Every finding on record at John Paul II Nursing Home

Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported immediately but not later than 2 hours ( for an injury of unknown origin involving serious bodily injury) to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 4 Residents (Resident #9) reviewed for a fall injury, in that: The facility did not report an allegation of injury of unknown origin with serious injury to the State Survey Agency (HHSC) within the 2 hours time frame for Resident #9's unwitnessed fall that occurred on 6/19/25. This deficient practice could affect any resident and could contribute to the non-reporting of injuries of unknown origin. The findings were: Review of Resident #'s 9 face sheet dated 9/12/25, revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included: Alzheimer's (a progressive disease that affects memory and other mental functions), anxiety disorder ( a mental health disease in which persistent feeling of worry and fear interfere with daily tasks), and Parkinson's disease ( a disorder of the central nervous system that affect movement). Record review of Resident #9's quarterly MDS assessment dated [DATE] revealed a blank BIMS score, indicating the resident could not complete the interview. The MDS revealed that Resident #1 was ambulatory and used a walker. Record review of Resident # 9's care plan initiated on 11/4/24 revealed Resident #9 had an identified risk for falls. The interventions for fall risk included encouraging Resident when ambulating to use her walker and to wear her shoes. Record review of the facility incident report dated 6/19/25 at 3:00am and approved by the DON revealed Resident #9 had fallen onto her bedroom floor. Resident #9 was assessed and was noted to have blood on the back of her head with complaints of neck and back pain and was transported to the hospital for further evaluation. Record review of hospital admission report dated 6/19/25 revealed Resident #9 was diagnosed with a subdural hematoma and subarachnoid hemorrhage (a pool of blood noted in the brain) related to the unwitnessed fall at the facility and was admitted to the hospital. During and interview with the Director of Nurses (DON) on 9/12/25 at 1025am she stated that the fall event for Resident #9 which occurred on 6/19/25 at 3:00am was not reported to Tx HHS as the facility was aware that the fall had occurred in the resident's room. The DON state an in-service training on fall prevention related to the fall incident on 6/19/25 was not presented to the nursing staff since the incident was not self-reported to Tx HHS. During an interview with LVN-A on 9/12/25 at 10:25am revealed Resident #9 had an unwitnessed fall in her room on 6/19/25 at 3:00am and was found on the floor with blood noted on the back of her head and complaints of neck and back pain. LVN-A stated that Resident #9 was transported to the hospital for further evaluation. LVN-A stated that Resident #9 had been self ambulatory in her room with a walker and was able to self-toilet. LVN-A stated that Resident #9 had been observed in her room on her bed by the nursing staff less than 30 minutes prior to the fall. During an interview with the Administrator on 9/12/25 at 11:30am the Administrator stated that the fall incident for Resident #9 which occurred on 6/19/25 was not reported to Tx HHS since the facility was aware that the fall had occurred in the resident's room. The Administrator stated that facility in-service on fall prevention to nursing staff related to the fall incident on 6/19/25 was not completed since the incident was not self-reported to Tx HHS. During an interview with C.N.A.-B on 9/12/25 at 4:35pm the aide stated Resident #9 had fallen in her room on 6/19/25 at 3:00am and had blood noted to the back of her head. C N.A.-B stated that Resident #9 stated she had just used the bathroom prior to the fall. C.N.A.-B stated that Resident #9 used a walker while ambulating and was able to use the bathroom independently. C.N.A.-B stated that Resident #9 had not pushed the room call light prior to the fall Record review of the facility policy on Abuse Investigation and Reporting that was undated revealed injuries of unknown origin will be reported to Tx HHS within 2 hours if the incident did involve abuse/neglect but there was serious bodily injury.

Based on interviews, and record reviews the facility failed to have evidence all allegations of an injury of unknown with serious bodily injury were thoroughly investigated and documented for 1 of 4 residents (Resident #9) reviewed for a fall injury. The facility failed to have evidence that a thorough investigation was conducted following the allegation Resident #9 had an unwitnessed fall which resulted in serious bodily injury. These failures could place residents at risk for abuse and neglect by not investigating injuries of unknown origin that involve serious bodily injury. The findings were: Record review of Resident # 9's face sheet, dated 9/12/25, revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included: Alzheimer's (a progressive disease that affects memory and other mental functions), anxiety disorder ( a mental health disease in which persistent feeling of worry and fear interfere with daily tasks), and Parkinson's disease ( a disorder of the central nervous system that affect movement). Record review of the facility incident report dated 6/19/25 at 3:00am revealed Resident #9 had an unwitnessed fall onto her bedroom floor. Resident #9 was assessed and was noted to have blood on the back of her head with complaints of neck and back pain and was transported to the hospital for further evaluation. There was not a facility self- report investigation as part of the event report provided to the surveyor that was conducted for the fall incident dated 6/19/25. Record review of hospital admission report dated 6/19/25 revealed Resident #9 was diagnosed with a subdural hematoma and subarachnoid hemorrhage ( a pool of blood noted in the brain) related to the unwitnessed fall at the facility and was admitted to the hospital. During an interview with the Director of Nurses (DON) on 9/12/25 at 1025am the DON stated that the unwitnessed fall event for Resident #9 which occurred on 6/19/25 at 3:00am was not reported to Tx HHS since the facility was aware that the fall had occurred in the resident's room. The DON stated that facility in-service on fall prevention provided to nursing staff related to the fall incident on 6/19/25 was not completed since the incident was not self-reported to Tx HHS. The DON stated there was not a facility self-report investigation completed by facility staff related to the unwitnessed fall incident which occurred on 6/19/25. During an interview with the Administrator on 9/12/25 at 11:30am the Administrator stated that the unwitnessed fall incident for Resident #9 which occurred on 6/19/25 was not reported to Tx HHS since the facility was aware that the fall occurred in the resident's room. The Administrator stated that facility in-service on fall prevention provided to nursing staff related to the fall incident on 6/19/25 was not completed since the incident was not self-reported to Tx HHS. The Administrator stated there was not a facility self-report investigation completed by facility staff related to the unwitnessed fall incident which occurred on 6/19/25. Record review of the facility policy on Abuse Investigation and Reporting that was undated revealed injuries of unknown origin will be reported to Tx HHS within 2 hours if the incident involved serious bodily injury and a facility investigation of the incident will be conducted that would include: 1-review of the completed documentation, 2-review of the medical record, staff interviews, 3-resident interview, other resident interviews, review of all events leading up to the incident.

Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one medication cart out of two carts reviewed for medication storage, in that : LVN A left the medication cart unsecured on Hallway two while administering medications. These deficient practices could place residents at risk for misappropriation, misuse or tampering of medications. The findings included: Observation on 09/11/2025 at 09:34 a.m. on hall way two revealed that the medication cart was left unattended and not locked. During an interview on 9/11/2025, at 09:45 with LVN A, it was revealed she had left the medication cart unlocked, which was a practice she claimed to have never done before. Her focus was checking a resident that led to the oversight. She acknowledged the potential for misappropriation, misuse, and harm if someone were to gain unauthorized access to the cart and acquire medications. Interview on 09/11/2025 at 10:30 a.m. the DON, stated LVN A was one of her fairly new nurses hired. The DON emphasized that it was imperative for nurses and medication aides to rigorously adhere to the protocol of securing medication carts when not in use due to the potential risks of misappropriation and harm if unauthorized individuals access the medications. Furthermore, she was accountable for overseeing the random locking of medication carts, while her MDS nurse was tasked with daily monitoring of the crucial security measure during rounds. Record review of the facility's policy and procedure titled Medication Cart System, undated, revealed, If the cart must be left at any time during medication pass due to an emergency, it must be locked.

Based on observations, interviews and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 5 residents' (Resident #7) refrigerators reviewed. The personal refrigerator in Resident #7's room contained food items which were unlabeled and undated. This deficient practice could place residents at risk of foodborne illness due to consuming foods which are spoiled. The findings were: Observations on [DATE] at 10:15 a.m., revealed Resident #7's personal refrigerator contained a cinnamon roll and a cupcake in an unlabeled and undated zip lock bag. Further observation on [DATE] of Resident #7's personal refrigerator at 11:50 a.m. revealed the cinnamon roll and cupcake in an unlabeled and undated zip-lock bag was still present. Interview with Resident #7 on [DATE] at 1020 a.m. revealed she could not recall how long the cinnamon roll and cupcake had been in her personal refrigerator or who brought it. On [DATE] at 10:30 a.m., LVN A stated during an interview that she was assigned nurse for Resident #7's room. She added that housekeeping was accountable for removing undated and unlabeled food items from the residents' refrigerators. However, the nursing staff was expected to label and date any food items brought in by families and place them in the refrigerators. LVN A stated Resident #7 risked some form of food borne illness by possibly consuming food that was unlabeled and undated. During an interview with CNA B on [DATE] at 10:40 a.m., she stated that she was the assigned nursing assistant for Resident #7's room. She confirmed Resident #7's personal refrigerator contained a cinnamon roll and a cupcake in an unlabeled and undated zip-lock bag. She was unaware of how long the food items had been in the refrigerator and said she would dispose of them after informing her supervisor as Resident #7 risked possible consumption of expired food that could make her sick. Interview with housekeeping supervisor, on [DATE] at 11:50 a.m., revealed housekeeping was accountable for removing undated and unlabeled food items from the residents' refrigerators daily, she was unaware why this was not done for Resident #7's refrigerator. She added Resident #7 risked food borne illness by possibly consuming expired food that was undated and unlabeled. During an interview with the Director of Nursing on [DATE] at 2:30 p.m., the DON confirmed that perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent residents from consuming spoiled foods. The DON stated that housekeeping was responsible for removing undated and unlabeled food items from the residents' refrigerators daily. However, the nursing staff was expected to label and date any food items brought in by families and place them in the refrigerators. An interview with the Administrator on [DATE] at 3:00 p.m. revealed food in all residents' refrigerators should be labeled and dated to prevent residents from consuming spoiled foods. The Administrator stated that housekeeping was responsible for daily removing undated and unlabeled food items from the residents' refrigerators. However, the nursing staff was expected to label and date any food items brought in by families and place them in the refrigerators. The Administrator stated that families sometimes bring food for residents and do not let the nursing staff know; she said she would send a memo to all family members indicating that nursing staff should be informed when they bring food to residents' refrigerators. She added that the housekeeping supervisor is responsible for overseeing this task, but this was not being monitored. Record review of the facility policy, In Room Refrigerator, undated, revealed: All food in refrigerators must be covered, dated and labeled, staff will inspect content of refrigerators weekly and dispose of expired, unlabeled, undated food.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Main Kitchen), in that: The facility failed to ensure an opened items in the reach in refrigerators were dated or discarded correctly This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness. The findings included: During an observation, in the dry storage area, on 06/27/2023 at 11:59 a.m., revealed a box container of Idaho potatoes with a received date of 06.23.2023, but no opened date. During an observation, in the walk-in refrigerator, on 06/27/2023 at 12:04 p.m., revealed one 32 oz. container of Arrezzio chopped garlic with no opened date or received date; one 3 lb. container of [NAME] cottage cheese with a received date 06/23/2023 but no opened date; one 18 oz of egg white with no received date; three 16 oz packages of cooked ham with no received date on them. During an observation, in a standing freezer, on 06/27/2023 at 12:13 p.m., revealed two packages of 30 count of corn tortillas with no received date. During an observation, in a standing refrigerator, on 06/27/2023 at 12:15 p.m., revealed one container of strawberry syrup with a received date of 03/23/2023 but no opened date, one package of black forest ham with no received date or opened date; and one container of sugar free syrup with a received date of 06/23/2023 but no opened date documented. During an observation and interview on 06/27/2023 from 3:59 p.m. through 4:15 p.m., Cook D confirmed, by observations, that mentioned items in the dry storage area, walk in refrigerator, standing freezer and standing refrigerator were not dated with received and or opened dates. During an interview on 06/02/2023 at 5:29 p.m., the DM stated items were separated between dry storage area, freezer or refrigerator and labeled with a received dates after collecting from the vendors. The DM stated the items were probably forgotten about or because the item gets wet the date rubbed off. The DM stated she was ultimately responsible for ensuring items were dated correctly. The potential harm to residents by not having items dated correctly was residents being exposed by bacteria. Record review of Food Storage, dated 2021, revealed 7b. Food should be dated as it is placed on the shelves if required by state regulation. [ .] Further record review under 13f. titled refrigerated food storage and under 14c titled frozen foods, which read All foods should be covered, labeled, and dated

Based on interview and record review, the facility failed to conduct a performance review at least once every 12 months and provide regular in-service education based on the outcome of these reviews for 6 of 6 CNA's, NA's or RA's (RA F, NA G, NA H, NA I, NA J, NA K) reviewed for performance reviews, in that: The facility failed to conduct performance reviews at least every 12 months for RA F, NA G, NA H, NA I, NA J, NA K. This failure could result in residents not receiving the necessary care and services due to nurse aides not receiving training based on their performance review outcome. The findings included: Record review of the facility's personnel files revealed the personnel files of RN F (hired 09/15/2014), CNA G (hired 07/19/2022), CNA H (hired 05/07/1991), CNA I (hired 07/01/2010), CNA J (hired 06/20/2022) and CNA K (hired 06/18/2012) . During an interview on 06/30/2023 at 1:22 p.m., the DON stated she was aware that aides were required to have a 12-month performance review every year. The DON stated she was unable to find where the previous DON had the paperwork. She further stated that some of the current staff actually caught that previous DON tossing/shredding some of the facilities paperwork prior to her leaving. The DON stated the potential harm was staff not knowing how skills should be done correctly. During an interview on 06/30/2023 at 3:29 p.m. the MDS Coordinator stated they do not have a policy for the 12 month performance reviews on all aids.

Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 10 of 16 employees (RA F, NA G, NA H, NA I, NA J, NA K, LVN L, RN M, LVN N, LVN O) reviewed for training, in that: The facility failed to ensure RA F, NA G, NA H, NA I, NA J, NA K, LVN L, RN M, LVN N, LVN O completed QAPI training within the last year. These failures could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings included: a. Record review of Staff Roster, dated 06/30/2023, revealed RA F was hired on 09/15/2014. Record review of RA F's training history revealed RA F had not completed QAPI training in the last year. b. Record review of Staff Roster, dated 06/30/2023, revealed CNA G was hired on 07/19/2022. Record review of CNA G's training history revealed CNA G had not completed QAPI training in the last year. c. Record review of Staff Roster, dated 06/30/2023, revealed CNA H was hired on 05/07/1991. Record review of CNA H's training history revealed CNA H had not completed QAPI training in the last year. d. Record review of Staff Roster, dated 06/30/2023, revealed CNA I was hired on 07/01/2010. Record review of CNA I's training history revealed CNA I had not completed QAPI training in the last year. f. Record review of Staff Roster, dated 06/30/2023, revealed CNA J was hired on 06/20/2022. Record review of CNA J's training history revealed CNA J had not completed QAPI training in the last year. g. Record review of Staff Roster, dated 06/30/2023, revealed CNA K was hired on 06/18/2012. Record review of CNA K's training history CNA K had not completed QAPI training in the last year. h. Record review of Staff Roster, dated 06/30/2023, revealed LVN L was hired on 03/21/2022. Record review of LVN L's training history revealed LVN L had not completed QAPI training in the last year. i. Record review of Staff Roster, dated 06/30/2023, revealed the RN M was hired on 08/19/2000. Record review of the RN M's training history revealed the RN M had not completed QAPI training in the last year. j. Record review of Staff Roster, dated 06/30/2023, revealed the LVN N was hired on 06/24/1997. Record review of the LVN N's training history revealed the LVN N had not completed QAPI training in the last year. k. Record review of Staff Roster, dated 06/30/2023, revealed LVN O was hired on 07/03/2003. Record review of LVN O's training history revealed LVN O had not completed QAPI training in the last year. During an interview on 06/30/2023 at 1:22 p.m., the DON stated she was not aware all staff was required to have QAPI training. She further stated there was not an HR staff member located in this building and that the HR paperwork was completed mobile from their corporate office. The DON stated there was no one assigned to ensure all staff training was completed. During an interview on 06/30/2023 at 3:29 p.m. the MDS Coordinator stated they do not have a policy for QAPI training.

Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for 16 of 16 employees (RA F, NA G, NA H, NA I, NA J, NA K, LVN L, RN M, LVN N, LVN O, MR, DM, AD, DON, MDS Coordinator and SW)reviewed for training, in that: The facility failed to ensure RA F, NA G, NA H, NA I, NA J, NA K, LVN L, RN M, LVN N, LVN O, MR, DM, AD, DON, MDS Coordinator and SW completed behavioral health training within the previous year. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. The findings included: a. Record review of Staff Roster, dated 06/30/2023, revealed RA F was hired on 09/15/2014. Record review of RA F's training history revealed RA F had not completed Behavioral Health training in the last year. b. Record review of Staff Roster, dated 06/30/2023, revealed CNA G was hired on 07/19/2022. Record review of CNA G's training history revealed CNA G had not completed Behavioral Health training in the last year. c. Record review of Staff Roster, dated 06/30/2023, revealed CNA H was hired on 05/07/1991. Record review of CNA H's training history revealed CNA H had not completed Behavioral Health training in the last year. d. Record review of Staff Roster, dated 06/30/2023, revealed CNA I was hired on 07/01/2010. Record review of CNA I's training history revealed CNA I had not completed Behavioral Health training in the last year. f. Record review of Staff Roster, dated 06/30/2023, revealed CNA J was hired on 06/20/2022. Record review of CNA J's training history revealed CNA J had not completed Behavioral Health training in the last year. g. Record review of Staff Roster, dated 06/30/2023, revealed CNA K was hired on 06/18/2012. Record review of CNA K's training history CNA K had not completed Behavioral Health training in the last year. h. Record review of Staff Roster, dated 06/30/2023, revealed LVN L was hired on 03/21/2022. Record review of LVN L's training history revealed LVN L had not completed Behavioral Health training in the last year. i. Record review of Staff Roster, dated 06/30/2023, revealed the RN M was hired on 08/19/2000. Record review of the RN M's training history revealed the RN M had not completed Behavioral Health training in the last year. j. Record review of Staff Roster, dated 06/30/2023, revealed the LVN N was hired on 06/24/1997. Record review of the LVN N's training history revealed the LVN N had not completed Behavioral Health training in the last year. k. Record review of Staff Roster, dated 06/30/2023, revealed LVN O was hired on 07/03/2003. Record review of LVN O's training history revealed LVN O had not completed Behavioral Health training in the last year. l. Record review of Staff Roster, dated 06/30/2023, revealed the MR was hired on 05/01/1971. Record review of the MR's training history revealed the MR had not completed Behavioral Health training in the last year. m. Record review of Staff Roster, dated 06/30/2023, revealed the DM was hired on 04/13/2007. Record review of the DM's training history revealed DM had not completed Behavioral Health training in the last year. n. Record review of Staff Roster, dated 06/30/2023, revealed the AD was hired on 02/25/2015. Record review of AD's training history revealed the AD had not completed Behavioral Health training in the last year. o. Record review of Staff Roster, dated 06/30/2023, revealed the DON was hired on 05/01/1971. Record review of DON's training history revealed DON had not completed Behavioral Health training in the last year. p. Record review of Staff Roster, dated 06/30/2023, revealed the MDS Coordinator was hired on 05/01/1971. Record review of the MDS Coordinator training history revealed she had not completed Behavioral Health training in the last year. q. Record review of Staff Roster, dated 06/30/2023, revealed the SW was hired on 05/01/1971. Record review of SW's training history revealed SW had not completed Behavioral Health training in the last year. During an interview on 06/30/2023 at 00:00 p.m., the DON stated she was not aware all staff was required to have Behavior Health training. She further stated there was not an HR staff member located in this building and that the HR paperwork was completed mobile from their corporate office. The DON stated there was no one assigned to ensure all staff training was completed. During an interview on 06/30/2023 at 3:29 p.m. the MDS Coordinator stated they do not have a policy for QAPI training.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 2 of 4 residents (Residents #20 and, #29) reviewed for privacy, in that: 1. CNA A did not completely close Resident #20's privacy curtain while providing catheter care for the resident. 2. CNA B and CNA C did not completely close Resident #29's privacy curtain while providing incontinent care for the resident. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings included: 1. Record review of Resident #20's face sheet, dated 06/29/2023, revealed an admitted [DATE], and a readmitted [DATE], with diagnoses which included: Dementia (decline in cognitive abilities), Cellulitis(skin infection), Depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Retention of urine (inability to voluntarily pass urine) and, Edema (swelling). Record review of Resident #'20's Annual MDS, dated [DATE], revealed the resident had a BIMS score of 8 indicating moderate impairment. Resident #20 required extensive assistance and was frequently incontinent of bowel and had an indwelling catheter. Observation on 06/29/23 at 02:10 p.m. revealed CNA A provided catheter care for Resident #20, CNA A did not pull the curtains completely around Resident 20's bed to offer privacy to the resident during care. Resident #20's genitals were exposed during care. Anybody opening the room's door and entering would have been able to seen the resident. During an interview with CNA A on 06/29/2023 at 2:20 p.m., CNA A verbally confirmed the end of bed was uncovered. She stated she did not know she had to completely close the curtain around the bed. She confirmed receiving training about privacy during care. 2. Record review of Resident #29's face sheet, dated 06/29/2023, revealed an admitted [DATE], with diagnoses which included: Vascular dementia (decline in cognitive abilities), Osteoporosis (Systemic skeletal disorder characterized by bone deterioration) , Chronic kidney disease stage 3 (gradual loss of kidney function) , Hypothyroidism (under active thyroid), Type 2 diabetes mellitus(high level of sugar in the blood) , Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood) and, Hypertension (High blood pressure). Record review of Resident #'29's quarterly MDS, dated [DATE], revealed the resident did not have a BIMS. Resident #20 required extensive to total care assistance and was always incontinent of bowel and bladder Observation on 06/29/23 at 01:50 p.m. revealed CNA B and CNA C provided incontinent care for Resident #29, CNA B and CNA C did not pull the curtains completely around Resident 29's bed to offer privacy to the resident during care. Resident #29's genitals and buttocks were exposed during care. Anybody opening the room's door and entering would have been able to seen the resident. During an interview with CNA B and CNA C on 06/29/2023 at 1:58 p.m., they verbally confirmed the end of bed was uncovered. they stated they did not know she had to completely close the curtain around the bed and that they only had to pull the curtain between the beds. They confirmed receiving training about privacy during care. During an interview with the DON on 06/30/2023 at 8:20 a.m., the DON verbally confirmed the privacy curtains had to be completely closed around the bed of the resident during care to insure complete privacy. The staff was trained within this year about resident rights. The management checked on the staff and how they provided care. The DON did not know they had to do annual skills check and competency with all the staff annually Review of facility policy titled Privacy and confidentiality, dated 11/26/2017, revealed you have the right to: privacy, including privacy during visits and telephone calls and while attending to personal needs

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 of 4 residents (Resident #92) reviewed for respiratory care, in that: Resident #92's humidifier bottle (a pre-filled bottle of sterile water for an oxygen concentrator machine) was not dated. This deficient practice could affect residents who require an oxygen concentrator and result in infection and respiratory compromise. The findings were: Record review of Resident #92's face sheet, dated 05/17/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #92's quarterly MDS, dated [DATE], revealed a brief interview for mental status was not performed because the resident was rarely or never understood. A staff assessment for mental status indicated Resident #92 had short-term and long-term memory problems. Record review of Resident #92's care plan, dated 10/02/2017, revealed the resident was at risk for [CONDITION(S)] d/t [due to] episodes of hallucinations, delusions; Blind; and hx [history] of UTI's [urinary tract infection]; Receives antidepressant, antianxiety, and antipsychotic medications; On psychiatric services; Dx [diagnosis] of dementia w/ [with] behaviors, [CONDITION(S)] with delusions r/t [related to] known physiological condition, depression with interventions, Psychiatric services as ordered/indicated, Administer medications as ordered . Observation on 05/15/2022 at 10:30 a.m. revealed Resident #92 was utilizing supplemental oxygen and the humidifier bottle connected to his oxygen concentrator was not dated. During an interview with CNA A on 05/15/2022 at 10:32 a.m., CNA A confirmed Resident #92's humidifier bottle was not dated. During an interview with the ADON on 05/18/2022 at 1:30 p.m., the ADON stated Resident #92 had been readmitted to the facility from the hospital on 05/13/2022 with new orders for supplemental oxygen which he did not have prior to his latest hospital visit. The ADON stated Resident #92's humidifier bottle was not dated because it had only been in use for two days. Record review of the facility's policy, Oxygen Equipment, undated, revealed, All oxygen equipment should be changed on the following schedule: 1) Change every week as needed, a) Cannula and humidifier .Label all equipment with the date and initials of change.

Based on observation, interview, and record review, the facility failed to follow infection prevention policies and procedures designed to provide a safe, sanitary, environment to help prevent the development and transmission of infections and follow accepted national standards for 2 of 25 residents (Residents #27 and #31) reviewed for infection control, in that: 1. LVN D failed to change gloves after touching her face and mask during a blood sugar check on Resident #27 and did not sanitize the glucometer after use with Resident #27. 2. RN E #18 failed to wash her or sanitize her hands between changing her gloves during wound care. These deficient practices could place residents at risk for infection due improper infection control procedures. Findings included: 1. Record review of Resident #27's face sheet, dated 05/18/22, revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #27's MDS, dated [DATE], revealed the resident had a BIMS score of 3, which indicated the resident was severely cognitively impaired. Record review of Resident #27's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 05/18/2022 at 4:30 PM revealed LVN D was wearing personal protective equipment, washed her hands, and then put on gloves. Further observation revealed, just before performing a blood sugar check on Resident #27, LVN D realized her mask had started to come off of her ear and used her left gloved hand to put her mask back on her ear, touching her mask and hair. LVN D's mask fell down again immediately after readjusting it continued to readjust her mask with her left gloved hand to place her mask back on her ear. Once the mask was secured LVN D then grabbed the pricking needle and pricked Resident #27's finger without changing gloves and washing or sanitizing her hands. During an interview with LVN D on 05/18/2022 at 4:30 PM, LVN D stated the process for changing gloves was she was supposed to change gloves any time they were soiled or contaminated. LVN D stated she was nervous and accidentally touched her face, mask, and glasses and did not think about changing them. When asked what possible harm could come to the resident by her practice, LVN D stated there was the risk of giving a resident an infection from bacteria that was on her face but could not recall the name of the bacteria. Observation on 05/18/2022 at 4:35 PM revealed LVN D did not disinfect the glucometer after it was used on Resident #27 and before she put it away. During an interview with LVN D on 05/18/2022 at 4:40 PM LVN D stated the process for disinfecting a glucometer was supposed to be that she disinfected the glucometer after each use. LVN D stated she did not disinfection the glucometer after using it with Resident #27 because she had misplaced the disinfectant wipes which were usually found on the treatment cart. When asked what possible harm could have happened to the resident by her not disinfecting the glucometer, LVN D stated she risked the resident getting a possible infection. During an interview with the ADON on 05/17/2022 at 11:20 AM, the ADON stated all nurses had been trained on infection control practices including changing gloves and disinfecting reusable equipment when they became contaminated and/or after patient use. The ADON stated failure to change gloves and disinfect reusable equipment could place patients at risk for possible exposure to infection. 2. Record review of Resident #31's face sheet, dated 05/18/22, revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #31's MDS, dated [DATE], revealed the resident had a BIMS score of 11, which indicated the resident was moderately cognitively impaired. Record review of Resident #31's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply small piece of collagen to wound bed and cover with bandaid. Change daily until healed Once a day. Start day 5/17/2022. Open Ended. Observation on 05/17/2022 at 10:34 AM revealed LVN F and RN E performed wound care for Resident #1. Further observation revealed RN E moved the resident's drink, tissue, and television remote control off of the resident's bedside table, and then changed her gloves without washing or sanitizing her hands, and proceeded with wound care. During an interview with RN E on 05/17/2022 at 10:36 AM, RN E stated staff usually kept hand sanitizer on the treatment cart outside in the hall and she should have either sanitized or washed her hands after changing her gloves. Record review of the facility's policy titled, Universal Precautions and Body Substance Isolation, undated, revealed, Hands are to be washed immediately after removing gloves, between any resident's contact, or when otherwise indicated. Record review of the facility's policy titled, Cleaning and Disinfection of Resident Care items and Equipment, revised October 2018, revealed, reusable items are cleaned and disinfected or sterilized between residents.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframe for 2 of 4 residents (R#1 and #4), reviewed for care plans, in that: R#1 and R#4 care plans did not document dental hygiene (denture) services that would attain or maintain the residents highest practical physical well-being. This deficiency could result in residents not receiving the care and treatments; and could lead to a diminished quality of life, not attaining medical, nursing, and mental and psychosocial needs. The findings were: R#1 Record review of R#1's face sheet, dated [DATE], and EMR (electronic medical record) revealed, the resident was admitted on [DATE] and deceased on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was a female; age 86. Advanced Directive: DNR (do not resuscitate). RP (responsible party) was listed as: a family member. Record review of Care Plan (CP), dated [DATE], revealed, the goal of ADL(activity of daily living); interventions were restorative for ambulation and transfers one staff assistance, bathing and grooming one staff assistance. [Measurable objectives and time-frames for denture oral care was not documented in the care plan]. Record review of Physician' Orders, dated [DATE], revealed diet was regular, no concentrated sweets. Also, dental evaluation and treatment as indicated. Record review of CP dated [DATE] revealed, goal of altered mood behaviors; interventions around ADLs included: explain procedures from the beginning to end, encourage participation. [Measurable objectives and time-frames for denture oral care was not documented in the care plan]. Record review of MDS (minimum data set), dated [DATE] (annual), revealed, o BIMS (brief interview of mental status) Score was 9 (moderately impaired) o ADLs (activities of daily living): B/B (bowel and bladder) frequently incontinent of both; one staff assistance. Transfer and mobility were extensive one staff assistance. ROM (range of motion) revealed no impairments. Record review of MAR (medication administration record), dated [DATE], revealed no medications for [CONDITION(S)] (urinary tract infection) or infections. Some medications included: [MEDICATION(S)] 25 mgs once per day (diabetes), [MEDICATION(S)] 20 mgs daily (diuretic). and [MEDICATION(S)] 70 mgs one per week [CONDITION(S)] (disease that thins and weakens the bones). Record review of Nursing Notes past 30 days ([DATE]-[DATE]) revealed no notes dealing with R#1 wearing dentures, observation of dentures by staff, or resident refusing for staff assistance in oral care. During an interview on [DATE] at 3:14 PM, LVN A stated, .regarding denture care, she (R#1) cleaned her own dentures .she self brushed her teeth with supervision .she did not want to leave the dentures in a cup after she cleaned them .she slept with the dentures . denture care was considered as part of grooming and not a separate ADL (in the CP as a general ADL) . During an interview on [DATE] at 3:39 PM, LVN B, stated, .she (R#1) was independent in cleaning her dentures; she cleaned them daily and spent a lot of time in the bathroom .at bed time she would take them off and put them in a cleaning solution .she was a on a regular a diet . During an interview on [DATE] at 3:37 PM, Medication Aide C stated, .there were no issues with her (R#1) dental care .she cleaned her dentures daily .she cleaned and washed her dentures .she spent a lot of time in the bathroom cleaning her dentures .she was independent and active .I supervised her in grooming . During an interview on [DATE] at 3:49 PM, CNA D, stated, .I provided to the resident all her (R#1) ADLs .grooming, dressing and changing, feeding, she cleaned her own dentures .she wanted to be independent .she cleaned her own dentures she did not want us to help her .she always cleaned them daily .I do not know how long she soaked them . During an interview on [DATE] at 5:09 PM, LVN E stated, .the resident was refusing ADL care .dental care is part of ADL .and it is documented in the CP .there is no specific section dealing with the care of dentures .a CP is developed for dentures if the resident is on restorative care or there are issues with the teeth .#1 and R#4 care plans do not have goals and interventions when the resident is independent in denture care or refuses assistance .CP is developed from an interdisciplinary meeting . R#4 Record review of Resident #4's face sheet, dated [DATE], and EMR (Electronic medical record), revealed the following information: Resident was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was a female age 72. RP (Responsible Party) was the resident. Record review of Resident #4's Care Plan revealed, dated [DATE], revealed: no measurable objectives or time frames dealing with oral dental care around dentures. CP plan in the area of ADLs read, .allow the resident to do as much as possible independently; Assist only as needed .explain all procedures to resident prior to beginning . Goal was listed as: .will continue to groom and dress self with assist over the next 3 months Target date:[DATE] . During an observation and interview on [DATE] at 2:47 PM, Resident #4 was in her room watching TV. Cleaned and groomed; no signs of abuse/neglect. The Resident removed her lower dentures and allowed surveyor to observe. The dentures were cleaned, not broken, no tarter, no food particles and no black spots. The Resident stated, ' .I am treated pretty good .I clean my dentures .no need for staff assistance .no complaints . [CP did not contain evidence that staff needed to observe the dentures as an ADL service and document the findings.] During an interview on [DATE] at 2:50 PM, ADON confirmed the dentures were cleaned and the resident did not request staff assistance. ADON revealed, the CP was general in ADLs and did have a specific section dealing with denture hygiene. Record review of facility's Oral Hygiene (Dentures) policy, undated, read, .Oral hygiene for the patient who wears dentures consists of giving mouth care when dentures are removed observe and report any of the following: .a. Discoloration, irritation, redness, bleeding, paleness, sores, [CONDITION(S)], or cracks of mouth, gums, or lips .c. Complaints of pain or discomfort of mouth or teeth .d. Loose. Broken, damaged, or decaying teeth .e. Changes in resident's ability to tolerate or participate in oral care . Record review of facility Care Plan policy, undated, read, Assessment The comprehensive care plan will: a. Include measurable objectives and timeframe: b. Describe the services that are to furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would be provided, but are not provided due to the residents exercising his or her rights to refuse treatment .

Based on interview and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 2 of 12 residents (Residents #26 and #9) reviewed for accidents in that: 1. Resident #26 fell fifteen times in a seven month period and sustained a laceration and a fracture. 2. Resident #9 fell four times in a six month period and sustained a laceration and a head injury. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 02/02/2021. While the IJ was removed on 02/05/2021, the facility remained out of compliance at a severity of potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern until interventions were put in place to ensure residents who were at risk for falls were being monitored and supervised. These deficient practices could result in residents who require protective measures sustaining accidents, injury, or death. The findings were: 1. Record review of Resident #26's facesheet, dated 01/20/2021, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #26's quarterly MDS, dated [DATE], revealed a BIMS score of 2 which indicated severe cognitive impairment. Further review revealed Resident #26 required extensive assistance from staff in transferring to and from surfaces including to and from bed, chair, wheelchair, and standing position. Further review revealed the resident was not steady when moving from seated to standing position and utilized a wheelchair to ambulate. Record review of Resident #26's Care Plan, revised 01/13/2021, revealed a problem, At risk for fall d/t (due to) hx (history) of falls, decreased vision, bilateral lower leg weakness, decreased safety awareness, use of narcotic pain medications and hx (history) of wandering ., and a goal, Will have no falls over next 3 months. Further review revealed approaches initiated 03/19/2014, Administer medications as ordered, assist with transfers as needed - 1 person, assure resident is wearing eyeglasses, assure eyeglasses are clean and in good repair, coordinate with MD (medical doctor) for possible medication reduction/elimination, encourage resident to use environmental devices such as hand grips, hand rails, etc., encourage resident to use w/c (wheelchair) for mobility, ensure resident wearing proper, well-maintained footwear, keep bed in lowest position with brakes locked, keep call light in reach at all times, keep personal items and frequently used items within reach, labs as ordered; notify MD (medical doctor) of abnormal results, provide resident an environment free of clutter, restorative nursing as ordered/indicated, screen resident for side effects that could possibly affect quality of life ( i.e. tardive dyskinesia, [DIAGNOSES REDACTED], Parkinsonism, [MEDICAL CONDITION], constipation, etc.) notify MD (medical doctor) of side effects observed. Further review revealed approached initiated 09/11/2019, Antiroll bars to w/c (wheelchair) to prevent w/c (wheelchair) from rolling back, encourage and remind resident to use call light to ask for assistance, and an approach initiated 06/03/2020, Bed alarm to alert staff of self-transfer. Further review revealed an approached was initiated 06/09/2020 following Resident #26's fall on 06/07/2020, Wheelchair alarm to alert staff of attempts to get up without assistance. Further review revealed approaches with unknown date of initiation, Remind resident to call for help, discourage resident from removing w/c (wheelchair) alarm and turning off bed alarm, check alarms during rounds to ensure alarm is on and attached to resident. During an interview with the DON and MDS/Care Plan Coordinator on 02/03/2021 at 12:42 p.m., the DON and MDS/Care Plan Coordinator confirmed the undated approaches were added to Resident #26's care plan after 06/09/2020 and before Resident #26's fall on 12/26/2020 when she sustained a laceration and a fracture. Record review of the facility incident report following Resident #26's fall on 12/26/2020 revealed the resident was found on the floor of her room yelling for help. Further review revealed the resident sustained [REDACTED]. During attempted interviews with Resident #26 at various times from 01/17/2021 to 01/20/2021 and from 02/03/2021 to 02/05/2021, Resident #26 did not respond to questions. Review of Resident #26's Clinical Record revealed the resident fell on [DATE], 06/09/2020, 06/18/2020, 07/20/2020, 07/26/2020, 09/13/2020, twice on 09/25/2020, twice on 11/09/2020, twice on 11/26/2020, 12/26/2020, 01/02/2021, and 01/13/2021. Further review of Resident #26's Care Plan, revised 01/13/2021, revealed no new or different interventions were added following each fall. During an interview with the DON and MDS/Care Plan Coordinator on 02/03/2021 at 12:42 p.m., the DON and MDS/Care Plan Coordinator confirmed no new or different interventions were added to Resident #26's care plan following the resident's falls on 06/18/2020, 07/20/2020, 07/26/2020, 09/13/2020, 09/25/2020, 11/09/2020, 11/26/2020, 12/26/2020, 01/02/2021, or 01/13/2021. During an interview with the DON on 01/20/2021 at 10:20 a.m., the DON stated the staff checked Resident #26 when aides and nurses make rounds up and down the halls and confirmed there is no set time period to check Resident #26. During an interview with CNA C on 01/20/2021 at 10:45 a.m., CNA C confirmed there was no set time period to check Resident #26. During an interview with LVN B on 01/20/2021 at 11:05 a.m., LVN B confirmed there was no set time period to check Resident #26. 2. Record review of Resident #9's facesheet, dated 01/20/2021, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #9's quarterly MDS, dated [DATE], revealed a BIMS score of 4 which indicated severe cognitive impairment. Further review revealed Resident #9 required extensive assistance from staff in transferring to and from surfaces including to and from bed, chair, wheelchair, and standing position. Further review revealed the resident required supervision and was not steady when walking and normally utilized a walker to ambulate. Record review of Resident #9's Care Plan, revised 12/31/2020, revealed a problem, Resident is at risk for falling r/t (related to) poor safety awareness, forgetfulness, generalized weakness, use of diuretics, antidepressants, oral hypoglycemic medications and insulin; ambulatory with frequent episodes of incontinence and history of falls, episodes of wandering, uses rolling walker for locomotion/ambulation ., a goal, Will have no falls over next 3 months. Further review revealed approached initiated 05/13/2016, Review medication for possible reduction/elimination, provide resident an environment free of clutter, labs as ordered; notify MD (medical doctor) of abnormal results, keep personal items and frequently used items within reach, keep call light in reach at all times, keep bed in lowest position with brakes locked, ensure resident wearing non-skid socks or shoes, assure resident is wearing eyeglasses, assure eyeglasses are clean and in good repair, assist with transfers as needed, assist with toileting as needed, administer medications as ordered, approached initiated 05/08/2019, Wander guard to alert staff of exiting building, remind resident to use walker when standing or ambulating, and an approach added at an unknown date, Wander guard on each side of walker. Further review revealed the resident fell on [DATE], 09/11/2020, and twice on 12/29/2020. Further review revealed no new or different interventions were added following each fall. Further review revealed staff supervision of the resident was not a listed intervention. Record review of Resident #9's clinical record revealed the resident sustained [REDACTED]. Record review of the facility incident report following Resident #9's second fall on 12/29/2020 revealed the resident was attempting to stand from a recliner in the sunroom near the nurses' station when she fell . During attempted interviews with Resident #9 at various times from 01/17/2021 to 01/20/2021 and from 02/03/2021 to 02/05/2021, Resident #9 did not respond to questions. During an interview with the DON on 01/20/2021 at 10:20 a.m., the DON stated the resident was no longer able to utilize a walker and had been in a wheelchair since her fall on 12/29/2020. The DON stated the staff checked Resident #9 when aides and nurses make rounds up and down the halls and confirmed there was no set time period to check Resident #9. During an interview with CNA C on 01/20/2021 at 10:45 a.m., CNA C confirmed there was no set time period to check Resident #9. During an interview with LVN B on 01/20/2021 at 11:05 a.m., LVN B confirmed staff could hear but not see the sunroom while seated at the nurses' station. LVN B further confirmed there was no set time period to check Resident #9. Record review of the facility policy, titled, Routine Resident Checks, revised July 2013, revealed, To ensure safety and well-being of our residents, nursing staff shall make a routine resident check on each unit at least once per each 8-hour shift. The Administrator was notified on 02/02/2021 at 9:57 p.m., in person, that an Immediate Jeopardy situation was identified, surveyor emailed the IJ template to the Administrator on 02/02/2021 at 10:04 p.m. and a Plan of Removal was requested. The facility's Plan of Removal was accepted on 02/04/2021 at 5:57 p.m. and included: The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: *Resident #9 was moved to room closest to nurses' station on 02/04/2021. *Resident #26 was offered room closer to nurses' station and refused to move on 02/04/2021. *Hourly checks performed by direct-care nursing staff have been initiated for Resident #9 and Resident #26 as of 02/03/2021. Direct care nursing staff will assist if resident needs to transfer, toilet, reach, or perform any action likely to result in a fall and will ensure correct placement of bed and chair alarms (Resident #26 only). *Additional hourly checks to be performed by all staff have been initiated for Resident #26 as of 02/03/2021. All staff will ensure correct placement of bed and chair alarms and will assist resident with any action likely to result in a fall as appropriate for staff's certification. Staff not certified to perform direct care may assist resident in reaching for items or performing similar tasks but must obtain a member of direct-care staff to assist resident with tasks such as transferring and/or toileting. *Hourly checks were added to each resident's care plan and Treatment Flow Sheets were created as of 02/03/2021. Hourly nursing checks are performed by charge nurse and documented on Treatment Flow Sheet. Hourly all staff checks are performed by non-direct care staff and documented in Angel Round binder located at resident's room. *The DON educated the Charge Nurses on 02/03/2021 to utilize Treatment Flow Sheet for documenting hourly checks performed by nursing staff. *The Training Coordinator began educating all staff via in-service on 02/03/2021 to utilize Angel Rounds log for documenting hourly checks performed by non-direct care staff. *Administrator contacted Resident #26's physician on 02/04/2021 and obtained orders for Resident #26 to receive Physical and/or Occupational Therapy from a local provider. Interventions and Monitoring Plan: *Charge Nurses will utilize the Resident Fall Tracking Log tool and the Neurological Record tool to assess each resident who sustains a fall immediately following each fall. *The DON or designee will monitor for accurate and timely completion of the Resident Fall Tracking Log and Neurological Record tools weekly for four weeks then monthly thereafter. *Charge Nurses will complete an Incident Report before the end of their shift following each resident fall. *The DON or designee will monitor for accurate and timely completion of the Incident Report weekly for four weeks then monthly thereafter. *The DON or designee will review the Resident Fall Tracking Log, Neurological Record, Fall Risk Evaluation, and the Incident Report following each fall during morning meeting weekly for four weeks; then monthly for two months. *The DON, RN Supervisor, and/or the MDS Coordinator will review the Resident Fall Tracking Log, Neurological Record, Fall Risk Evaluation, and the Incident Report within 24 hours of each instance of a resident fall. *The DON, RN Supervisor, and/or the MDS Coordinator will establish new and/or revised interventions within 24 hours of each instance of a resident fall. *The DON, RN Supervisor, and/or MDS Coordinator will communicate the new/and or revised interventions to all facility staff by updating the Care Plan within 24 hours of establishing new and/or revised interventions, and by providing training to staff on shift immediately, to oncoming staff as they begin their shifts, and via in-service either in person or by phone to include any staff not scheduled to work for the next week to be completed within 48 hours of establishing new and/or revised interventions. *Charge Nurses will utilize the Fall Risk Evaluation tool to perform Fall Risk assessments on residents on Admission, Readmission, and with any new falls. The MDS Coordinator will perform Fall Risk Assessments on residents quarterly according to the MDS schedule, and with any significant change in condition MDS. *The MDS Coordinator will re-assess all facility residents utilizing the Fall Risk Assessment tool to ensure all residents that are at risk for falls have been identified. At least five residents will be re-assessed per day beginning 02/04/2021 and continuing until all facility residents have been re-assessed. Any resident who is newly identified as at risk for falls will have their care plan reviewed by MDS Coordinator, or DON or designee to determine if any further interventions are needed to prevent falls. This will be completed on or before 02/19/2021. *The DON or designee will monitor for accurate and timely completion of the Fall Risk Evaluation tool as described above weekly for four weeks then monthly thereafter. *Additional education regarding Falls, Fall Prevention, and performing hourly checks for residents at high risk for falls will be added to new hire orientation and mandatory annual staff training curriculum. Completed: 02/04/2021 *Administrator and/or DON will review Treatment Flow Sheets and Angel Round logs during morning meetings for four weeks then monthly. *QAPI Committee will review effectiveness of new safety interventions at least monthly or as needed. Ad hoc QAPI meeting held on 02/03/2021 with Interdisciplinary Team (IDT) to review and discuss items identified by surveyor regarding Immediate Jeopardy. A Plan of Removal was developed, implemented, and completed as designed in this document (Plan of Removal). The investigator confirmed the plan of removal had been implemented sufficiently to remove the IJ by: Hourly checks to be performed by direct-care nursing staff have been initiated for Resident #9 and Resident #26 as of 02/03/2021. Direct care nursing staff will assist if resident needs to transfer, toilet, reach, or perform any action likely to result in a fall and will ensure correct placement of bed and chair alarms (Resident #26 only). --Verified by record review of Treatment Flow Sheets and interview with Charge Nurses on 02/04/2021 and 02/05/2021 --Observed direct-care staff performing checks, record review of direct care staff documenting checks in Treatment Flow Sheet, interviews with direct-care staff on 02/04/2021 and 02/05/2021 confirmed training received and understood increased monitoring via hourly checks on Residents #9 and #26. Interviewed 16 direct care staff (3 RNs, 5 LVNs, 1 Restorative Aide, 7 CNAs) who all verbalized understanding of the in-service on Falls, Fall Prevention, and increased monitoring of Residents #9 and #26 with hourly checks. Interviewed Administrator, DON, MDS Coordinator, and 2 Charge Nurses regarding new post fall protocols and fall monitoring. Additional hourly checks to be performed by all staff have been initiated for Resident #26 as of 02/03/2021. All staff will ensure correct placement of bed and chair alarms and will assist resident with any action likely to result in a fall as appropriate for staff's certification. Staff not certified to perform direct care may assist resident in reaching for items or performing similar tasks but must obtain a member of direct-care staff to assist resident with tasks such as transferring and/or toileting. --Verified by record review of Angel Round binder and interviews with Administrator, BOM, Receptionist, Social Worker, Activity Director, Activity Assistant, Hospitality Aide, Housekeeping Staff and Maintenance Staff on 02/04/2021 and 02/05/2021. --Observed non-direct care staff performing checks, record review of non-direct care staff documenting checks in Angel Round binder, Interviews with 15 non-direct care staff (Medical Records Coordinator, MDS Coordinator, 4 Housekeeping/Laundry staff, Social Worker, 1 Hospitality Aide, Administrator, BOM, Activity Director, Activity Assistant, Kitchen Manager, 1 Maintenance staff, and Receptionist) who all verbalized understanding of increased monitoring of Resident #26 with hourly checks. Hourly checks were added to each resident's care plan and Treatment Flow Sheets were created as of 02/03/2021. --Verified by record review of Treatment Flow Sheet 2/04/2021. The DON educated the Charge Nurses on 02/03/2021 to utilize Treatment Flow Sheet for documenting hourly checks performed by nursing staff. --Verified by record review of Treatment Flow Sheet and interview with 2-10 shift Charge Nurse 02/04/2021 and 6-2 shift Charge Nurse 02/05/2021. The Training Coordinator began educating all staff via in-service on 02/03/2021 to utilize Angel Rounds log for documenting hourly checks performed by non-nursing staff. --Verified by record review of in-service and by interview with Training Coordinator, Administrator, BOM, Receptionist, Social Worker, Activity Director, Activity Assistant, Hospitality Aide, Housekeeping Staff, and Maintenance Staff on 02/04/2021 and 02/05/2021. Confirmed 79% of staff trained as of 02/04/2021 and 91% of staff trained as of 02/05/2021. -- Interviews with 15 non-direct care staff (Medical Records Coordinator, MDS Coordinator, 4 Housekeeping/Laundry staff, Social Worker, 1 Hospitality Aide, Administrator, BOM, Activity Director, Activity Assistant, Kitchen Manager, 1 Maintenance staff, and Receptionist) who all verbalized understanding of the in-service on Falls, Fall Prevention, and increased monitoring of Resident #26 with hourly checks. All staff interviewed able to verbalize understanding about training and identify key elements of fall prevention program. Resident #9 will be moved closer to the nurses' station on or before 02/05/2021 to facilitate increased staff supervision of resident. --Verified via observation on 02/04/2021 Administrator or designee will contact Resident #26's physician on 02/04/2021 to obtain orders for Resident #26 to receive Physical and/or Occupational Therapy from a local provider. --Verified by interview with Administrator on 02/04/2021 that order received 02/04/2021 and appointment with outside provider was in place. On 02/05/2021 at 2:55 p.m. the Administrator was informed the IJ was lifted.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly in 1 of 1 Medication room reviewed for labeling and storage, in that: 1. The Medication Room was left unlocked and unattended. 2. The key to the Medication Room was stored on a bulletin board in a public space. These deficient practices could result in residents not receiving the intended therapeutic benefit of their medications and possible drug diversion. The findings were: 1. Observation on 01/17/2021 at 12:17 p.m. revealed the Medication Room was unlocked and unattended. During an interview with the DON on 01/17/2021 at 12:18 p.m., the DON confirmed the Medication Room was unlocked and unattended and should not have been. The DON further confirmed the facility has one Medication Room and confirmed all drugs and biologicals not on medication carts are stored in the Medication Room. 2. Observation on 01/19/21 2:30 p.m. revealed LVN B utilized a key hanging from a bulletin board on the wall in a public space, accessible by residents, staff, and visitors to unlock the door to the Medication Room. During an interview with the DON on 01/19/2021 at 2:32 p.m., the DON stated two nurses for each shift have a key to the Medication Room, and a spare key is kept on the bulletin board in the event one of the nurses with the keys are unavailable. The DON confirmed the bulletin board is in a public space and accessible by residents, staff, and visitors in the facility. Record review of the facility policy, titled, Storage of Medications, revised April 2007, revealed, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Compartments (including, but not limited to drawers, cabinets, rooms . containing drugs and biologicals shall be locked when not in use. Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys.

Based on interview and record review, the facility failed to ensure the resident's right to formulate an advance directive for 1 of 12 residents (Resident #42) reviewed for advance directives, in thResident #42's OOH-DNR form was not signed twice by each witness and was therefore invalid. This deficient practice could result in residents who choose to formulate an advance directive not having their wishes known and fulfilled. The findings were: Record review of Resident #42's facesheet, dated 01/20/2021, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #42's quarterly MDS, dated [DATE], revealed a BIMS score of 8 which indicated moderate cognitive impairment. Record review of Resident #42's Care Plan, revised 01/01/2021, revealed the resident's code status was DNR with a goal, Will respect resident/responsible party's wishes regarding DNR status and approaches, Ensure out of hospital DNR in resident's active medical record and Review DNR status with resident/RP routinely and as needed. Record review of Resident #42's physician order summary, dated 01/20/2021, revealed an order, Code Status: DNR Status was written on 04/03/2018. Record review of Resident #42's OOH-DNR revealed the document's two witnesses did not sign the Two Witnesses section. During an interview with the Director of Medical Records on 01/18/2021 at 12:42 p.m., the Director of Medical Records confirmed she is one of the staff members responsible for securing signatures for OOH-DNR forms, and confirmed Resident #42's OOH-DNR form had not been signed by two witnesses in the Two Witnesses section of the document and should have been, and confirmed the document was invalid due to the missing signatures. Record review of the Texas Health and Human Services webpage titled, Frequently Asked Questions for DNR, retrieved 01/20/2021, revealed, Two witnesses or a notary public must sign that they have witnessed the patient's signature or the signature of a person(s) acting on the patient's behalf . health professionals can refuse to honor a DNR if they think the form is not signed twice by all who need to sign it or is filled out incorrectly. Record review of the facility policy titled, Advance Directive Policy and Procedure, undated, revealed, The resident has a right and the facility will assist the resident to formulate an advance directive at their option. Resident has the right to accept, request, refuse and/or discontinue medical or surgical treatment .

Based on interview and record review the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being for 1 of 12 residents (#16) whose records were reviewed for behavioral health services, in that: Resident #16 was not referred for a psychiatric or psychological evaluation after showing increasing signs of depression. This deficient practice could result in residents with depression and/or mood disorders failing to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The findings were: Record review of Resident #16's facesheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #16's annual MDS, dated [DATE] revealed a BIMS score of 13 which indicated intact cognition and a PHQ-9 score of 4 which indicated minimal depression. Record review of Resident #16's quarterly MDS, dated [DATE] revealed a BIMS score of 13 which indicated intact cognition and a PHQ-9 score of 20 which indicated severe depression. Record review of Resident #16's quarterly MDS, dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment and a PHQ-9 score of 18 which indicated moderately severe depression. Record review of Resident #16's Care Plan, revised [DATE], revealed a problem, Risk for altered mood/behavior d/t (due to) episodes of feeling down, depressed . Further review revealed a problem, At risk for altered mood and decline in psychosocial well-being d/t (due to) social distancing, restricted visitation with family/loved ones, restricted activities, and no communal dining r/t (related to) COVID-19 pandemic . Record review of Resident #16's clinical record revealed a Monthly Nurse's Note, dated [DATE] which indicated the resident displayed signs and symptoms of depression including: little interest or pleasure in doing things, poor appetite or overeating, and being short-tempered or easily annoyed. Further review revealed the resident displayed verbal behavioral symptoms directed toward others. Record review of Resident #16's clinical record revealed a Dietary Note, dated [DATE] which quoted the resident as saying, 'I think I was just feeling sorry for myself. It all just hit me that this is not my home and these people are not my family'. Further review revealed, Resident fed self in room today, says 'I prefer to eat in here when I'm feeling like this. I usually eat in the DR (dining room).' Reports (family member) died 2 years ago and she 'still is not over that.' Per nursing, (family members) have not been visiting as frequently, appetite/intake has been fluctuating. Recommend: psych (psychiatric/psychological) consult, encourage resident to be up in DR (dining room) for meals. Record review of Resident #16's clinical record revealed a Dietary Note, dated [DATE], .noted decline in intake per nursing, likely depression, signs of depression noted during previous RD (Registered Dietician) visit as well. Record review of Resident #16's clinical record revealed a Monthly Nurse's Note, dated [DATE] which indicated the resident displayed signs and symptoms of depression including: little interest or pleasure in doing things, feeling tired or having little energy, poor appetite or overeating, and being short-tempered or easily annoyed. Further review revealed the resident displayed verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, and delusions. Record review of Resident #16's clinical record revealed a Monthly Nurse's Note, dated [DATE] which indicated the resident displayed signs and symptoms of depression including: little interest or pleasure in doing things, feeling tired or having little energy, poor appetite or overeating, and being short-tempered or easily annoyed. Further review revealed the resident displayed verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, and delusions. Record review of Resident #16's physician orders revealed the resident receives three anti-depressant and anti-anxiety medications. During an interview with Resident #16 on [DATE] at 1:00 p.m., Resident #16 stated she was very unhappy that she lived at facility, wants to return home, and knows she is unable to do so due to her need for medical care. Resident #16 stated I hate it here and indicated she has no pleasure in any aspect of her life. Resident #16 stated she enjoyed reading in the past but said her memory is too poor to do so anymore. Resident #16 did not verbally respond when asked about psychiatric/psychological services but did roll her eyes. During an interview with Resident #16 on [DATE] at 9:30 a.m., when asked if she would like to discuss her feelings about living at the facility with someone, Resident #16 stated, What's there to talk about, it's horrible and declined further interview. During an interview with the MDS Coordinator on [DATE] at 10:36 a.m., the MDS Coordinator confirmed Resident #16 had not been offered a consultation with a psychiatric practitioner stated, She was a nurse, she would refuse, and stated We have increased her [MEDICATION NAME] (anti-depressant medication). During an interview with the DON on [DATE] at 10:20 a.m., the DON confirmed Resident #16 had not been offered a consultation with a psychiatric practitioner. The DON stated the resident is an old nurse and she would refuse. Record review of the facility policy titled, Behavioral Health Services, revised February 2019, revealed, The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care .Residents who exhibit signs of emotional/psychological distress receive services and support that addresses their individual needs and goals for care.

Based on interview and record review, the facility failed to ensure nurse aides received the required minimum 12 hours of annual in-service training, and were provided with one hour of Falls, Restraints [MEDICAL CONDITION] for 3 of 8 nurse aides (CNAs E, G, and H) and 1 of 1 Food Service Director reviewed for training, in that: 1. CNAs [NAME] and H did not complete 12 hours of annual in-service training to include 1 hour of Falls and 1 hour of Festraints training. 2. Food Service Director and CNA G did not complete 12 hours of annual in-service training to include 1 hour of Restraints training. 3. CNA H did not complete 12 hours of annual in-service training to include 1 hour [MEDICAL CONDITION]. These deficient practices could place residents who reside at the facility at-risk of inadequate care due to uncompleted training. The findings were: Record review of CNA E's personnel file revealed a hire date of 05/09/1991. Further review of CNA E's training record revealed their last training on Falls and Restraints was on 03/22/2018. Record review of CNA G's personnel file revealed a hire date of 05/05/2016. Further review of CNA G's training record revealed their last training on Falls and Restraints was on 03/22/2018. Record review of the Food Service Director's personnel record revealed a hire date of 04/24/1992. Further review of the Food Services Director's training record revealed their last training on Restraints was on 03/22/2018. Record review of CNA H's personnel file revealed a hire date of 06/12/2018. Further review of CNA H's training record revealed their last training [MEDICAL CONDITION] on 07/12/2018. During an interview with the MDS Nurse on 05/30/2019 at 5:10 PM, the MDS Nurse confirmed the most recent fall in-service was on 03/22/2018 and Prevention of Falls & Injuries 04/26/2018; Use of restraints in-serviced 03/22/2018. During an interview with Administrator on 05/30/2019 at 5:30 PM, the Administrator stated she was unaware of in-service delinquencies. Record review of facility policy titled Nursing Facility Requirements for Licensure and Medicaid Certification, dated 00/00/0000, revealed: Each facility must implement and maintain programs of orientation, training, and continuing in-service education to develop the skills of its staff, as described in §19.1903 of this title (relating to Required Training of Nurse Aides). 1. As part of orientation and annually, each employee must receive instruction regarding (A) Human Immunodeficiency Virus ,[MEDICAL CONDITION]. (B) restraint reduction and the prevention of falls through competency-based training .

Based on observation, interview, and record review, the facility failed to ensure 1 of 4 CNAs (CNA A) demonstrated competency in skills and techniques necessary to care for resident needs to provide perineal/incontinent care for 1 of 2 residents (Residents #24) observed during perineal/incontinent care, in that: CNA A did not separate Resident #24's labia while performing perineal care. This deficient practice could place residents who received perineal/incontinent care at-risk of urinary tract infections or the spread of disease. The findings were: Record review of Resident #24's face sheet, dated 05/31/2019, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #24's Quarterly MDS, dated [DATE], revealed the resident was indicated to always be incontinent bowel and bladder. Record review of Resident #24's care plan, dated 01/08/2019, revealed, At risk for UTI's due to history of UTI; incontinent bowel and bladder . Provide good perineal care after each episode of incontinent. Observation on 05/28/2019 at 3:53 PM revealed CNA A performed perineal care for Resident #24. Further observation revealed CNA A sprayed the perineal cleanser on the wipes to wipe the resident's left and right groin and in a downward motion in the middle. Further observation revealed CNA did not separate the resident's labia to clean the urethral meatus. During an interview with CNA A on 05/28/2019 at 4:08 PM, CNA A confirmed she did not separate Resident # 24's labia to clean the urethral area, and further confirmed she only wiped the left and right groin and wiped down in the middle. During an interview with DON B on 05/31/2019 at 8:28 AM, DON B confirmed CNA A should have separated Resident #24's labia when she provided perineal care for the resident. DON B further stated that when CNA A wiped down in the middle, wash cloth could separate the labia already. Record review of the facility policy titled Perineal Care, undated, revealed, Perineal Care for female patient without urinary catheter has these steps: . Separate the labia and wash, rinse and dry the urethral area first with short downward [MEDICAL CONDITION] alternating from side to side and proceeding until the exposed area around the urethra is done. Based on observation, interview, and record review the fcility failed to maintain an infection prevention and control program to provide a sanitary and comfortable environment to help prevent the development and transmission of infections for 1 out of 2 residents ( # _ and # _) reviewed for infection control in that: 1. CNA D did not sanitize her hands after cleaning feces for resident # __ and placed a clean brief and pants on Resident # __. 2. CNA C recieved a soiled wipe from CNA D placed the soilde wipe in a bag and used the same gloved hand to assist Resident # ___ while he stood and pivoted to the wheel chair. This deficient practice could affect 15 residents who received pericare on Unit II and could result in the spread of infections. The findings were: 1. Review of Resident # ___'s facesheet dated 5/31/2019, revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. 2. Observation on 5/31/2019 at 9:07 am with CNAs C and D revealed they provided incontinent care for Resident # ___. Resident # __ was soiled with feces and CNAs C and D did not change gloves prior to placing a clean brief and pant on the resident.

Based on observation, interview and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services for 3 of 3 residents (#31,38,42) reviewed for urinary catheters in that: 1. Resident #38's urinary catheter was not strapped to the leg to prevent pulling. 2. Resident #31's urinary catheter was not strapped to the leg to prevent pulling. 3. Resident #42's urinary catheter was not secured to prevent pulling, the urinary bag was on the floor of the restroom during a shower and the urinary catheter bag was positioned higher than the bladder during a transfer. This deficient practice could affect 4 residents who had urinary catheters and could result in trauma to the bladder or urinary tract infections. The findings were: 1. Review of Resident #31's face sheet, dated 5/8/18 with an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #31's Care Plan, dated 5/1/18 revealed risk of complications due to urinary tract infection as evidence by pain with repositioning with catheter with interventions which included catheter care every shift as needed and administer medications as ordered. Observation on 05/09/18 at 09:29 AM with LVN I during wound care revealed that Resident #38's suprapubic urinary catheter tubing was not secured in place to the leg to prevent pulling on the bladder. Interview on 5/9/18 at 9:45 am with LVN I confirmed that the suprapubic urinary catheter tubing was not secured in place. 2. Review of Resident #31's face sheet, dated 5/8/18 with an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #31's Care Plan revealed the resident was at risk for urinary tract infections and had a history of [REDACTED]. Observation on 05/09/18 at 09:15 AM revealed that Resident #31's urinary catheter tubing was not strapped in place to the leg to prevent pulling on the bladder. Interview on 5/9/18 at 9:18 am with CNA H and CNA J confirmed that resident #31 did not have his urinary catheter tubing secured to the leg to prevent pulling on the bladder. CNA J stated that only the nurses could place a strap on the resident for the urinary catheter. 3. Review of Resident #42's face sheet, dated 5/8/18 with an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #42's quarterly MDS dated [DATE] revealed a BIM's score of 11 which indicated that the resident was moderately cognitively impaired. Review of Resident #42's most current Care Plan revealed that the resident was at risk for a urinary tract infection due to indwelling catheter and catheter pulling on penis with interventions which included leg strap to leg. Observation of Resident #42 on 05/07/18 at 03:14 PM revealed that during a transfer from wheelchair to shower chair by CNA G, the urinary catheter bag was not secured in place to prevent pulling on the bladder. Further observation revealed that CNA G placed the urinary catheter bag on the hand rail of the sit to stand lift which rested at approximately upper chest/chin level with the resident. CNA G then placed the urinary catheter bag on the floor of the bathroom while Resident #42 was in the shower. Observation of Resident #42 on 5/7/18 at 3:49 pm revealed that during the transfer from shower chair to bed, CNA G placed the urinary catheter bag on a hook on the handrail of the sit to stand lift which rested above the bladder level of the resident. Further observation revealed that the [MEDICATION NAME] tubing was not secured in place to the leg to prevent pulling on the bladder. Interview with CNA G on 5/7/18 at 3:53 pm confirmed that the catheter had not been secured in place to the leg to prevent pulling on the catheter. CNA G further confirmed that she had placed the catheter bag on the floor of the bathroom and had positioned the urinary catheter bag at a level above resident #42's bladder. Interview with Resident #42 on 5/7/18 at 4:00 pm confirmed that the urinary catheter tubing was not secured in place to the leg. Resident #42 revealed that he had previously complained to staff that the catheter pulls on his penis and that he did not like that feeling. Observation of Resident #42 pm on 5/9/18 at 8:35 am with CNA G revealed that that the urinary catheter tubing was not strapped in place to the leg to prevent pulling on the bladder. Interview with CNA G on 5/9/18 8:38 am confirmed that the urinary catheter for Resident #42 was not strapped in place. Interview on 5/9/18 at 9:45 am with the DON revealed that urinary catheters should be secured in place by a leg strap, but that suprapubic catheters do not need to be secured because they go directly into the bladder. The interview further revealed that CNA's and licensed nurses may both secure a catheter in place to prevent pulling. Review of a facility policy dated 1/2008 titled Catheter Care for Supra Pubic Catheters revealed 7. Note: do not pull on catheter .and a facility policy titled Indwelling Catheter revealed 6. Secure urinary drainage bag below level of the bladder and keep off the floor. Coil extra tubing and secure. Information received from the facility indicated that there were 4 residents with urinary catheters.

Based on interviews and record reviews the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 3 of 13 (#3,#5,#4) residents reviewed for MDS assessments in that: The facility did not provide Residents #3, #5 and #4's Quarterly MDS for (MONTH) (YEAR). This failure could result in 13 residents that had (MONTH) (YEAR) MDS's and could result in decrease in care. Findings were: 1. Review of Resident #3's face sheet dated 5/10/18 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's most current MDS (minimum data set) was dated 1/5/18 and was a Annual. Further review of Resident #3's MDS's revealed a Quarterly was in progress,but not finalized. 2. Review of Resident #5's face sheet dated 5/10/18 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's most current MDS on 1/3/18 which was a Quarterly and on 4/5/18 a Quarterly MDS was documented in process. 3. Review of Resident #4's face sheet dated 5/10/18 revealed she was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4 most current Quarterly MDS was on 1/4/18 and Quarterly MDS dated [DATE] was documented in process. Interview on 05/10/18 at 09:42 AM with the MDS coordinator revealed she had been out sick and had not had the opportunity to complete the Quarterly MDS's that were due for Resident # 4, Resident # 14 and Resident # 3. Interview on 05/10/18 at 09:55 AM with the DON revealed after the MDS Coordinator completed the MDS's, the DON reviewed and signs, then sends the MDS's to be finalized. Further interview with the DON revealed she would be the one to complete the MDS's, if the regular MDS staff was not working. Interview with the DON revealed she missed the MDS's because she did not think the MDS coordinator would be out too long. Review of the Facility policy on MDS coordinator revealed they would assure the MDS/RAI and support documentation are accurate representations of the resident and meet regulatory and auditor expectations. Review of the information provided by the facility revealed 13 residents had MDS's that were due in (MONTH) (YEAR).