The second refrigerator had 1 box of Tuberculosis (TB) vaccines with no open date and 2 open vials of Influenza (flu) with no open date. The Influenza Vaccine read Influenza vaccine, Flucelvax Quadrivalent ,d+[DATE] formula. DON said that the vaccines should be dated with an open date. He said it was the responsibility of every nurse to date a vaccine and any other medicine after it is opened. He said that he expected nurses to date the vaccine vials when opened so that they can be discarded after 30 days of being open. He said that he was however not sure the discard date for the open flu vaccine vials because it did not specify as the TB boxes were labeled with warning to discard after 30 days. He said the risk was administration of low potency vaccines and it would not produce the desired protection outcome. He said that the infection control preventionist was expected to monitor the vaccines and to in-service on how to administer vaccines. Interview with LVN E on [DATE] at 03:28 PM, revealed that she was the infection control preventionist. She said that the floor nurses gave the vaccines but on occasion she gave the flu and pneumonia vaccines. She said that she always wrote the open date and discard dates on any vaccines she opened. She said that all nursing staff are supposed to write the date on the box or vial of the vaccine when opened. She said that the vaccines in the refrigerator were to be used on various residents (multi dose), however, they should be discarded 30 days after opening. She said that she was not sure who was responsible for tracking the vaccines. She said every nurse was responsible for making sure vaccines were dated and unexpired prior to administration. She said that if she found an open vaccine vial without a date, she would remove it from the refrigerator and dispose of it according to facility policy. She said that she has not done an in-service on vaccines. She said the risk to residents was that the vaccine vials would be ineffective. Review of facility policy titled Influenza vaccine revised [DATE], reflected .administration of the influenza vaccine will be made in accordance with current Centers for Diseases Control and Prevention (CDC) recommendations at the time of the vaccination . Review of facility policy titled Medication Labeling and Storage revision date February 2023, reflected . Medication is stored separately from food and labeled accordingly, .multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial .

Based on observations, interviews and Record Reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure foods stored in the refrigerator and freezer were labeled with the use by date. These failures could place resident at risk for food-borne illness and food contamination. Findings included: Observation on 02/21/2024 at 9:11 am revealed in the refrigerator a plastic container containing a mixture of tomatoes and okra covered with plastic wrap was not labeled with the use by date. Observation on 02/21/2024 at 9:12 am revealed in Freezer #3 a plastic zip lock bag contained two sausage links without a label with the use by date. Interview on 02/21/2024 at 9:13 am with Dietary Manager revealed she did not know who prepared the tomato and okra mix and placed it in the refrigerator. She stated that the sausage was used for breakfast. Interview on 02/23/2024 at 10:00 am with Dietary Manager revealed that the person who prepares the dish is responsible to label and date the dish prior to storage. She stated that not properly labelling and dating the dish may result in contamination and food being in the danger zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause a foodborne illness outbreak if consumed. The policy Food : Preparation dated 2/2023 reflected 17. All refrigerated, ready-to-eat TCS prepared food that are to be held for more than 24 hours at a temperature of 41 degrees Fahrenheit or less, will be labeled and dated with a prepared date (Day 1) and a use by date (Day 7).

Based on interviews and record review, the facility's interdisciplinary team (IDT) failed to ensure the resident's person-centered comprehensive care plan was reviewed and revised for 1 of 8 (Resident #15) residents reviewed for care plans. The facility failed to revise Resident #15's care plan to update and remove conflicting hospice status. This failure could place residents at risk for harm with conflicting care plans and having personalized plans developed to address their specific needs. The findings included: Record review of Resident #15's Face Sheet, retrieved on 02/23/2024, showed a [AGE] year-old female with an original admitted [DATE]. Diagnoses included Chronic Obstructive Pulmonary disease (unspecified)(a group of lung diseases that block airflow and make breathing difficult), unspecified Dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities), unspecified Parkinsonism (a disorder of the central nervous system that affects movement, often including tremors), other Alzheimer's disease (other type of the disease that destroys memory and other important mental functions), Mood disorder due to known physiological condition (marked disruptions in emotions), and Anxiety disorder due to known physiological condition (disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). The resident's face sheet revealed an advance directive showing a code status of DNR/DNI. Record review of Resident #15's MDS quarterly assessment dated [DATE] reflected a BIMS score of 03 indicating severe cognitive impairment. Record review of Resident #15's care plan dated 02/08/2024 showed a focus on Hospice care related to: end stage Parkinson's. The care plan revealed the hospice focus was initiated on 09/02/2021 and revised on 09/02/2021 . Record review of Resident #15's physician's orders summary retrieved on 02/23/2024 showed the orders summary active as of 02/23/2024. Resident #15's order summary reflected an active Admit to [hospice provider] for Dx of Parkinson's verbal order dated 08/25/2021. A prescriber written order dated 04/15/2023 revealed an active Discharge from [hospice provider] related to extended prognosis for Resident #15. During an interview on 02/23/2024 at 3:16 PM with the facility Administrator, he said that the MDS coordinator usually updated and reviewed care plans. He said care plan reviews were conducted quarterly or after a resident's significant change of condition. He said the IDT met regularly to review care plans. He said the IDT consists of all department heads: wound care nurse, rehabilitation, MDS nurse, and all department heads. He said end of life care was decided by the resident's physician after having a conversation with the resident and/or the resident's family. He said a care conference with the family was then scheduled and if all parties agreed, hospice was contacted. He said that entering and discharge from hospice would be considered a significant change of condition that would require updating a resident's care plan. During an interview on 02/23/2024 at 3:28 PM with the Social Worker, she said that care plan meetings and care conferences were held quarterly with the residents and their families. She said that during the meetings, concerns were expressed. She said the meetings were conducted early morning on Wednesdays. She said during the meetings, they discussed any situations or issues about the residents. She said if a significant change of condition existed, a care conference was set up. She said end-of-life care was decided through meetings with the nursing department. She said the DON would bring any issues that were observed to the table and also bring the resident's families into the discussion. She said a Hospice company was often involved in deciding a resident's need for end-of-life care. She said entering and discharge from Hospice would require a change in the resident's care plan. She said the MDS coordinator was typically responsible for reviewing and updating care plans. She said resident updates were discussed during care conference meetings which allowed the staff to update and make changes to care plans. She said the resident care plans were the knowledge about the resident and allowed the staff to care for the resident appropriately, so it was important for the care plan to be reviewed and updated. During an interview on 02/23/2024 at 3:37 PM with the MDS Coordinator, she said that a resident's significant change of condition required an updated care plan. She said after an MDS was completed, she reviewed and updated the care plans. She said that care conferences allowed the department heads/IDT to contribute to the meetings regarding the residents' care. She said that entering and discharge from hospice would require an update to the residents' care plan. She said if care plans were not reviewed and updated, it could cause some confusion for the nurses. She said that orders should reflect if the residents were on or discharged from hospice. During an interview on 02/23/2024 at 4:10 PM with the DON, he said he had been with the facility since 3/20/2023. He said two reasons that would trigger a discharge from hospice would be if the resident had been on hospice for a while or if a resident's family member wanted the resident discharged from hospice. He said if a resident was discharged from hospice, the care plan should be changed to reflect the change. He said there were morning meetings with the IDT to work on issues together and address these types of issues. He said if care plans were not updated, problems that arose with the resident would not be properly addressed. Record review of the facility's Care Planning-Interdisciplinary Team policy dated March 2022 showed, The interdisciplinary team is responsible for the development of resident care plans. Resident care plans are developed according to the timeframes and criteria established by S483.2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for one (Resident #14) of four residents reviewed for intravenous fluids. The facility failed to ensure LVN C used proper technique of flushing Resident #14's midline (a midline is a long flexible tube that is inserted into the large vein in the upper arm) with 0.9 % sodium chloride and avoiding pushing air into the midline intravenous (IV) catheter. This failure could cause a resident to get an air bubble into their blood stream and cause hospitalization . Findings included: Review of Resident #14's Admission Record on 02/23/2024, revealed an [AGE] year old female with no known allergies admitted to the facility on [DATE] with diagnoses of cellulitis of the lower legs (a condition in which the skin has a bacterial infection), surgery of skin and fat tissue, type 2 diabetes (body has trouble controlling blood sugar), heart failure, depression, heart burn, dementia, pacemaker (a device that helps the heart to pump blood), muscle weakness, and high blood pressure. Review of Resident #14's MDS dated [DATE], did not reveal a BIMS screen. Review of Resident #14's order summary dated 02/22/2024, revealed antibiotic Zosyn Intravenous Solution Reconstituted 3.375 (3- 0.375) GM (Piperacillin Sodium-Tazobactam Sodium) Use 3.375 gram intravenously every 8 hours for wound infection for 10 Days, start date 02/15/2024 to 02/26/2024. Sodium Chloride Solution 0.9 % Use 10 ml intravenously every 8 hours for flush before and after IV medication Start date 02/15/2024. Review of Resident #14's care plan dated 02/07/2024, reflected focus: Resident is receiving ABT [antibiotics] and has. Potential for complications r/t ABT. Date initiated 01/24/24 Goal: Resident will be free from s/s [signs & symptoms] of infection daily through next 90-day review. Date Initiated: 01/24/2024. Interventions: .Evaluate for proper infection control procedure, monitor for s/s of infection eg: a) increased temperature, b) redness, c) warmth, d) purulent (pus) drainage, e) N/V [nausea and vomiting], f) odor. Use good standard precautions before and after providing care Date Initiated: 01/24/2024. Observation and interview with LVN C on 02/22/2024 at 08:43 AM revealed Resident #14 had patchy redness around the IV area on her left upper arm. The IV had one port opening that was open to air. IV dressing was dated 02/16/24. LVN C verified that Resident #14 had a midline IV for medication. LVN C verified medication in the EMR with the medication bag in hand. LVN C prepared the tubing for the IV medication. She cleaned the midline IV port opening with an alcohol swab and then LVN C opened a 10 milli liter (10 mL) syringe filled with 0.9 % sodium chloride (normal saline) from a plastic wrapper and she pushed the fluid from the syringe into Resident #14's IV. She emptied the entire syringe of saline into the midline. LVN C did not check the midline to verify IV line worked and was open before connection to the IV medication. LVN C said that the physician was aware of the redness around the IV. She said that the physician asked nursing staff to watch for swelling or spread in the area. She said that Resident #14 might be allergic to the IV adhesive tape. LVN C said that she forgot to remove the air out of the syringe before flushing the IV. She said that the risk was that the resident could get an air embolus (An air embolus is a blockage of blood supply caused by air bubbles in the blood vessels or the heart). Interview with ADON on 02/22/2024 at 11:57 AM, revealed that she expected nursing staff to follow proper IV medication administration and IV site assessment before medication administration. She said she expected them to aspirate (take air out the syringe) before pushing the saline fluid in the IV line. She said that pushing air in an IV line is a risk for embolus. ADON said she would start to in-service the nursing staff on Peripheral and Midline IV catheter and flushing. Interview with DON on 02/23/2024 at 04:08 PM revealed that LVN C had already told him that she had made an error during medication administration. DON said that he expected all staff to follow facility policy and procedures. He said the risk of emptying the entire saline syringe without either taking air out or leaving 1 mL of the 10 mL in the syringe into the IV line could cause an air embolus. He said that he and ADON would start an in-service immediately. Review of facility policy titled Peripheral and Midline IV catheter Flushing and Locking revised march 2022 reflected, . a physician order is not needed to flush a peripheral short catheter, .use preservative-free 0.9 % sodium chloride (normal saline) for flushing a Peripheral and Midline IV catheter, . leave 0.5 to 1 mL of preservative-free 0.9% sodium chloride in the syringe to avoid pushing air into the catheter, frequency; For short and long PIV's and midline catheters used for intermittent infusions, flush the catheter and aspirate for return of blood return prior to each infusion

Based on observations, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (#1 and #43 ) reviewed for infection control practices, in that: The Nursing Scheduler failed to follow proper infection control practices when assisting Resident #1 with her meal. The LPN failed to maintain a safe, sanitary surface during wound care for Resident 43. The failure could place residents at risk for the spread of infection. Review of Resident #1's Admission Record, reflected a [AGE] year-old female admitted to the facility on [DATE] whose diagnoses included: Unspecified sequelae of unspecified cerebrovascular disease (paralysis of some parts of the body such as arms or legs or hemiplegia). Review of Resident #1's Medication Review Report reflected, regular diet soft and bite size texture, thin (regular) 1 consistency. Review of Resident #1's MDS assessment reflected, BIMS summary score of 15 indicating cognition is intact. Eating self-performance 4- Total dependence full staff performance every time during entire 7-day period. Support- 2 one person physical assist. Observation of assistance with feeding on 02/22/2024 at 12:00 PM revealed Nursing Scheduler assisting resident #1 with lunch. Resident #1 stated that the soup was hot., Staff was observed lifting the spoonful of soup to her mouth and blowing on it in an effort to cool off the soup. Observation revealed the staff member blew on the spoonful of soup three separate times. Interview with Nursing Scheduler on 02/23/2024 at 1:41 pm revealed, staff member stated that she blew on the soup to cool it off for the resident because the resident stated it was hot. In an effort to not upset the resident by waiting for the soup to cool off naturally she blew on the soup. She stated that the risk was spread of germs with saliva. Interview with LPN on 02/23/2024 at 3:57 PM revealed, they cannot allow staff to blow on a resident's food. This is an infection control issue and there is a risk of COVID and respiratory infections. Interview with DON on 02/23/2024 at 4:08 PM revealed, the risk is infection control and respiratory infections. Review of Resident #43's Admission Record reflected, a [AGE] year-old male admitted on [DATE] whose diagnoses included acquired absence of other left toe(s), acquired absence of right leg below knee, Type 1 diabetes mellitus with Ketoacidosis (The condition develops when the body can't produce enough insulin) without coma. Review of Resident #43's Medication Review Report reflected, left heel wound; cleanse with n/s gauze pat dry, apply xeroform, cover with dry dressing daily and as needed one time a day for wound care. Observation of wound care performed by LPN on 02/22/2024 at 9:43 AM revealed LPN did not apply a draping on Resident #43's air mattress prior to performing wound care. During wound care resident's wound began to bleed. Blood landed on the air mattress. After cleaning the wound, the nurse noticed blood had dripped on the bed and cleaned the area with antibacterial wipes. In an interview with LPN on 02/22/2024 at 10:00 AM., she revealed she was aware that Resident #43's wound bled on the uncovered air mattress. She stated that the wound does not usually bleed and that is why she did not take the precaution of placing a draping on the mattress. She stated that the risk is infection control. Review of Infection Control policy dated 10/2018, Reflected All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to help prevent the development and transmission of disease and infection for 8 (PT Assistant A, Speech Therapist B, PT Assistant C, LPN D, LPN/ Infection Preventionist E, MA F, and CNA G) of 15 facility staff reviewed for infection control. 1. The facility failed to maintain isolation precautions between the hot (COVID Positive) unit and the cold (COVID Negative) units when PT Assistant C did not remove his N95 mask before re-entering the cold ( COVID Negative) units. 2. The facility failed to maintain isolation precautions between the hot (COVID Positive) unit and the cold (COVID Negative) units when LPN/Infection Preventionist E wheeled a Covid positive resident (Resident #1), out of the hot (COVID Positive) unit into the cold (Covid Negative) units, through the main hallway of the facility, and through the front doors of the facility. 3. The facility failed to ensure facility staff (PT Assistant A and Speech Therapist B wore their N95/KN95 masks over their mouth and nose at all times when in resident care areas. An Immediate Jeopardy (IJ) was identified on 10/20/22. While the IJ was removed on 10/21/22, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to complete in-service training and to evaluate the effectiveness of their corrective systems. These failures placed residents at risk of exposure of COVID-19 virus which could result in serious illness, hospitalization , and/or death. Findings included: Review of an untitled and undated spreadsheet revealed a total of 29 residents who tested positive for COVID-19 since 10/10/22, and as of 10/20/22 were on the hot unit. Further review of the spreadsheet revealed a total of 14 staff members who had tested positive for Covid-19 since 09/09/22. 1.In an observation with the DON on 10/20/22 at 10:05 AM, LPN/Infection Preventionist E wheeled Resident #1 out of the double doors of the hot (COVID Positive) unit, into the main hallway of the cold (COVID Negative) units, and out the front door of the facility. Resident #1 had on a loose fitting surgical mask. LPN/Infection Preventionist E had on the same face shield and N95 mask worn on the hot (COVID Positive) wing. In a telephone interview on 10/20/22 at 1:18 PM, LPN/Infection Preventionist E stated that she was working on the Covid wing. She stated she wore a N95 mask, face shield, gloves, and gown when in Covid positive resident's room. She stated she doffed the PPE as she left the resident's rooms. She stated she and the residents who go to dialysis all used the double doors to enter and exit the Covid wing. She stated the two residents would wear surgical masks during the transport. She stated that one resident had gone to dialysis on Mondays, Wednesdays, and Fridays, and the other dialysis resident had gone on Tuesdays, Thursdays, and Saturdays. She stated she had been trained on infection control and Covid-19 prevention and had been trained to wear her mask properly. She stated that the mask prevented the spread of COVID-19. 2.In an observation on 10/20/22 at 9:50 AM, PT Assistant A was seen sitting in an open area near the front entrance of the facility with her green N95 mask below her chin, not covering her nose or mouth. Speech Therapist B was observed walking into the same area, wearing a black KN95 mask, with her nose exposed, while she had a conversation with PT Assistant A. There were two, unmasked residents on exercise bikes in the immediate area. In an interview on 10/20/22 at 11:45 AM, PT Assistant A stated she had worked at the facility for about three weeks. She stated the facility trained her on infection control and Covid-19 prevention. She stated she was told to wear a face shield and an N95 mask while working on the hot (COVID Positive) unit. She stated she was trained to put on a gown when going into a resident's room on the Covid wing. She stated some of her residents in the hot (COVID Positive) unit liked to walk around, so she had walked with them up and down the unit. She stated she was trained to take the gown off once she left the resident's room on the Covid wing, to sanitize her face shield, remove the N95 mask, then to get a new face mask once outside of the Covid wing. She stated she had never used the back exit door of the Covid wing. She stated she entered and exited the hot (COVID Positive) unit through the same double doors. She stated she sometimes went back to her desk in the open area and lift her face shield and/or removed her mask to eat. She stated sometimes they get distracted and forget to put their mask back on. She stated earlier, she and Speech Therapist B probably got distracted by the alarm on the front entrance which was why her N95 mask was not pulled down. She stated she always thought as long as she was six feet away from a resident she could pull her mask down. She stated she was not sure if it was okay to have her face mask down when her co-worker was within six feet of her. She stated one risk of not properly wearing her mask was the risk of her getting Covid or a resident getting Covid. She stated she cannot afford to catch Covid. In an interview on 10/20/22 at 12:12 PM, Speech Therapist B stated she had worked for the facility since last June (2021). Speech Therapist B stated she has worked in the hot (COVID Positive) unit with the Covid positive residents. She stated at first, she was not going into the Covid unit, but then her co-worker was positive for Covid, so she had to start going back there to help the residents. She stated she tried to work with the Covid positive residents at the end of her shift. She stated she entered and exited the hot (COVID Positive) unit through the double doors g. She stated she entered the Covid wings with a face shield and N95 mask. She stated she put on the gown before she entered a resident room and would take that gown off, then put another one on if she had to go to another resident room in the hot unit. Speech Therapist B stated she took all PPE off before exiting the hot (COVID Positive) unit. She stated she sprayed and wiped her face shield and donned (put on) another N95 mask before exiting through the double doors of the Covid wing into the cold unit. She stated after she left the hot unit she would go into the other area of the facility, and finish her work, then left through the front entrance of the facility at the end of the day. Speech Therapist B stated she was trained on infection control and Covid-19 prevention when she started working at the facility. She stated staff and residents are tested for Covid-19 every Monday, Wednesday, and Friday. She stated she did realize her nose was exposed from her mask while speaking to PT Assistant A. She stated that one risk of not wearing a mask properly was to spread infection. 3.In an observation on 10/20/22 at 10:00 AM, PT Assistant C exited the double doors of the hot (COVID Positive) unit without doffing (removing) his face shield and N95 mask and walked through the main hallway of the cold (COVID Negative) unit. Surveyor could see the PT Assistant C walking towards the double doors through the two windows of the Covid unit. He was not observed changing his face mask before or after leaving the Covid unit. Surveyor followed PT Assistant C through the main hallway and back to the front area where the Physical Therapy area was temporalily set up. Surveyor observed PT Assistant C walk within six feet of residents and other staff members. In an interview on 10/20/22 at 10:03 AM, PT Assistant C stated he had been on the COVID hall today. He stated he went in and out of the COVID wing to assist residents. He stated he used the double doors of at hot (COVID Positive) unit to enter and exit the unit. He stated today (10/20/22) was his first day back at the facility, because he had tested positive for COVID on 10/10/20. In an interview on 10/20/22 at 12:34 PM, PT Assistant C stated he was doing physical therapy on the hot (COVID Positive) unit. He stated when he entered, he had on a face shield and an N95 mask. He stated he put on a gown once he's inside of the unit. He stated when he left a resident's room, he throws the PPE away but kept on the face shield and the N95 mask. He stated before went through the double doors to the main area of the facility (cold unit), he takes off almost all of the PPE. He would wipe his face shield down and take off his mask ,if there were new N95s available outside of the entrance to the Covid wing. He stated if he did not take off his N95, it was because there was not any outside of the hot (COVID Positive) unit doors. He stated that he cleaned his face shield, but did not change into a new N95 after leaving the Covid hall during the observation. He stated he was trained on infection control and Covid-19 prevention. He stated he had not received a specific training on working on the hot (COVID Positive) unit today after returning back to work. He stated he just looked over the donning and doffing sign on the wall near the entrance. He stated there was a risk of infection if someone did not do the PPE correctly. He stated he has used the back exit door of the hot (COVID Positive) unit that goes to the courtyard for when his residents would like to walk around and smoke. In an interview with the DON on 10/20/22 at 1:32 PM, she stated she had just put up the signs today, to remind the staff to take off all PPE when leaving the hot (COVID positive) unit, and to put new PPE on after leaving the hot unit. She stated they are getting the in-service together now, so they can go over the process with the staff. 4. In an observation through the window of the Covid wing double doors on 10/20/22 at 3:10 PM, , LPN D and CNA G were in the hallway while two residents in wheelchairs sat in the hallway. The two residents were not wearing masks. Neither staff member had on gowns. CNA G was standing close to the front entrance of the Covid wing, near a resident's door, and less than six feet away from a resident in a wheelchair. LPN D was sitting next to a cart working on a laptop. She was sitting about two to three feet away from CNA G. LPN D's face shield was at the top of her head . 5. In an observation through the window of the Covid wing double doors, on 10/20/22 at 3:38 PM, CNA G was in hallway still with no gown on, with one resident in a wheelchair within six feet of her. LPN D was sitting in hallway with no gown on, within in six feet of a COVID positive resident. LPN D's face shield was still at the top of her forehead, not covering her face. MA F entered the double doors of the Covid wing, and walked towards the back of the wing. She stood near a cart and next to a resident in a wheelchair, neither staff member put on a gown. MA F was less than six feet apart from the resident, with no mask covering his nose or mouth. MA F was the medication aide for hot and cold units. In an interview on 10/20/22 at 3:05 PM, the DON stated the staff members working in the hot (COVID positive) unit should be taking their gowns off when leaving one resident's room, then put on another gown when going into another resident's room. She stated if staff members are in the hot unit hallway, they do not have to wear a gown, unless there are residents in the hallway. She stated most of the time the residents are in their rooms. The DON asked if that was the correct way or if it should be done another way? 6.In an observation and interview with the DON on 10/20/22 at 10:40 AM, revealed the courtyard had a gated exit that could be opened. The DON stated they never thought about using the gate as an exit for the COVID positive dialysis residents to use instead of walking them through the cold units to exit the facility. She stated the gate exit was only used for emergencies like fires. In an interview on 10/20/22 at 10:52 AM, the DON stated there were two Covid positive residents (Resident #1 and Resident #3) on the COVID wing that have to leave the facility for dialysis. She stated the dialysis residents have to use the front entrance of the Covid unit to exit, because the back exit of the Covid unit goes into the courtyard. She stated there was no way for them to get to their transportation from the courtyard. The DON stated the first person that tested positive for COVID-19 was a Dietary Staff Member in September 2022. She stated they did contract tracing, and no one else tested positive until October 10, 2022, and that was Resident #2. She stated others tested positive that day as well. She stated there have been 29 residents who had tested positive for COVID-19. She stated there were several employees that tested positive as well. The DON stated that initially, the positive residents were all on the One East wing, but the Covid-19 positive residents had to be moved to the Two West wings due to space. The DON stated she started as the DON at this facility on 07/25/22, and she stated t she assumed the staff here got the same kind of Covid-19 prevention training the staff at her previous facility received. She stated both facilities are owned by the same company. She stated all staff members had been trained on how to properly wear a mask to cover their nose and mouth. T She stated the staff members that work on the Covid wing should know how to don and doff their PPE. The DON stated she just printed another donning and doffing training after what happened this morning. She stated that she would be going over donning and doffing again with staff members to ensure they understand exactly what and how to do it. The DON stated there was no specific training on how to dispose of the PPE once it's taken off, so she would put something together, and go over that with staff as well. The DON stated she would be putting reminder signs up regarding PPE donning and doffing near the Covid wing. She stated that properly donning and doffing PPE could prevent infection when entering and exiting the Covid wing. She stated that certain staff members are dedicated to the Covid wing during that shift, but they are not always the same staff members every day. She stated they have tried to use the same staff members when possible. The DON stated that MA F is the staff member that has worked the cold and hot halls (Two West and Two East) during her shift. She stated that during her shift, she has passed medications to the residents on the cold and hot hall. The DON stated that CMA F does know to take off all her PPE and sanitize before returning to the area with the negative Covid residents. In an interview at 10/20/22 2:07 PM, the Administrator stated he had been the Administrator at the facility for about 4.5 years. He stated on 10/10/20, during the initial outbreak of Covid-19, the facility had used the front hall, but when other residents tested positive, they had to move the Covid wing to the back hall. He stated the facility had continued to do Covid-19 in-services. He stated he did not have dedicated staff to only work on the Covid wing, but he has tried to keep the same staff members on the Covid wing for the entire shift. He stated that the Housekeeper goes to the Covid unit in the mornings. He stated that MA F had to do two halls, which were the Covid wing and a non-Covid wing. He stated the therapists have to go back and forth to the Covid wing as well. The Administrator stated he believed the Housekeeper works 8-12 PM in the Covid wing then goes home. He stated the Environmental Services Director would know more about their schedule. He stated staff members were trained to work on the Covid wing. He stated t the staff members are trained to try to keep the Covid positive residents in their rooms. The Administrator stated the staff had been trained to wear full PPE, then take off the PPE after finishing with one resident. He stated every resident room on the Covid wing had a bin inside the room where used PPE could be placed. The Administrator stated all PPE should be taken off before leaving the Covid wing, and a new mask should be put on outside of the door. He stated the staff members disinfect their face shields before leaving the Covid wing. The Administrator stated the staff members have used the exit door in the Covid wing to take the residents that smoke outside to smoke. He stated the exit door of the Covid wing fed into the courtyard. He stated the door on the gate around the courtyard had a magnetic lock. He stated the gate would unlock if the fire system went off. He stated the main entrance door to the courtyard goes back into the main area of the facility, so they were having the dialysis residents or any other residents that needed to leave the Covid wing would exit through the front entrance double doors of the Covid wing. He stated he had the ability to unlock the gate even if there was no emergency, but he stated it was his personal preference not to use the door on the gate of the courtyard. The Administrator stated he had not used the gate on the courtyard entrance, because he was worried that a resident would elope. The Administrator stated it was not the norm for the facility to open the gate of the courtyard. He stated the residents on dialysis should have a mask on when they leave the Covid wing. He stated they come out of the Covid wing through the double doors and go straight through the hall to the front doors. He stated he felt the risk was low if the masks were worn by the residents. He stated they had typically put the surgical masks on the dialysis residents when they left out. He stated the masks should have been pretty snug on their faces when they leave out the Covid wing. The Administrator stated that PT Assistant C should have put on a new mask once he was outside of the Covid wing. He stated they would ensure PT Assistant C had been retrained before he went back to the Covid unit. He stated they had been doing competency checks during the visit to ensure the everyone knew the donning and doffing process. He stated t they were reeducating the staff. The Administrator stated the facility had tested all staff and residents every Monday, Wednesday, and Friday. The Administrator stated that he felt they have done the best they can do with Covid-19 prevention. In an interview on 10/20/22 at 3:30 PM with the DON and the Administrator, the Administrator stated they did not know what caused the outbreak of Covid. The DON stated they had relaxed the mask policy for a very short period before the outbreak. The Administrator stated they could not really say that caused the outbreak of Covid. Record review of the PPE Competency in-service dated 10/20/22 (provided after Surveyor observed PT Assistant C exiting the Covid wing with PPE still on), indicated the following: Donning and Doffing PPE Donning (putting on the gear) Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on training, if applicable) Perform hand hygiene using hand sanitizer. Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by another HCP. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). . Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients . Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them appropriately around your ears. Put on a face shield or goggles. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common. Perform hand hygiene before putting on gloves. Gloves should cover the cuff (wrist)of gown. HCP may now enter patient room. Doffing (taking off the gear) 1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique. 2. Remove gown. Untie all ties(or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in a gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle. 3. HCP may now exit patient room. 4. Perform hand hygiene 5. Remove face shield or goggles 6. Remove and discard respirator (or facemask if used instead of respirator). Do not touch the front of the facemask or respirator. 7. Perform and hygiene after removing the respirator/facemask Record review of an in-service dated 09/09/22 stated, indicated the following: Topic: Face Shields/Goggles When the facility is in Covid-19 outbreak status, all staff are required to wear a face shield or goggles in addition to an N95 or KN95 mask. These are to be work over your eyes (not on top of your head). Work as a team and hold each other accountable!!!. Record review on an in-service dated 10/10/22, indicated the following: Topic: N95/KN95 Masks When the facility experiences a COVID outbreak, staff should wear an N95 or KN95 masks while in the facility. Record review of the facility's policy, Infection Prevention and Control Program undated indicated: Policy Statement 1. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 2. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee healthy and safety. 6. Outbreak Management a. Outbreak management is a process that consists of: 1. determining the presence of an outbreak; 2. managing the affected residents; 3. preventing the spread to other residents 4. documenting information about the outbreak; 5. reporting the information to the appropriate public health authorities; 6. educating the staff and the public; 7. monitoring for recurrences; 8. reviewing the care after the outbreak has subsided; and 9. recommending new or revised policies to handle similar events in the future. b. Specific criteria will be used to help differentiate sporadic cases from true outbreaks or epidemics. c. The medical staff will help the facility comply with pertinent state and local regulations concerning the reporting and management of those with reportable communicable diseases. 7. Prevention of Infection a. Important facets of infection prevention include: 1. identifying possible infections or potential complications of existing infections; 2. instituting measures to avoid complications or dissemination; 3. educating staff and ensuring that they adhere to proper techniques and procedures; 4. enhancing screening for possible significant pathogens; 5. immunizing residents and staff to try to prevent illness; 6. implementing appropriate isolation precautions when necessary and; 7. following established [NAME] and disease-specific guidelines such as those of the Centers for Disease Control (CDC). The facility policy did not address the re-entry into the cold unit after being on the hot unit. The administrator was notified on 10/20/22 at 4:41 PM an Immediate Jeopardy(IJ) situation was identified due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 10/21/22 11:47 AM and reflected the following: Date: 10/20/22 [Facility Name] [Facility Address] PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of Details which lead to outcomes On 10/20/22 an abbreviated survey was initiated at [Facility Name], [Facility Address]. On 10/20/22, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F880 - Infection Prevention & Control The facility failed to contain the COVID-19 infection to just the designated COVID-19 wing. They do not have dedicated staff members for the COVID wing only. Staff members were observed exiting the COVID wing still wearing a face shield and N95 mask. Another staff member was observed leaving the COVID wing with a positive resident, leaving for dialysis. The resident had on a surgical mask. He was wheeled down the main hallway to the front entrance around other residents. Problem #1: The facility should try to prevent more positive residents and staff members by ensuring staff members are doffing all PPE upon exit from the COVID unit. Identification of Others: o o The facility's 40 non-positive residents had the potential to be impacted by the alleged deficient practice. Action Taken: o o Once the facility was made aware of the deficient practice, the Director of Nursing/Designee instructed the staff member who was witnessed not changing his mask or sanitizing his face shield as well as the facility's RNs, LVNs, CMAs, CNAs, therapy staff, housekeeping staff, dietary staff, maintenance staff, activities staff, administrative staff, and agency staff to do so upon leaving the COVID unit. o o The facility Director of Nursing/Designee began an in-service with the facility's RNs, LVNs, CMAs, CNAs, therapy staff, housekeeping staff, dietary staff, maintenance staff, activities staff, administrative staff, and agency staff regarding proper procedures for doffing PPE when coming off the COVID unit. The in-service will be completed prior to their next scheduled shift. o o The Director of Nursing/Designee will review 24-hour reporting and alert charting for residents who have potential symptoms of COVID-19, notify physician, note orders, test as applicable, and revise care plan as applicable. o o Once the facility was made aware of the deficient practice, the Director of Nursing/Designee instructed the staff member who was witnessed not changing his mask or sanitizing his face shield to do so upon leaving the COVID unit. o o The Director of Nursing/Designee will conduct routine testing as scheduled on 10/21/2022. o o The Director of Nursing/Designee will continue to test 3x weekly until out of outbreak status. Monitoring: o The Administrator/Designee will ensure that 100 percent of all staff will be trained prior to their next scheduled shift regarding doffing PPE when coming off the COVID unit. o The Director of Nursing/Designee will conduct observational rounds and interviews with staff daily for 7 days, and then 3 times a week to validate that staff are adhering to current guidelines related to PPE use in health care facilities including the use of mask, PPE requirements in a COVID unit, and procedure for transporting COVID-19 positive residents. o The Infection Preventionist will monitor the system, conduct observational rounds and address any concerns. o The Director of Nursing/Designee will report any identified trends to the Quality Assurance Performance Improvement Committee monthly and as needed until a [NAME] frequency is deemed appropriate. Problem #2: The COVID wing has an exit door that is not being used that COVID-19 positive dialysis residents can use to prevent contact with non-positive residents. Identification of Others: o o The facility's 40 non-positive residents had the potential to be impacted by the alleged deficient practice. Action Taken: o o The Administrator/designee validated that the COVID-positive resident who was witnessed exiting the facility through the main hall to go to dialysis was brought back into the facility through the separate designated exit on the end of the COVID unit. o o The Administrator/Designee instructed staff on the COVID unit as well as the facility's RNs, LVNs, CMAs, CNAs, therapy staff, housekeeping staff, dietary staff, maintenance staff, activities staff, administrative staff, and agency staff that COVID-positive residents will use the separate designated emergency exit at the end of the COVID unit to enter or exit the facility for dialysis, appointments, or any other non-emergency matters. o o The facility Director of Nursing/Designee provided immediate training with ongoing in-service training with the facility's RNs, LVNs, CMAs, CNAs, therapy staff, housekeeping staff, dietary staff, maintenance staff, activities staff, administrative staff, and agency staff regarding a separate designated exit for COVID-positive residents if applicable. The in-service will be completed prior to their next scheduled shift. o o The Director of Nursing/Designee will conduct routine testing as scheduled on 10/21/2022. o o The Director of Nursing/Designee will continue to COVID-19 testing per regulations 3x weekly until out of outbreak status. o o The Director of Nursing/Designee will review 24-hour reporting and alert charting for residents who have potential symptoms of COVID-19, notify physician, note orders, test as applicable, and revise care plan as applicable. Monitoring: o The Administrator/Designee will ensure that 100 percent of staff will be properly trained prior to their next scheduled shift regarding the separate designated exit for COVID-positive residents. o The Administrator/Designee will monitor the proper exit procedures within the COVID unit regarding residents leaving the emergency exit door daily x7 days, then weekly x4 weeks, then monthly x3 months or until the facility is free of COVID. o The Infection Preventionist will monitor the system, conduct observational rounds and address any concerns. o The IDT will monitor during monthly QAPI meeting. Problem #3: The facility staff was observed not properly wearing their masks. Identification of Others: o o The facility's 40 non-positive residents had the potential to be impacted by the alleged deficient practice. Action Taken: o o Once the facility was made aware of the deficient practice, the Director of Nursing/Designee instructed the staff members who were witnessed not wearing their masks properly as well as the facility's RNs, LVNs, CMAs, CNAs, therapy staff, housekeeping staff, dietary staff, maintenance staff, activities staff, administrative staff, and agency staff to properly don their masks to cover their mouth and nose. o o The facility Director of Nursing/Designee began an in-service with the facility's RNs, LVNs, CMAs, CNAs, therapy staff, housekeeping staff, dietary staff, maintenance staff, activities staff, administrative staff, and agency staff regarding wearing a facemask to cover the mouth and nose appropriately within the facility. The in-service will be completed prior to their next scheduled shift. o o The Director of Nursing/Designee will conduct routine testing as scheduled on 10/21/2022. o o The Director of Nursing/Designee will continue to test 3x weekly per regulations until out of outbreak status. o o The Director of Nursing/Designee will review 24-hour reporting and alert charting for residents who have potential symptoms of COVID-19, notify physician, note orders, test as applicable, and revise care plan as applicable. Monitoring: o The Administrator/Designee will ensure that 100 percent of staff will be properly trained prior to their next scheduled shift regarding proper wearing of a mask to cover their mouth and nose. o The Administrator/Designee will conduct daily rounds on various shifts and in various departments x7 days to ensure that staff are wearing masks throughout the facility appropriately. Then weekly x4 weeks, followed by monthly x3 months. o The Infection Preventionist will monitor the system, conduct observational rounds and address any concerns. o The IDT will monitor during monthly QAPI meeting. Problem #4: The facility staff was observed not wearing proper PPE on the COVI [TRUNCATED]

Based on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to one (medication cart #1) of three medication carts reviewed. The facility failed to ensure medication cart #1 was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings include: An observation on 10/21/22 at 11:43 AM revealed Medication Cart #1 was unlocked and unattended. All drawers of the medication cart could be opened, and medication was easily accessible. No staff were observed within eyesight of the medication cart. The Agency LVN was seen coming out of a resident room, towards the middle of the hall, and the medication cart was toward the end of the hall by the exit door. In a short interview on 10/21/22 at 11:46 AM, the Agency LVN stated that she was contracted through an agency. She stated that it was her first time working at the facility. She stated that she thought she had locked the cart. She stated that she should have pressed the lock button at least three times to ensure the cart was locked. Agency LVN apologized for unlocked medication cart, and stated that in the past she had always locked the medication carts. She stated that the medication on the cart was for all of the residents on One West Wing. In an interview on 10/21/22 at 12:15 PM, the Agency LVN provided her name and stated that she accepted the shift early this morning around 4:30 AM. She stated that she had been a nurse for about [AGE] years. She apologized again for the unlocked medication cart. Agency LVN stated that she thought she had pushed the lock all the way. She stated that she had been trained on locking the medication carts and also on drug diversion. She stated one risk of leaving a medication cart unlocked is someone could get the medications off the cart. She stated hat someone could take medication that isn't prescribed to them. In an interview on 10/21/22 around 1:45 PM, the DON advised that they heard about the unlocked medication cart. She stated that all staff had been trained on locking the medication carts. She stated that she was going to complete an in-service to remind the staff to lock the medication carts. She stated that all medication carts should be locked. Record review of the following in-service document was completed on 10/21/22, which revealed: Topic: Locking Medication Carts when not standing at cart The Nurse/Medaide that has the keys to the cart is responsible for ensuring that the cart is secured and locked at all times when the nurse/med aide is not standing at the cart. Never walk away or leave the cart without locking it. Record review on 10/21/22 of the facility policy titled, Security of Medication Cart, and dated QTR 3, 2018, stated that the following: The medication cart shall be secured during the medication passes. Policy Interpretation and Implementation 1. The nurse must secure the medication cart during the mediation pass to prevent unauthorized entry.

Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for 1 (Resident #1) of 5 residents whose clinical records were reviewed accuracy. The facility failed to ensure Resident #1's change of condition, oxygen saturations, and oxygen administration were documented accurately and completely. This failure could place residents receiving oxygen at risk for inaccurate or incomplete clinical records. Findings included: Record Review of Resident #1's quarterly MDS dated [DATE] indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record Review of Resident #1's Treatment Administration Record dated 01/01/22 - 01/31/22 indicated the resident's oxygen saturation was to be monitored and recorded daily. On 01/04/22 the residents oxygen saturation was blank. There was no order for oxygen or documentation oxygen was administered to the resident. Record Review of Resident #1's Nurses' Note dated 01/4/2022 5:51 PM, indicated LVN C documented, a chest x-ray was done, and the report was pending. In a telephone interview on 01/11/22 at 4:23 PM LVN C said Resident #1 had a change of condition on 01/04/22. She said the resident appeared to be having difficulty breathing and was not eating well. She said she contacted the physician and obtained orders for labs, a chest x-ray, and oxygen administration. She said she thought the order she received was for oxygen at 3 liters , as needed but she was not certain. She said she had a lot going on with another resident who also had a change of condition and she thought she documented in the resident's clinical record but may not have. She said she did not know why she did not document or what happened, but the documentation was important to have a complete record . Record Review of Resident #1's Nurses' Note dated 01/4/2022 at 9:53 PM, indicated LVN B documented, Resident #1's x-ray results were received. The x-ray report indicated, no acute cardiopulmonary process, pneumothorax, and no pleural effusion. The lab results were pending. The resident was noncompliant with oxygen therapy and kept taking her oxygen off. Her oxygen level was within normal limits at 96 %. In an interview on 01/11/22 at 3:42 PM, LVN B said on 01/04/22 LVN C told her Resident #1 had a change of condition. She said LVN C obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the resident removed her oxygen and refused care, at times. Record Review of Resident #1's Nurses' Note dated 01/5/2022 at 10:53 AM, indicated RN A documented, Resident #1 was in respiratory distress, the chest x-ray from yesterday (01/04/22) came back negative, but the resident had labored breathing and the nurse tried to read the pulse ox and she could not. The physician was notified. An order was received to send the resident to the emergency room via ambulance. The resident's responsible party was notified. The resident left the facility at 11: 20 AM. In an interview on 01/11/22 at 1:40 PM, RN A said she had been off for several days and returned to work on 01/05/22 for her morning shift at 6:00 AM. She said Resident #1 had oxygen on when she arrived at work. She said the resident was in respiratory distress and she sent her to the hospital. She said she did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 01/11/22 at 2:56 PM the DON said she reviewed Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the resident did not have oxygen administered until 01/04/22. She said she expected the nurses to document the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of the facility's policy, Charting and Documentation dated 2018 indicated all services provided to the resident, or any changes in the resident's condition shall be documented in the resident's medical record.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation, in that: 1. Potentially hazardous foods (PHF) were not maintained, on the serving line, at 41 degrees Fahrenheit (F) or below. 2. The food thermometers in the meat freezer, vegetable freezer, and milk refrigerator were not in the warmest part of the unit. These deficient practices could affect the residents who ate food from the kitchen and put them at risk for foodborne illness. Findings include: 1. Observation on 10/19/2021 at 4: 45 pm revealed Cook A obtained temperature for chicken salad sandwiches, on the serving line, as 12.7 degrees Celsius (C, equivalent to 54.86 degrees Fahrenheit. Observation on 10/19/2021 at 5:00 pm revealed Regional Kitchen Manager B obtained temperature for chicken salad sandwiches, on the serving line, as 72 degrees F. In an interview on 10/19/2021 at 4:45 pm with Cook A, revealed temperatures could be taken in C. Cook A also revealed cold food should measure 32 degrees C (equivalent to 89.6 degrees Fahrenheit ) or below and hot food should measure 157 degrees C (equivalent to 314.6 degrees Fahrenheit )or above at the time of serving. In an interview on 10/19/21 at 5:00 pm with Regional Kitchen Manager B revealed the chicken salad sandwiches were not at a correct temperature to be served. Regional Kitchen Manager B went on to reveal cold foods on the serving line should be maintained at 41 degrees F or below. In an interview on 10/20/21 at 8:51 am with District Kitchen Manager C revealed in-service training to begin on 10/20/21, for all kitchen staff, regarding cold food temperatures. In an interview on 10/20/21 at 10:07 am with District Kitchen Manager C revealed the expectation for food temperatures, on the service line for holding, must be 41 degrees F, or below, for cold food. District Kitchen Manager C also revealed safe temperatures for food will be ensured through training and in-service training for employees. 2. Observation on 10/19/21 at 8:22 am revealed the meat freezer, vegetable freezer, and milk refrigerator did not have a thermometer in the warmest part of the unit. In an interview on 10/19/21 at 5:00 pm with Regional Kitchen Manager B revealed a thermometer should be placed in the warmest part of the refrigerator or freezer, near the door. In an interview on 10/20/21 at 4:15 pm with District Kitchen Manager C revealed in-service training to begin on 10/20/21, for all kitchen staff, regarding temperature/thermometers in refrigerators and freezers . Review of the Texas Food Establishment Rules (TFER), October 2015, §228.75 (f)(1) (B) revealed Time/temperature controlled for safety food, hot and cold holding. 5 degrees C (41 degrees F) or less. Review of the Texas Food Establishment Rules (TFER), October 2015, §228.106 (l)(1) revealed Temperature measuring devices. In a mechanically refrigerated or hot food storage unit, the sensor of a temperature measuring device shall be located to measure the air temperature or a simulated product temperature in the warmest part of the mechanically refrigerated unit and in the coldest part of a hot storage unit. (2) Cold or hot holding equipment used for time/temperature controlled for safety (TCS) food shall be designed to include and shall be equipped with at least one integral or permanently affixed temperature measuring device that is located to allow easy viewing of the device's temperature display. Review of facility policy, Food: Preparation revised 9/2017, revealed 13 All foods will be held at appropriate temperatures, greater than 135 degrees F (or as state regulation requires) for hot holding, and less than 41 degrees F for cold holding.

Based on observation, interview and record review, the facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for one (Resident #65) of two residents reviewed for enteral feedings. The HOB for Resident #65, who was being fed continuously by enteral means, was not kept elevated above 30 degrees per accepted standards of practice for residents who are being fed by enteral means. This failure could place residents who are fed by enteral means at an increased risk for complications including, but not limited to, aspiration pneumonia. Findings include: Review of Resident #65's Admission Record dated 10/20/21, revealed she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #65's quarterly MDS (minimum data set), dated 09/30/21, revealed cognitive skills for daily decision making was a 3 showing she was severely impaired. It further revealed she was extensively dependent on two staff for bed mobility, transfers, and was totally dependent on one staff for eating. Her quarterly MDS also revealed she received 51% or more of her nutrition and 501 CC of fluid or more from a feeding tube. Review of Resident #65's Medication Review Report dated 10/20/21, revealed an order with a start date of 04/20/21 that read: [MEDICATION(S)], (a brand of feeding formula), every shift for enteral feeding [MEDICATION(S)] 1.5 @52CC/HR (Hour). Off @9AM and on @11AM. Review of Resident #65's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] NPO (nothing by mouth) NPO Texture, NPO Consistency. Review of Resident #65's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Elevate HOB (head of bed) 45 degrees at all times every shift for enteral feedings. Review of Resident #65's care plan dated 05/10/21, revealed the following: [Resident #65] is Dependent on tube feeding due to: Dysphagia Elevate HOB at least 30-45 degrees during and for 30-60 minutes after feeding An observation on 10/20/21 at 11:25 AM revealed Resident #65 was in bed, in a gown, on her right side. She made frequent vocalizations. Her HOB was only up 5-10 degrees, and her GT (gastrostomy tube) was running [MEDICATION(S)] 1.5 calories at 52 CC/HR. During an interview with RN B on 10/20/21 11:32 AM she revealed Resident #65's head should be up unless they were changing her and then the feeding should be paused. Surveyor informed her the HOB was down at 5-10 degrees and she stated the [CNAs] will change her, but the feed was supposed to be paused. Surveyor asked RN B to go check on Resident #65. The DON and surveyor followed the nurse down to Resident #65's room. The surveyor and DON arrived at the room RN B had lifted Resident #65's HOB up to 30 degrees. When RN B was asked if the HOB had been down when she entered the room, she said yes that she had raised it up when she came in as it was too low. RN B stated the HOB should be up at 30-40 degrees to prevent aspiration of feed. During an interview with the DON on 10/20/21 at 11:34 AM the HOB should be up 30-40 degrees while a GT is running. She stated she was going to do an in-service on it and also stated you do not let it run with their head down because they can choke or cause it to go up the esophagus causing vomiting and or possible aspiration into the lungs instead of down into the intestines. The facilities policy and procedure for Enteral Nutrition dated, 2018, revealed the following: 15. Risk of aspiration may be assessed by the Nurse and Physician and addressed in the individual care plan. Risk of aspiration may be affected by: 1 Improper positioning of the resident during feeding; and Failure to confirm placement of the feeding tube prior to initiating the feeding.

Based on observation, interview and record review, it was determined that the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #1) of eight residents reviewed for falls. Resident #1 sustained a left hip fracture as a result of a fall on 09/16/13 in her room. Resident #1 was found on the floor on her left side on 09/16/13, and did not have a personal safety alarm. Resident #1 had been care planned to have a personal safety alarm while she was in bed and up in the wheelchair. The failure of the facility to follow it's care plan for Resident #1 placed this resident and all 17 residents listed as fall risks at possible risk for falls and injury including fractures, pain, and a decreased quality of life. Findings included: Observation of Resident #1 on 10/10/13 at 10:17 AM revealed a slender elderly female who was asleep in her bed. She woke up and complained of pain in her leg, and she stated she was hungry. Resident #1 was observed again at 12:04 PM on 10/10/13, and the resident was still in her bed. A bed alarm was observed attached to the resident's bed. The resident was noted to have confused speech at the time of this observation. Resident #1's annual MDS assessment dated [DATE] reflected Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] from an acute hospital. The assessment reflected she had the following Diagnoses: [REDACTED]. Resident #1's MDS assessment reflected she had severe cognitive impairment with both short-term and long-term memory problems. In regards to Resident #1's functional status, the assessment reflected she required the extensive assistance of two people for bed mobility and setup help/ supervision with transfers. The assessment further reflected Resident #1 was not steady, but able to stabilize with staff assistance when moving from a seated to a standing position, walking, turning around while walking, moving on and off the toilet, and surface-to-surface transfers. The CAT Worksheet Problem Area reflected: "11. Falls associated with the annual MDS assessment reflected Resident #1 had the following triggers which increased her risk of falls: impaired balance during transitions, antipsychotic medications, antidepressant medications, incontinence, anemia, delirium, wandering, cognitive impairment, anxiety, depression, and dementia. Resident #1's most recent Quarterly MDS assessment dated [DATE] reflected Resident #1 was most recently admitted to the facility from an acute hospital on [DATE]. The assessment reflected the resident had the following Diagnoses: [REDACTED]. The assessment reflected Resident #1 had severe cognitive impairment with short-term and long-term memory problems. The assessment further reflected Resident #1 required the extensive assistance of two people for bed mobility and transfers. An interview on 10/10/13 at 9:55 AM with Resident #1's Hospice Nurse revealed she had observed the resident pushing her wheelchair around the facility many times. She stated she had been the resident's hospice nurse since mid-summer 2013. When asked if she observed a chair or bed alarm on Resident #1's wheelchair or bed before she fell and fractured her hip, she stated she had not observed an alarm on the bed or chair before the last fall on 09/16/13. A communication form about a fall on 07/20/13 listed the resident was on hospice. An interview on 10/10/13 at 1:41 PM with the DON revealed the MDS Coordinator had care planned for Resident #1 to have a bed alarm, but she did not relay this to staff. The alarm was never ordered nor put in place. The DON stated she questioned the MDS Coordinator about the care plan not being communicated to nursing staff. She stated she asked her how the staff could follow the care plans if they did know about them. The DON acknowledged this was why the oversight had occurred, and why Resident #1 did not have a personal safety alarm in place when she fell on [DATE]. Review of the Care Plan for Resident #1 dated 02/13/13 and signed as updated on 05/16/13 and 08/16/13 revealed one of the approaches to address the resident's fall risk was: "Use bed/chair alarm." Fall risk assessments for Resident #1 dated 02/06/13 and 05/14/13 reflected Resident #1 was assessed to be at high risk for falls. A SBAR communication form, which was used before calling the physician, dated 07/20/13 reflected Resident #1 fell or slid out of her wheelchair. The fall investigation worksheet, dated 09/16/13, had a section titled Room/Resident Check after fall. The following items were checked Yes: - Was call light functioning, - Was the bed in low position, - Were side rails ordered, and - Does the resident have history of prior falls. The following items were checked No: - Were side rails up, and - Was the resident restrained. There was no notation that reflected there was an alarm on Resident #1's bed or chair in this section or listed under additional comments. Review of the hospital Discharge Summary for Resident #1, dated 09/21/13, revealed that she was a "...female with a history of dementia who accidentally fell while she was at the nursing home and developed left hip pain." She was then brought into the ER and was found to have a left hip fracture. It further reflected that a surgical repair of the hip was performed. She had an episode of acute blood loss anemia and received a blood transfusion. The facility's undated Resident Roster/Matrix Form CMS-802 provided to the survey team on 10/10/13 reflected there were 17 residents identified as having falls including falls with major injury.