Every finding on record at Life Care Center of Plano

Based on interview and record review, the facility failed to ensure medical records were maintained on each resident that were complete and accurately documented for one (Resident #1) of four residents reviewed for medical records. LVN B, LVN C and LVN D failed to ensure Resident #1's clinical record accurately reflected the left arm was approximated with Steri-Strips (thin, sterile adhesive skin closure tapes) and monitoring for signs/symptoms of infection on four days (07/25/26, 07/26/26, 08/01/26 and 08/02/26). These failures could affect residents by placing them at risk for not receiving necessary care and services due to the interdisciplinary team not having an accurate record upon which to make care decisions. Findings included: Review of Resident #1's MDS assessment, dated 06/14/26, revealed the resident was an [AGE] year-old male with a most recent reentry date into the facility of 04/12/24. Review of Resident #1's care plan, dated 07/20/26, revealed a focus area of skin tear to left arm related to a shirt being put on and the resident has fragile skin. Interventions/tasks revealed observe for and report signs and symptoms of infection to MD to left arm skin tear. Review of Resident #1's August 2026 Physician's Orders revealed an active order dated 07/20/26 for left arm-skin well approximated with Steri-Strips clean and dry. Continue monitoring for signs/symptoms of infection until fully healed. Review of Resident #1's TAR for July 2026 and August 2026 revealed there were no initials to indicate the left arm was approximated with Steri-Strips, clean and dry. Continue to monitor for signs/symptoms of infection until fully healed on 07/25/26, 07/26/26, 08/01/26 and 08/02/26. Interview and record review of the TAR with the DON on 08/05/26 at 8:19 AM confirmed the TAR was not initialed or signed for Resident #1's Steri-Strips for 07/25/26, 07/26/26, 08/01/26 and 80/02/26. She stated the policy of the facility was for the nurses to initial the TAR when providing care. The DON stated that if the TAR did not have initials or signed then the assumption is care wasn't provided. The DON stated the risk of incomplete documentation could result in an inaccurate medical record. The DON stated the facility expectation was for all treatments to be completed as well as documented. Interview on 08/05/26 at 8:40 AM with the ADM revealed that all treatments should be documented to reflect an accurate record. The ADM stated that the risk of not documenting a treatment could result in an inaccurate record. Interview on 08/05/26 at 12:15 PM with LVN B revealed she had forgotten to sign the TAR on 08/01/26 for Resident #1's Steri-Strips, and it was an oversight on her part. LVN B stated she did the Steri-Strips and observation on that day. LVN B stated the facility expectation was once she did a treatment she was to sign/initial the TAR. LVN B stated that the risk of not documenting correctly could result in double treatment or a missed treatment. Interview on 08/05/26 at 12:24 PM with LVN C revealed she did not sign the TAR for Resident #1's Steri-Strips and observation on 07/25/26 and 07/26/26. LVN C stated she did provide Steri-Strips and observation on both days. LVN C stated she did not have a reason why she did not sign/initial the TAR. LVN C stated she was aware that she was supposed to sign/initial the TAR to document the treatment was completed. LVN C stated the risk of not documenting resulted in inaccurate records. Interview on 08/05/26 at 12:27 PM with LVN D revealed she did not sign the TAR for Resident #1 Steri-Strips and observation on 08/02/26. LVN D stated that the Steri-Strip treatment and observation was completed but it was an oversight that it wasn't documented. LVN B stated that the expectation was to document all treatments. LVN D stated the risk of not documenting accurately could result in a missed treatment. Review of the facility's policy titled Nursing Documentation, dated 08/29/25, revealed This facility will ensure nursing documentation is consistent with professional standards of practice, the state nurse practice act, and any state laws governing in scope of nursing practice.Medical Records.Staff must document a resident's medical and non-medical status when any positive or negative condition change occurs, at a periodic reassessment and during the annual comprehensive assessment. The medical record must also reflect the resident's condition and the care and services provided across all disciplines to ensure information is available to facilitate communication among the interdisciplinary team. The medical record must contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident progress, including his/her response to treatment and/or services, and changes in his/her condition, plan of care goals, objectives and/or interventions.

Based on observation, interviews, and record review the facility failed to ensure all drugs were only accessible by authorized personnel, 2 (C hall carts) of 2 medication carts reviewed for storage of medications.The facility failed to ensure RN A kept the two C hall medication carts secured and was unable to be accessed by unauthorized personnel or residents on 08/05/26.This failure could put residents at risk of medication theft or drug diversion.Findings included:Observation on 08/05/26 at 4:29 AM, revealed two medication carts for hall C were located at the nurse's station and observed unlocked for appropriately 10 minutes. Two unlicensed staff members (CNAs) passed by the unlocked medication carts. Observation of the medications carts revealed all the drawers were facing outward and were able to be opened. Observation and interview at 4:40 AM, RN A exited a resident's room from behind a closed door that was approximately twenty feet from the nursing station. RN A proceeded to the nursing station and locked both medication carts. RN A stated she had worked at the facility for five months and had been a nurse for several years. RN A stated she knew that a medication carts should be locked when left unattended. RN A stated that not locking the medication carts could cause a drug diversion if a visitor, resident, or unlicensed staff member entered the unlocked carts. Interview on 08/05/26 at 8:19 AM, the DON stated the medication carts should always be locked when unattended. The DON stated that the medication carts needed to be locked even if residents were in bed and not out in the hallways. The DON stated there was a risk of harm if a resident entered the cart, and consumed medications. She said there was a risk of drug diversion if visitors or unlicensed staff had access to medications. Interview on 08/05/26 at 8:40 AM, the Administrator stated it was the responsibility of the DON or her designee to train and in-service the nursing staff on medication storage. The Administrator said that the medication cart should be locked while not attended and the unopened cart could cause harm if the cart was accessed by a confused resident.Review of the facility's policy titled Storage and Expiration Dating of Medications and Biologicals, revision date 06/30/25 revealed .5. Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room and is inaccessible by residents and visitors.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services.The facility failed to discard expired bread from the main kitchen.The facility failed to ensure bread was properly labeled and dated.These failures could place residents who received meals and/or snacks from the kitchen at risk of food-borne illness and food contamination if consumed.An observation on 06/16/26 at 9:30 a.m. in the facility's only kitchen revealed two unlabeled trays that contained 10 loaves of bread each. One loaf of bread reflected a best if used by date of 06/11/26 and contained four slices of bread with green mold.An interview on 06/17/2026 at 10:05 a.m., the Dietary Manager revealed he was responsible for checking and labeling delivered food supplies and Cooks were responsible in his absence. He stated he was responsible for ensuring expired food was discarded. He stated expired food placed residents at risk of sickness, hospitalization, or death. He stated the best if used by date was not checked on bread, instead the tray that contained the loaves of bread was labeled.An interview on 06/17/2026 at 1:15 p.m., [NAME] I stated the trays that contained bread were checked and dated when received. She stated she checked the best if used by date on each loaf of bread to ensure it was not expired. She stated it was important to avoid putting residents at risk for getting sick.An interview on 06/17/2026 at 1:25 p.m., [NAME] J stated Cooks dated and checked food supplies delivered in the absence of the Dietary Manager. She stated the risks to residents who consumed undated and expired food were sickness and diarrhea.Record review of the Safe Food Handling policy dated 10/07/19, reflected, . Food Safety Requirements: Store, prepare, distribute and serve food in accordance with professional standards for food.Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.

Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for 2 of 4 shower rooms (Shower Room D and Shower Room E) reviewed for environment. The facility failed to ensure Shower Room D was clean, sanitized and free from personal items on 6/17/26. The facility failed to ensure Shower Room E was clean and free from dirty linen and trash on 6/17/26. These failures could place residents at risk of exposure to infectious diseases, other unsanitary health hazards and affect their sense of dignity.An observation and interview of Shower Room D and Shower Room E with the Maintenance Director on 6/17/26 at 12:06 pm revealed a resident's wheelchair with rehab boots in the shower with no resident present. Observation of the floor revealed about 10 splatters of brown droplets that the Maintenance Director identified as feces. The Maintenance Director stated it was the CNAs responsibility to clean up feces or bodily fluid in shower rooms after showering a resident. The Maintenance Director stated once the CNA cleaned up the bodily fluids the CNA should have called housekeeping to sanitize the area. The Maintenance Director stated there should not have been any resident's personal items in the shower room. Observation of Shower Room in E revealed a dirty towel bunched up on top of the sink and several dirty paper towels on the floor by the trashcan. The Maintenance Director stated the CNAs were responsible for cleaning up the used towels and trash after every use. The Maintenance Director stated housekeeping staff cleaned the shower rooms twice per day, but CNAs needed to maintain their cleanliness throughout the day, since they use them with residents. The Maintenance Director stated a dirty shower room could have affected residents' sense of dignity. An interview with Agency CNA G on 06/17/2026 at 1:47 p.m. revealed the expectation for shower room was CNAs were supposed to clean up shower rooms after they finish showering a resident. Agency CNA G stated if the resident had a bowel movement during the shower the CNAs were responsible for cleaning it up. Agency CNA G stated personal items should not have been left in the shower rooms. Agency CNA G stated dirty towels should have been put in the dirty linens after the residents' shower. Agency CNA G stated a dirty shower room could have put the next resident who showered at risk of falling or infection. An interview with CNA H on 06/17/2026 at 2:30 p.m. revealed it was her responsibility to make sure the shower room was left clean after a resident's shower. CNA H stated she was responsible for picking up the trash and dirty linens and putting them in the barrels. CNA H stated if the resident had a bowel movement she would clean it up and then would have asked housekeeping to disinfect the shower room. CNA H stated resident's personal items like wheelchairs and rehab stuff should have been removed from the shower room after they were finished showering the resident. CNA G stated if a shower room was not cleaned after each resident, when a resident was brought to the shower room, they would have been at risk of getting sick or contracting diseases from the previous resident. An interview with the DON on 06/17/2026 at 2:51 p.m. revealed the expectation for splattered feces in a shower room was the CNA who showered the resident should have told the housekeeper they showered and needed cleaning. The DON stated CNAs were responsible for generally cleaning the shower rooms after every resident shower and if there were bodily fluids they needed to notify housekeeping so they could sanitize the shower room. The DON stated there should not have been any resident personal items left in the shower rooms after the CNAs were done with the shower. The DON stated there should not have been any dirty towels or trash left in shower rooms after showers. The DON stated the risk to the residents of having dirty shower rooms was infection. An interview with the Administrator on 06/18/2026 at 1:35 p.m. revealed the expectation was there should not have been any personal equipment kept in the shower rooms and CNAs should have been cleaning the shower rooms after each use. The Administrator stated housekeeping staff were responsible for cleaning the shower rooms at least once per day and as needed. The Administrator stated the dirty showers affected the residents in that it would not have been a homelike environment for them. Record review of the facility's policy Plant Operations - General Policy reviewed 4/1/26 reflected A safe, clean, and structurally sound environment shall be achieved in the facility through the development and implementation of the Plant Operations Program, the development and training of personnel, and the evaluation of goals in the department to assure correlation with the goals of the facility.

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (medication cart hall C ) of 3 medication carts reviewed for pharmacy services and reviewed for storage in that: The facility failed to ensure one vial of TB serum (used to test if you have a tuberculosis germs in the body) that was opened and used was in the refrigerator and was dated on 6/16/26. This failure could affect residents and staff resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications.Observation on 06/16/2026 at 12:01 p.m. of medication cart hall C with LVN D revealed a vial of TB PPD (purified protein derivative) serum was opened, had been used and was not dated and it was not in the refrigerator. An interview on 06/16/26 at 12:08 p.m., LVN D stated the TB PPD vial was open and was not dated or initialed. She stated the vial should have been in the refrigerator and should have been dated. She stated the risk, when given to staff or residents, would have been the wrong reading. She stated the nurse was responsible for checking the vial for the open date before use it. An interview on 06/18/26 at 12:30 p.m., the DON stated the TB PPD vial should have been refrigerated. She stated the staff who opened the TB PPD vials should write the open date and the initials. She stated the risk would have been ineffective medication and the wrong reading. She stated all nurses were responsible for checking the medication carts and the medication room for expiration and labeling of medication. The DON stated ADONs and the DON would check routinely the mediation carts and medication rooms for monitoring. Record review of the facility's policy Storage and Expiration Dating of Medications and Biologicals revised 06/30/25, reflected the following: .If multidose vial of an infectable medication has been opened or accessed ., the vial should be dated and discarded within 28 days unless the manufacturer specifies a different date for that open vial.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 resident (Resident #25) of 8 residents observed for infection control. The facility failed to ensure CNA E and CNA F changed gloves and performed hand hygiene during incontinent care for Resident #25 on 06/16/2026. These failures could place the residents at risk of cross-contamination and development of infection.Record review of Resident #25's Quarterly MDS assessment dated [DATE] reflected Resident #25 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Parkinson's disease (a progressive neurological disorder where the brain cells that produce dopamine die, leading to worsening movement issues and non-motor symptoms like tremors, stiffness, and depression), muscle weakness, and dementia (a decline in mental abilities such as memory, thinking, and reasoning, severe enough to interfere with daily life). Resident #25's BIMS score of 15, which indicated Resident #25's cognition was intact. The MDS assessment indicated Resident #25 was frequently incontinent of urine and required moderate assistance with toileting hygiene. An observation on 06/16/26 at 2:03 PM revealed CNA E and CNA F entered Resident #25's room to provide incontinence care. Both CNAs washed their hands and donned gloves. CNA E unfastened Resident #25's brief, she then provided peri-care to the resident, wiping across the resident's pubis bone and then down each groin. She changed her gloves without performing any kind of hand hygiene. She rolled the resident on his side. CNA F held Resident #25 on his side. CNA E wiped the resident's buttock area with peri-wipes, front to back, she then removed the soiled brief and discarded it. She changed her gloves without performing any kind of hand hygiene and placed the clean brief under the resident. She applied the skin barrier cream to the resident's buttocks, she then removed her gloves, washed her hands and donned clean gloves. CNA F rolled the resident on his back onto the clean brief and fastened the brief. She changed her gloves without performing any kind of hand hygiene. Both CNAs assisted Resident #25 with dressing. Once finished, both CNAs removed and discarded their gloves and washed their hands. An interview with CNA E and CNA F on 06/16/26 at 2:18 PM, CNA E stated she should have changed her gloves and performed hand hygiene when she went from dirty to clean. CNA E stated failing to provide proper care exposed the residents to infections. CNA F stated she thought since CNA E cleaned the resident she had not need to perform hand hygiene between change of gloves. An interview on 06/18/26 at 12:35 p.m., the DON stated she expected the staff to remove their gloves and sanitize their hands when going from dirty to clean. She stated CNAs were trained to change gloves and perform hand hygiene when going from dirty to clean. She stated failure to do so would potentially lead to cross-contamination and possible spread of infection. She stated the ADONs would do random rounds for monitoring. Record review of the facility's policy titled, Hand Hygiene, reviewed 6/1/26, reflected, . Associates perform hand hygiene in the following situations. After removing personal protective equipment (. gloves, gowns, masks) .

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1(Resident #25) of 4 residents reviewed for incontinent care. The facility staff failed to ensure Resident #25 was provided timely incontinent care on 6/16/26. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown.Record review of Resident #25's face sheet dated 6/16/26 reflected a [AGE] year-old male admitted on [DATE]. Resident #25 had the following pertinent diagnoses: Parkinson's Disease (a progressive brain disorder that primarily affects movement), muscle weakness, dementia (a decline in mental abilities that is severe enough to interfere with daily life), and wedge compression fracture of the spine. Record review of resident #25's Quarterly MDS assessment, dated 03/16/26, reflected his cognition was intact with a BIMS score of 15. Resident #25 was frequently incontinent of urine and bowel. Resident #25 required set up or clean up assistance for toileting hygiene. Review of Resident #25's care plan, initiated 1/14/26, reflected . The resident has ADL self-careperformance deficit r/t Activity Intolerance, Impaired balance Date Initiated: 01/14/2026 TOILET USE: The resident requires assistance by (1) staff for toileting transfer and adjusting clothing Date Initiated: 01/14/2026. Record review of Resident #25's Bowel and Bladder Elimination task generated on 06/16/26 at 11:44 a.m. reflected Resident #25 had been changed one time on 06/16/26 at 2:08am. An interview and observation of Resident #25 on 06/16/2026 at 10:42 a.m. revealed he had pajama pants on, but his crotch area was puffed out and tight. Resident #25 stated he had been waiting for an aide to change him for about an hour. Surveyor asked him to press the call light button and surveyor walked to the hall and noted the call light was on. Surveyor exited the room and stood in the hall next to Resident #25's door. At 10:45am the ADON entered Resident #25's room and asked what he needed. The ADON then exited Resident #25's room and saw an aide at the end of the hall and asked if she was covering Resident #25's room and the ADON stated he needs to be changed and proceeded to walk away from Resident #25's room. It was noted the ADON turned off the call light. The ADON proceeded to respond to a call light a few doors down from Resident #25. The ADON then exited the second room and left the hall. At 11:05 am the ADON entered Resident #25's room again, did not change him and left. The ADON was observed walking to all the rooms in the hallway checking on residents. At 11:09 am the assigned CNA entered Resident #25's room and dropped off a package of incontinent briefs and walked right out. Surveyor then entered Resident #25's room again and Resident #25 confirmed he still had not been changed. At 11:17 am the ADON walking up and down the hall. An interview and observation with the ADON on 06/16/2026 at 11:18 a.m. revealed she had answered Resident #25's call light and the resident had told her he needed to be changed. The ADON stated she was going to tell his assigned CNA to change the resident. The ADON stated any nurse, or CNA could have changed Resident #25. The ADON stated she could have changed the resident, but he required two people to change him. The ADON stated when staff answered the call light they could turn it off once they knew what the resident needed and had not needed to wait to turn off the call light until the task was completed. The ADON stated the expectation was the resident should have been changed 2 hours and as needed. The ADON stated it was the responsibility of any clinician in the hall to change the residents. The ADON stated the risk to the resident of untimely incontinent care was infection. The ADON stated she would look for someone to change him immediately. Observation on 06/16/2026 at 11:22 a.m. revealed the ADON had gotten the necessary items to provide incontinent care. At 11:23 am the ADON walked into Resident #25's room by herself with the supplies and exited the room. At 11:25 am the ADON got a male CNA and told him Let's go change [Resident #25] they then entered the room together. An interview with CNA E on 06/16/2026 at 12:40 p.m. revealed she was assigned to Resident #25. CNA E stated her shift was from 6:00 am to 2:00 pm. CNA E stated when she arrived on shift the first thing she had done was change the residents. CNA E stated she changed Resident #25 at about 6am. CNA E stated after that she had not changed him until about 30 minutes ago. CNA E stated the ADON had not told her Resident #25 needed to be changed today at any time. CNA E stated Resident #25 always called when he needed to be changed. CNA E stated if a resident was not changed timely, he could have gotten sores, redness or a UTI. CNA E stated Resident #25 was a one person assist and she provided incontinent care by herself. Resident #25 was a one-person assist. Observation of Resident #25's incontinent care by Nurse Surveyor on 06/16/2026 at 1:16 p.m. revealed no concerns with rash or sores in the perineal or buttock area. An interview with the DON on 06/17/2026 at 2:47 p.m. revealed any staff could answer a call light and the call light should stay on until the resident's needs were met. The DON stated if the staff answered the call light and could not meet the Resident's need, they should have left the call light on and found someone who could assist the resident. The DON stated her expectation was incontinent care should have been completed as soon as possible The DON stated the ADON should have been able to change Resident #25 because she was a nurse. The DON stated the resident could have been affected by untimely incontinent care by making them feel bad for not being changed and he could put the resident at risk for skin breakdown. An interview with the Administrator on 06/18/2026 at 1:40 p.m. revealed the expectation was call lights should have stayed on until the issue was resolved. The Administrator stated he had even answered call lights, and he had noted at times the call light was left on even when there was staff already in the room. It would affect the residents in that it would have been uncomfortable to sit in a dirty brief for a long time. Record review of the facility's policy Urinary Incontinence Management revised 1/20/26 reflected Each resident who is incontinent of urine is identified, assessed and provided appropriate treatment and service to achieve or maintain as much normal bladder function as possible.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #8) of 3 residents reviewed for incontinent care. The facility failed to ensure CNA A and LVN B maintained the foley catheter drainage bag below Resident #8's bladder during a mechanical lift transfer on 06/16/2026. This failure could place residents at risk for the development and/or worsening of urinary tract infections and dislodgement of the foley catheter.Record review of Resident #8's Comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included pressure ulcer (localized skin and tissue wounds caused by prolonged, unrelieved pressure, friction, or shear) of sacral region and retention of urine (the inability to completely empty the bladder or inability to urinate at all). He had a BIMS of 1 which indicated she was cognitively intact. He required extensive total assistance with transfer, and he had a foley catheter. Record review of the Resident #8's care plan initiated on 03/30/26 reflected, Has an indwelling catheter related to pressure ulcer Observe for and report to MD (medical doctor) for sign and symptoms of UTI (Urinary tract infection) . An observation on 06/16/26 at 10:31 a.m. revealed CNA A and LVN B entered Resident #8's room to transfer Resident from wheelchair to bed. CNA A unhooked the catheter bag from the wheelchair side and placed it on the resident lap, above resident's bladder. LVN B raised the resident from the wheelchair. Urine was observed flowing back toward the resident's bladder. LVN B then positioned Resident's over his bed and lowered him into his bed. CNA A removed the foley catheter bag from the resident's lap and placed it flat on the bed. LVN B instructed CNA A to place the foley catheter bag onto the side of the bed. An interview with CNA A and LVN B on 06/16/26 at 10:53 a.m., CNA A stated he was trained to make sure the catheter bag was always in a privacy bag, make sure the tubing was not kinked and make sure they emptied the drainage bag each shift. The CNA was not sure where the catheter bag should have been positioned during the transfer. He stated having it above the bladder could possibility cause the urine to run backwards, which could cause an infection. LVN B stated they should have held the drainage bag below the resident bladder level while they transferred him. She stated failing to do this could cause the urine to back up and might cause an infection. An interview with the DON on 06/18/26 at 12:30 p.m., she stated not keeping the foley catheter bag below the resident's bladder, placed them at risk of a urinary tract infection and cross contamination. She stated she would provide training to nursing staff on positioning the drainage bag during transfers. Record review of the facility's policy titled, Indwelling Urinary Catheter Management reviewed 9/4/2025 reflected, . Keep the collecting bag below the level of the bladder at all times.

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for comprehensive care plans.The facility failed to ensure Resident #1's preferences related to television channels and volume; room temperature and bed position were included in his care plan. This failure could place residents at risk of their preferences not being honored and feeling uncomfortable in the facility. Record review of Resident #1's comprehensive care plan, revised on 12/19/25, reflected . [Resident #1] has an ADL self-care performance deficit r/t Activity Intolerance, Dementia (a decline in mental ability) Date Initiated: 07/15/2024 Revision on: 12/19/2025 [Resident #1] will maintain current level of function in (ADLs) through the review date. Date Initiated: 07/15/2024 Revision on: 03/03/2026 Target Date: 01/12/2026 Assist resident to bed Daily after lunch (between 1-2pm) Date Initiated: 07/15/2024 LVN to provide nail care as indicated Date Initiated: 03/10/2026 Provide meal trays for all three meals. (even when family brings outside food for the resident) Date Initiated: 07/15/2024 Turn off lights and television at bedtime. Date Initiated: 08/09/2024.[Resident #1] is dependent on staff formeeting his cognitive stimulation needs, social needs. Date Initiated: 06/02/2021.The resident's preferred activities are: watching television, having visits by his family/sitter and ice cream snacks. Date Initiated: 07/09/2024 Revision on: 01/13/2025.[Resident #1] has an ADL self-care performance deficit r/t Activity Intolerance, Dementia Date Initiated: 07/15/2024 Revision on: 12/19/202 Resident #1 will maintain current level of function in (ADLS) through the review date.Date Initiated: 07/15/2024 Revision on: 03/03/2026 Target Date: 01/12/2026.Bed Mobility: Ensure feet are not touching foot board when in bed Date Initiated: 07/15/2024 Revision on: 07/15/2024 Bed Mobility: The resident is totally dependent on 1-2 staff for repositioning and turning in bed (2-4 hours) and as necessary Date Initiated: 07/15/2024. Resident #1's care plan had not included his preferences for his television to be on channel 54 or 55 and the volume at 30, the air conditioner to be set at 71 or 72 and his head to always be raised. Record review of Resident #1's Quarterly MDS assessment, dated 3/16/26, reflected the resident was rarely understood and therefore his cognition was not assessed. The resident was totally dependent on others for all self-care needs.Record review of Resident #1's face sheet, dated 4/9/26, reflected an [AGE] year-old male with an admission date of 10/2/22. The resident had the following active diagnoses: muscle weakness, vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving brain cells of oxygen and nutrients), peripheral vascular disease (a progressive circulation disorder involving damage to blood vessels), gastroparesis (a chronic disorder where stomach muscles work poorly slowing or stopping the movement of food), generalized anxiety disorder (a condition characterized by excessive, uncontrollable and persistent worry) and dysphagia (difficulty swallowing). An observation of Resident #1 room on 4/9/26 at 11:20 AM revealed several posters in the room with statements of Resident #1's preferences. Poster #1 reflected Always elevate head. Poster #2 reflected Turn on TV if awake on channel 54 or 55 and volume level at 30. Poster #3 reflected Please keep temperature at 71/72, heat when cold outside and cool when hot outside. Surveyor attempted to interview Resident #1 but he was unable to respond to questions. An interview with CNA A on 4/9/26 at 1:18 PM revealed she assisted the CNA with but was not his regular CNA. CNA A stated Resident #1's family had a lot of preferences and there were a lot of notes in the room that told them Resident #1's preferences.An interview with CNA B on 4/9/26 at 1:27 PM revealed she worked with Resident #1 daily and was familiar with his preferences. CNA B stated Resident #1 wanted his TV on, all the time, but should be muted when asleep, which included at night. CNA B stated Resident #1's head should have been up all the time except when they cleaned him up or took care of him. CNA B stated Resident #1 had to always have his head up because he would throw up. The CNA stated Resident #1's air conditioner should not be up but could not explain the right temperature. CNA B stated she had no access to Resident #1's care plan. An interview with LVN C on 4/9/26 at 1:41 PM revealed she would determine a non-verbal resident's preferences based on the family's request. LVN C stated there was no specific plan in the residents' medical record that list resident's preferences and did not look at Resident #1's care plan. LVN C was unable to state the importance of listing the residence preferences in the care plan because she stated she had not completed any portion of the care plan and had not looked at the care plan. An interview with Agency LVN D on 4/9/26 at 2:02 PM revealed it was her fist time working with Resident #1 and she stated she learned about his preferences when the previous nurse gave her report at the end of her shift. Agency LVN D stated she was told Resident #1 did not like to be woken before 8 and was assisted feed. Agency LVN D stated those were the only two things provided during report from the previous nurse, however Resident #1 had a bunch of signs on his walls in his room that would tell her what he liked. Agency LVN D stated if the signs were not there she would not have known about his preferences and would have expected the previous nurse to provide that information during report. Agency LVN D stated she had never looked at a resident's care plan. An interview with Resident #1's relative on 4/9/26 at 2:30pm revealed she had put the posters up with Resident #1's preferences for his bed, the air conditioner and the TV. The relative stated she was tired of reminding the staff what Resident #1 liked. The relative stated she had expressed these preferences to staff several times and had finally decided to put posters up so all staff would be on the same page with Resident #1's care. The relative was unable to state when she had put the posters up but stated it was in the last couple of weeks. An interview with MDS Nurse Coordinator E on 4/9/26 at 3:55 PM revealed she was familiar with Resident #1 but had not completed his care plan. MDS Nurse Coordinator E stated she had seen all the posters in Resident #1's room with his preferences and believed those should have been on his care plan. MDS Nurse Coordinator E stated she was unsure of how long the signs had been up, but as soon as a nurse or staff had seen them they should have notified the MDS Nurse Coordinators. MDS Nurse Coordinator E reviewed Resident #1's care plan and stated he did not have anything listed for the temperature of his room, his head needing to be elevated or anything about his preference for TV channels and volume level. MDS Nurse Coordinator E stated these preferences should have been added to the Care Plan immediately, as soon as staff were made aware of them. MDS Nurse Coordinator stated it was the responsibility of MDS Nurse Coordinator F to update Resident #1's preferences in his care plan. MDS Nurse Coordinator E stated the purpose of care plans was to inform the resident plan of care while at the facility. MDS Nurse Coordinator E stated nurses had access to the care plans in the event they were unsure of the residents' care. MDS Nurse Coordinator E stated the risk to the residents of their preferences not listed on the care plan would have been an effect on their comfort and safety at the facility. An interview with the DON on 4/9/26 at 4:13 PM revealed the expectation was all preferences stated by residents or their representatives should have been listed on the care plan. The DON stated all of Resident #1's preferences on the posters on his walls should have been listed on his care plan. The DON stated it was the responsibility of everyone (nurses, DON, and ADON) to update residents' preferences in their care plans. The DON stated if a resident's preferences were not listed in the Care Plan, then the care plan was considered incomplete and the resident could miss out on special care he required. An interview with the Administrator on 4/9/26 at 4:34 PM revealed preferences the resident or representative had should have been listed in the resident's care plan. The Administrator stated if the preferences were not in the care plan it could affect the comfort of the resident and the facility providing a home-like environment for them. The Administrator stated it was the responsibility of the MDS coordinators to update resident preferences in the care plan.An interview with MDS Nurse Coordinator F on 4/9/26 at 4:59 PM revealed she completed Resident #1's care plan. MDS Nurse Coordinator F stated she was aware of all the posters in Resident #1's room but had not paid attention to what they stated. MDS Nurse Coordinator F stated any preferences Resident #1 had should have been included in his care plan, however she stated no one told her to add the preferences he had on the wall to the care plan. MDS Coordinator F stated care plans should have been individualized and therefore if preferences were not included in the care plan, then the plan was not individualized and could affect the wellbeing of the resident. MDS Nurse Coordinator F stated preferences should have been updated as soon as the staff were made aware of them. A record review of the facility's policy Person Centered Care Planning, revised 8/29/25, reflected .Each resident will have a person-centered comprehensive care plan developed and implementedto meet his or her preferences and goals, and address the resident's medical, physical, mental andpsychosocial needs.

Based on interview and record review, the facility failed to ensure their activity program was directed by a qualified professional for 1 of 1 staff reviewed for activity professional qualifications. The facility failed to ensure the activities at the facility were directed by a qualified professional who was a qualified therapeutic recreation specialist or an activity professional. This failure could place residents at risk of not receiving an effective activities program developed and implemented for their physical and mental well-being. Findings included: Record review of the staff list provided by the facility revealed the Activity Director was hired 08/24/2024. During an interview on 01/13/2026 at 2:44 p.m., the Activity Director stated she had started doing activities on 10/18/2025. When asked to see her certificate, she stated she did not have it yet and the previous administrator agreed to pay for the certification, but they hadn't gotten that far yet. When asked what the risk was to the residents for her not being certified, she stated she did not have an answer for that. During an interview on 01/13/2026 at 3:11 p.m., the Administrator stated he just learned the Activity Director was not certified and would immediately get her enrolled in the class. He stated the risk to the residents was she might not be able to identify if residents were isolating themselves or secluded and how to deal with that. Record review of the policy Therapeutic Activities Program, dated 09/26/2025 revealed, The facility activities program will be directed by a qualified activities director. The director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. The activities program must be directed by a qualified professional who is a qualified therapeuticrecreation specialist or an activities professional who-(i) Is licensed or registered, if applicable, by the State in which practicing; and(ii) Is:(A) Eligible for certification as a therapeutic recreation specialist or as an activitiesprofessional by a recognized accrediting body on or after October 1, 1990; or(B) Has 2 years of experience in a social or recreational program within the last 5years, one of which was full-time in a therapeutic activities program; or(C) Is a qualified occupational therapist or occupational therapy assistant; or(D) Has completed a training course approved by the State.

49427 Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #329) of 5 residents reviewed for accidents and hazards. The facility failed to ensure Resident #329 was missing from the facility for approximately 1.5 hours without any staff being aware until notified by the apartment complex staff. Resident crossed a parking lot and service road to get to the apartment complex. Review of [NAME] maps ( [NAME] Maps to Apartment Complex, [NAME], TX 75075) revealed the apartment complex was about 500 feet from the facility. The noncompliance was identified as Past Noncompliance (PNC) Immediate Jeopardy on 04/24/25. The noncompliance began on 03/18/25 and ended on 03/31/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of elopements, falls, injuries, hospitalization and/or death. Findings included: Record Review of Resident #329's Discharge MDS, dated [DATE], reflected he was an [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE] to another facility. He had the diagnoses of metabolic encephalopathy (brain dysfunction caused by a metabolic disorder), chronic kidney disease, and he had a memory problem with inattention behaviors that came and went. Record review of Resident #329's Admission assessment dated [DATE] reflected he was able to make himself understood and was orientated to person, place, and time. Record review of Resident #329's Elopement Risk Evaluation, dated 03/07/25 reflected resident was not at risk of elopement. He did not have a history of elopement, did not wander, and did not verbally express that he wanted to leave the facility. Record review of Resident #329's care plan reflected he was at risk for elopement and had an actual elopement, dated 03/18/25. Interventions included add resident to elopement book, frequent one on one monitoring until discharge to a secure unit, provide for safe wandering and activities to divert from exit seeking. He was at risk for falls and required assistance with activities of daily living and interventions included to assist with mobility and activity of daily living care. Record review of Resident #329's nurse progress note, dated 03/18/25 at 6 PM by LVN M revealed Resident #329 had eloped and was brought back to the facility by staff and was assessed with no injuries or signs of discomfort. Resident #329 was moved rooms, placed on one-on-one supervision, 15-minute checks, and the Administrator, unit manager, physician, and family were notified. Further review revealed a progress note dated 03/19/25 at 10 PM by LVN M revealed Resident #329 had remained on one-on-one supervision until he was discharged to another facility. Record review of the Provider Investigation Report (PIR), dated 03/25/25, reflected an incident report, dated 03/18/25 by LVN G. Resident #329 had left the facility around 2:30 PM and was returned by the Maintenance Director at 4 PM. Staff were in-serviced on resident elopements and abuse and neglect dated 03/18/25 and included the Receptionist and LVN M. Resident #329 was assessed and showed no distress and had no injuries. He was moved to a room within eyesight of nurses' station, placed on one-on-one monitoring until discharged on [DATE] at 6:20 PM. The facility notified the physician and resident representative. Further review of PIR reflected an employee education form, dated 03/26/25, for the Receptionist with training that included the elopement policy, patient identification binder, reviewing the updated daily census, online training on elopements and reviewing and putting pictures of new residents who are at risk in the patient binder. Record review of Resident #329's elopement assessment, dated 03/18/25, completed by LVN M, reflected Resident #329 had left the building around 3 pm and was brought back to the facility by staff. Resident #329 had no injuries, distress, or discomfort noted with stable vital signs, and he was unable to describe what had happened. Notifications were made the physician, responsible party, and Administrator on 03/18/25. Record review of in-service, dated 03/18/25, by RN G, titled Missing Residents/Actual Development Event, reflected that all staff on all shifts had been in-serviced including LVN M and the Receptionist. Record review of the police incident report dated, 03/18/25 at 3:40 PM, reflected Law Enforcement Officer responded to a welfare concern regarding an elderly man who had entered an apartment complex for low-income seniors and was asking for assistance. The Law Enforcement Officer arrived and spoke to Resident #329, whose clothes appeared well maintained and clean and Resident #329 did not make sense when talking and stated that he had taken a bus from another city and was trying to get to another city. The apartment complex had reached out to the facility and was able to determine that he was a resident at the facility and when the Maintenance Director came to pick up Resident #329 he told the Law Enforcement Officer that he was not sure how the resident left the facility and all doors were locked and had passcodes to open the door. The Law Enforcement Officer reported the incident to Adult Protective Services. Record review of the facility's Logbook Report, dated generated on 04/09/25, of elopement drills for the past 12 months reflected the task name of: Emergency Preparedness Drills: Conduct Elopement drill (Missing Resident Drill) reflected the following due dates: 06/30/24, 09/30/24, 12/31/24, 03/31/25. Record review of the facility's Logbook Documentation for task: Conduct Elopement drill (Missing Resident Drill) for the past 6 months reflected: Start dated 06/26/24 at 1 PM, ended at 1:15 PM (6 AM- 2 PM Shift) and marked done on time by the Maintenance Director on 06/26/25. Start dated 09/17/24 at 9:30 AM, ended at 10:30 AM (6 AM- 2 PM Shift) and marked done on time by the Maintenance Director on 10/07/24. Start dated 12/31/24 at 11 AM, ended at 12 PM (6 AM-2 PM Shift) and marked done on time by the Maintenance Director on 12/31/24. Start dated 03/18/25 at 3:55 PM, ended at 4:10 PM (2 PM-10 PM Shift) and marked done on time by the Maintenance Director on 03/31/25. Interview on 04/07/25 at 12:34 PM with Law Enforcement Officer revealed on 03/18/25 in the afternoon he was called to an apartment complex around the corner from the facility because Resident #329 had wandered from the facility to a nearby apartment complex. He stated that the apartment complex called the facility to ask if Resident #329 was their resident after about 30 minutes and it was uncertain what time the resident had eloped from the facility. He stated that the resident did not seem to have any psychosocial harm or physical injuries, he was confused, and a staff member came and took Resident #329 back to the facility. Interview on 04/09/25 at 9:26 AM with the Receptionist revealed she did not realize Resident #329 was a resident at the facility when she unlocked the front door when another visitor was leaving the facility. She stated he exited behind the visitor around 2:30 PM. She stated she realized Resident #329 was a resident when he returned with the Maintenance Director. She stated she had been in-serviced on elopements, participated in elopement drills, and now updated the elopement book each day. Observation of elopement book with the Receptionist revealed it was updated to include face sheets with pictures of residents at risk of elopement. In an interview on 04/09/25 at 2:59 PM CNA N said she used to work with Resident #329 and was not working the day he eloped. She stated that Resident #329 walked around the facility but did not exit seek or show any signs of wandering before the elopement. She stated if she had seen any signs of exit seeking, she would have notified the nurse. She stated that she kept a list of residents at risk of elopement in her pocket and the facility conducted elopement drills. She stated that she had been in-serviced on elopements after the incident. In an interview on 04/10/25 at 8:59 AM LVN M said he noticed during his shift rounds around 3 PM that Resident #329 was not in his room and thought Resident #329 was in therapy and did not check. He stated he learned the resident had left the facility when he was brought back by the Maintenance Director. He stated that he assessed Resident #329 when he returned, and he had no injuries and did not appear upset. He stated that he had participated in past elopement drills and had been in-serviced on elopements after the incident. He stated that staff were updated on any residents who were elopement risks during morning meetings and shift change, and there was an elopement book at the nurses' station with residents who were at risk of elopement. He stated in the future he would find where the resident was and ensure they were in therapy rather than assume. He stated it was important to prevent elopements because a resident could be harmed if they left the facility without supervision. In an interview on 04/10/25 at 10:07 AM RN G said elopement drills were conducted by her and the Maintenance Director every 3 months. She stated that she was working when the resident came back to the facility, and he did not seem upset and had no injuries. She stated she conducted the elopement and abuse and neglect in-services with staff and notified the physician and the family. She stated Resident #329's room was moved in between both nurses' stations and he was on one-on-one supervision until he discharged to another facility. In an interview on 04/10/25 at 2:50 PM the Administrator said Resident #329 did not display any exit seeking or wandering behavior before the incident and was placed on one to one supervision until he was discharged to a facility with a secure unit. He stated that the Receptionist did not realize Resident #329 was a resident at the facility when he had exited along with a visitor of the facility. He stated that staff were immediately in-serviced on elopements and included the Receptionist who was also provided additional education. He stated that Resident #329 had no injuries and did not seem upset. He stated it was important to ensure residents did not elope from the facility to ensure residents are kept safe. In an interview on 04/10/25 at 3:27 PM the Maintenance Director said he was the employee that picked up Resident #329 from the apartment complex next-door to the facility that was separated from the facility with a grass median. He stated that the resident did not appear upset or injured. He stated that he and RN G conducted the elopement drills every 3 months and that there are elopement books at the receptionist and nurse's stations that identify the residents at risk of elopement. He stated that they conducted an elopement drill after the resident had eloped and staff were in-serviced on elopements and abuse and neglect. He stated that it was important to ensure residents did not elope because they could get lost, get hit by a car, or be seriously injured or die. In interviews covering all three shifts (6 AM- 2PM, 2 PM-10 PM, and 10 PM- 6 AM), the following staff said they had been in-serviced ( 03/18/25 -03/19/25) after the elopement on 03/18/25 on preventing and responding to elopements, participated in past elopement drills, knew the alert code for an eloped resident, were aware of where to find the elopement book at the nurses' station and carried a list of residents who were at risk of elopement: 04/08/25 from 1:20 PM to 1:46 PM with LVN C, CNA Q, and MA R 04/09/25 from 1 PM- 5 PM with 2 LVNs (LVN E & T), 7 CNAs (CNA S, D, Q, N, V, W, X), 2 Unit Managers (Unit Manager U & AA) 04/10/25 from 9:55 AM- 11:10 AM with the Restorative Aide I, the Treatment Nurse, and RN G Review of inservices sign in sheets dated 03/18/25 and 03/19/25 revealed staff were inserviced on elopement on 03/18/25 and 03/19/25. Record review of the facility's elopement policy, titled Area of Focus: Elopement, dated reviewed 11/19/24, reflected . Elopement occurs when a resident leaves the premises or a safe area without authorization . and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle . Residents will be assessed for unsafe wandering and elopement indicators upon admission, readmission, change in condition, quarterly and with any unsafe wandering or elopement event utilizing the Elopement Risk Evaluation UDA (Universal Design for Assessment) in PCC (Point Click Care ) (an electronic medical health record program) . Elopement drills will be conducted at least quarterly . Record review of the facility's policy for elopement prevention, titled Unsafe Wandering and Elopement Prevention, revised 03/04/25, reflected The facility will ensure that residents are assessed to determine risk for elopement in accordance with current standards of practice and implement interventions as appropriate to mitigate the risks identified . Record review of the facility's policy for an actual elopement, titled Missing Residents/Actual Elopement Event, dated reviewed 04/03/25 reflected .It is the responsibility of all associated to report any resident who is suspected of being missing to the nurse manager immediately . 11. When the resident is found, the charge nurse or designee will assess the resident's physical, mental, emotional, and cognitive state and notify the physician and responsible party. The resident will be monitored as deemed necessary by the interdisciplinary team . 12. An incident (event) report will be completed by the charge nurse or designee to include witness statements .13. The Executive Director or designee will report the event to all appropriate agencies as well as the regional and divisional team . The Administrator and DON were notified of PNC IJ on 04/24/25 at 3:32 PM and PNC IJ template was provided to the facility at this time. In an interview on 04/24/25 at 11:27 AM the Maintenance Director said on 03/18/25 the Administrator texted him to inform him about Resident #329 had eloped and he needed to go pick him up. He stated he went at 3:55 PM on 03/18/25 with a wheelchair and the Housekeeping Supervisor assisted him to go pick up Resident #329. He stated Resident #329 was wearing a t-shirt and sweatpants but could not recall if he had shoes on. He stated Resident #329 was confused stating he had come from another city. He stated he considered this incident an elopement drill but did not do an elopement drill like he usually did where the staff had to find a resident who was missing and implement code yellow which was missing resident. He stated he just discussed with staff to ensure they are aware of where their residents are. He stated he did check all the doors ensuring they were alarming and working properly. He had no issues with any of the doors on 03/18/25. He stated he did not complete his usual elopement drill which was done quarterly until later in December 2024. In an interview on 04/24/25 at 11:50 AM the Housekeeping Supervisor said she went with Maintenance Director to go get Resident #329 who had been found at a neighboring apartment complex. She stated the apartment complex was separated by a grass median in front of the facility, so they walked there to get him taking the wheelchair with them and they pushed him in the wheelchair back to the facility. She stated Resident #329 had on a t-shirt, sweatpants and shoes. She stated Resident #329 was confused but did not have any visible injuries. She stated it took about 15 minutes for them to get Resident #329 and bring him back in the wheelchair. She stated they brought him back to the facility about a few minutes after 4 pm. She stated she was in-serviced on missing residents and elopement protocol. She was knowledgeable of facility's policy and what to do if a resident reported missing. In an interview on 04/24/25 at 12:02 PM RN G said she was notified Resident #329 had eloped out of the facility by the Administrator. She stated she went to the floor a few minutes past 4 pm. She stated she and charge nurse went to assess Resident #329. She stated Resident #329 had no signs of heat exhaustion. Resident #329 was confused and could not remember leaving the facility. She stated vital signs were within normal limits and there were no injuries. She stated she assisted the charge nurse and ensured Resident #329 was safe. She stated she notified the physician and responsible party for Resident #329. She stated the physician ordered for the facility to start initiating a discharge to a facility with a secure unit since Resident #329 had eloped and facility had no current secure unit for resident safety. She initiated the in-service for elopement and abuse and neglect on 03/18/25 on the 2 pm to 10 pm shift and continued education with all shifts until 03/19/25 to get the last shift on the 6 am to 2 pm shift. She stated Resident #329 was placed on 1:1 until he was discharged to another facility with secure unit for resident safety. Observations on 04/24/25 from 12:52 PM to 1:05 PM with the Maintenance Director revealed all exit doors were working properly. Observations revealed all exit doors alarmed when pressed on and if held 15 seconds would continue to alarm. The front door alarmed when pressed on and if held for 15 seconds would alarm until the code was put in. In a follow-up interview on 04/24/25 at 12:58 PM the Maintenance Director said there was grass between the facility and the building Resident #329 was at. He stated he pushed the wheelchair across the grass. He stated he went to the front of the building. He stated Resident #329 had no visible injuries and was very confused. He did not know that he was a resident at the facility. The Maintenance Director stated Resident #329 was cooperative and they took him back in the wheelchair. He stated they used a side street to take Resident #329 back in the wheelchair. He stated they returned with Resident #329 at 4:10 PM. The noncompliance was identified as Past Noncompliance (PNC) Immediate Jeopardy (IJ). The noncompliance began on 03/18/25 and ended on 03/31/25. The facility had corrected the noncompliance before the Incident investigation began on 04/08/25.

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 one of one kitchen and 2 (Dietary Manager and Dietary [NAME] O) of 4 Dietary Staff reviewed for Food and Nutrition Services. 1. The facility failed to ensure food items in the walk-in refrigerator and freezer were dated, labeled and sealed. 2. The facility failed to ensure 2 chest freezers had a thermometer while in use and failed to ensure temperature logs were maintained for the chest freezers. 3. The facility failed to ensure the Dietary Manager had a facial hair restraint for his mustache and used proper hand hygiene while handling and serving food during the lunch meal preparation and service on 04/09/25. 4. The facility failed to ensure the Dietary [NAME] O had an effective hair restraint during meal preparation on 04/09/25. These failures could place residents at risk for food-borne illness and food contamination. Findings include: 1. Observations on 04/08/25 in the walk-in refrigerator revealed the following: -at 10:19 AM, bell peppers in a box, dated 04/01 with 3 bell peppers revealed the skin was wrinkling, soft with white spots were on it -at 10:20 AM, Chicken noodle soup revealed plastic wrap was not covering the food on 1 side, open a couple of inches. Observations on 04/08/25 at 10:25 AM of the walk-in freezer revealed the following: -the garlic bread bag was torn and opened, not sealed about 3 inches -Hash browns were in a torn plastic bag and not sealed -Beef steak patties were in an open box and were not sealed -2 packages of shrimp were not dated when received, and were undated. -Brussel sprouts had a best if used by dated 04/06/25. It was not dated when received. Interview with the Dietary Manager on 04/08/25 at 10:22 AM revealed the refrigerator items should be dated when received if taken out of the original container and when opened. He stated the items should be sealed. Observation revealed the Dietary Manager covered the chicken noodle soup back with the plastic wrap and showed it had a date of 4/07/25. He stated he was responsible to ensure items were dated, labeled and sealed properly. Interview on 04/08/25 at 10:27 AM with the Dietary Manager revealed the shrimp was delivered on Friday (04/04/25). The Dietary Manger stated he was not sure when the brussels sprouts were received. He stated he was going to use them and cook them. He stated the best if used by date was not an expiration date. He stated he would throw out the hash browns and garlic bread. These items should be sealed and dated . 2. Observation on 04/08/25 at 10:28 AM of 2 chest freezers in the kitchen revealed one of the freezers had chocolate ice cream cups. The ice cream cups appeared to be still frozen. The other freezer had a gallon of ice cream and boxes of frozen items. There were no thermometers found in either chest freezer. The chest freezers had ice accumulation on the sides of both. Interview on 04/08/25 at 10:30 AM with the Dietary Manager revealed he could not find thermometers in the chest freezers. The Dietary Manager stated he did not have any temperature logs for the chest freezers . He started moving the items out. He stated there should be a thermometer in the chest freezer. Interview on 04/09/25 at 04:32 PM with the Maintenance Director revealed he was not aware Dietary was still using the 2 chest freezers the facility had gotten those in the past when the kitchen had issues with the freezer not working. He stated he had not defrosted the chest freezers recently. He stated the freezers should have a thermometer in them to ensure freezer item temperatures maintained. Record review of the facility's policy Food Safety effective, date of 11/28/17 and last reviewed 05/01/24, reflected Food is store and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth .6. Food is labeled with the date received if not already indicated on the item .2. Ambient temperatures in freezers remain at 0 degrees F or lower and all food is frozen solid. 3. Temperatures are recorded at least twice daily on the refrigerator/freezer temperature log using an inside thermometer place near the door which is the warm part of the refrigerator .10. Leftovers are dated properly and discarded after 72 hours unless otherwise indicated 3. Observation on 04/09/25 from 12:00 PM to 12:42 PM for the lunch meal preparation and serving revealed the following: -at 12:00 PM, the Dietary Manager was in the kitchen plating food for the lunch meal trays with no facial hair restraint for his mustache which was about 1/2 inch thick with 2 inches length. -at 12:04 PM, the Dietary Manager took his gloves off, did not wash his hands and put new gloves on. He started plating food for resident meal trays and touched the inner part of the resident plate. At 12:07 PM, the Dietary Manager touched the cornbread with his gloved hand on the sides with a spatula. He was not wearing a facial hair restraint. At 12:11 PM, he touched the mashed potatoes and cauliflower with his gloved hand when scooping it onto the resident plate with his gloves touching the inner part of the resident plate. -At 12:13 PM, the Dietary Manager got clean plates with his gloved hands. At 12:15 PM, he touched the cornbread with his gloved hand on the sides with a spatula. The Dietary Manager continued plating the food with his gloved hands. -At 12:27 PM, the Dietary Manager took off both gloves, did not wash his hands and put on new gloves. He continued plating food and touched, with his gloved hands, the inner part of the plate and food with his gloved hands. He continued plating food for the resident meal trays. The Dietary Manager did not wash his hands and finished with all resident meal trays . 4. Observation on 04/09/25 at 12:29 PM, revealed Dietary [NAME] O cutting up turkey meat with 3/4 inch of hair not covered by her hat and 1/2 inch hair on both sides in front of her ears were not covered by her hat. Interview on 04/09/25 at 12:46 PM with Dietary [NAME] O revealed she was not aware the back of her hair and sides of her hair were uncovered. She stated she was aware she should have her hair covered while in the kitchen. Interview on 04/09/25 at 12:52 PM with the Dietary Manager revealed he did not wash his hands between glove use because when he washed his hands and put on new gloves it was difficult to put on the gloves. He stated the gloves were large on the box but they were tight fitting. He was aware he should wash hands when changing gloves. He stated the risk to not washing hands was contamination of the food. He stated he did not wear a facial restraint for his mustache. He said he only needed it if he had a beard. He stated the importance of wearing the hair restraints or hats were to cover the hair and to keep hair from getting in the food. Interview on 04/10/25 at 10:15 AM with Dietitian revealed the bell peppers needed to be removed when it showed signs of spoiling and should be thrown away. She stated the facility had gotten the 2 chest freezers when the walk-in freezer was having repairs. She stated there should be a thermometer in each chest freezer and temperature log should be kept for each chest freezer. She stated not monitoring the chest freezer temperatures could place residents at risk for issues with temperature which included freezer items not being at proper temperatures. She stated she had discussed with the Dietary Manager about the importance of the temperature logs and having a thermometer. She stated food items in the refrigerator and freezer should be dated and sealed. She stated leftovers were good for 3 days and then thrown out after the 3 days if not used. She stated not having labels, date on the items and unsealed could place food items at risk of potential hazards and critical control points not kept. She stated these food items were at risk for bacteria and contamination of food. She stated using the Brussel sprouts before the best use by date of 04/06/25 ensured flavor was kept. She stated food items in the refrigerator and freezer should be dated for when received and when opened. She stated she had in-serviced dietary staff which included the Dietary Manager about the facility's policy including facial restraints and hair restraints. She stated she educated the Dietary Manager about ensuring proper hand hygiene for dietary staff. She stated Dietary staff not washing their hands could pass along germs and contamination in the food and it could place residents at risk who ate the food. Interview on 04/10/25 at 03:28 PM with the Administrator revealed he expected the chest freezers to be maintained with thermometer and temperatures log if using. He stated he expected dietary staff to wash hands. Record review of the facility's in-service by the Dietary Manager, dated 02/05/25, reflected he in-serviced dietary staff on handwashing and how to properly wash hands. Record review of the facility's policy Associate Conduct and Dress Code, last revised 04/30/24, reflected The facility will ensure all foodservice associates adhere to the company's established code of conduct and dress code .Hair Restraints .-Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food .e. All facial hair including moustaches and beards should be trimmed and covered .3. The food and Nutrition Services associates wear a hair covering, which covers all unpinned hair, including all facial hair while on duty a. According to the Food Code, food service staff must wear hairnets when cooking, preparing, or assembling food . Record review of the U.S Department of Health and Human Services Food Code, dated 2022, reflected 3-202.15 Package Integrity .Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. Record review of the Food and Drug Administration Food Code, dated 2022, reflected the following: - .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food .3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety . 2-301.11 Clean Condition. The hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code. Even seemingly healthy employees may serve as reservoirs for pathogenic microorganisms that are transmissible through food. Staphylococci, for example, can be found on the skin and in the mouth, throat, and nose of many employees. The hands of employees can be contaminated by touching their nose or other body parts. 2-301.12 Cleaning Procedure. Handwashing is a critical factor in reducing fecal-oral pathogens that can be transmitted from hands to RTE food as well as other pathogens that can be transmitted from environmental sources

49427 Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to attain or maintain the resident's highest practicable mental and psychosocial well-being for 3 of 10 residents (Resident #73, #4, and #14) reviewed for Care Plans. 1. The facility failed to ensure Resident #73's comprehensive care plan reflected her psychotropic medications and ADL dependence. 2. The facility failed to ensure Resident #4's comprehensive care plan included her preference for bed baths and her specific ADL assistance needs. 3. The facility failed to ensure Resident # 14 care plan reflected she preferred her family member, Resident #33, to assist her with eating and assistance with activities of daily living. These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: 1. Review of Resident #73's Admission MDS dated [DATE] reflected Resident #73 was admitted to the facility on [DATE] with diagnoses of hypertension, dementia, malnutrition, depression and cognitive communication deficit. Resident #73 had a BIMS of 3 indicating he was severely cognitively impaired. Resident #73 was dependent with ADLs of hygiene, showering and dressing. Review of Resident #73's telephone physician order dated 04/03/25 reflected Resident #73 was taking Depakote 125 po BID for diagnosis of Impulse Disorder. Review of April 2025 MAR reflected Resident #73 was administered Depakote as ordered by physician. Observation on 04/08/25 at 12:11 PM revealed Resident #73 sleeping in the recliner. Interview on 04/08/25 at 12:14 PM with CNA Y revealed Resident #73 was dependent on staff for assistance in transfers and other ADLs. Interview on 04/10/25 at 2:02 PM with DON revealed Resident #73 was dependent with ADLs and it should be care planned so the staff were aware of his assistance needs. DON stated he could not find the Depakote medication care planned for Resident #73. Interview on 04/10/25 at 02:20 PM with MDS Coordinator A revealed Resident #73 should be care planned for total assistance for ADL care and recently had a decline. She stated Resident #73 should be care planned for his psychotropic medication of Depakote with interventions. 2. Review of Resident #4's face sheet undated reflected Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] with included diagnoses of heart disease, type 2 diabetes and hypertension. Review of Resident #4's Quarterly MDS dated [DATE] reflected Resident #13 had a primary diagnosis of type 2 diabetes. She had a BIMS of 13 indicating she was cognitively intact. Resident #4 required substantial/maximal assistance with personal hygiene and dependent with ADLs of toileting, showering and dressing. Review of Resident #4's comprehensive care plan last revised on 11/25/24 reflected Resident #4 is at risk for falls. Intervention included to assist with ADLs as needed. It did not reflect specifically what type of assistance needed for ADLs. It did not specify Resident #4 preferred bed baths. Observation and interview on 04/08/25 at 11:49 AM revealed Resident #4 lying in her bed. She stated she was provided bed baths on Monday, Wednesday and Fridays per her preference. Interview on 04/09/25 at 03:01 PM with CNA P revealed she did give resident bed baths on Mondays, Wednesdays and Fridays on her shift per resident preference. Interview on 04/09/25 at 03:04 PM LVN B revealed Resident # 4 required assistance with ADLs and preferred bed baths. Interview on 04/09/25 at 3:06 PM with LVN C revealed Resident #4 was dependent on staff for her ADL assistance needs. Interview on 04/10/25 at 2:02 PM with DON revealed Resident #4's ADL assistance needs should be care planned. DON stated it was important for resident care plans to be person-centered and specific about ADL assistance needs and psychotropic medications so staff would be aware of resident needs and to include interventions specific to these areas. Interview on 04/10/25 at 02:20 PM with MDS Coordinator A revealed Resident #4's ADL care should be care planned she needed assistance with ADLs. She stated the care plan should be person-centered to reflect Resident #4's needs. 3. Record review of Resident #14's Comprehensive MDS, dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of quadriplegia (paralysis of all limbs) and hypotension (low blood pressure) and a BIMS score of 12 (moderately impaired cognition). Record review of Resident #14's care plan revealed she had little to no activity involvement due to physical limitations, dated 12/10/24, interventions included prefers to socialize with: [Resident #33] who lives in the room with her . There were no focus areas that addressed Resident #14's preference to be fed and provided assistance with other activities of daily living by Resident #33. Record review of Resident #33's Quarterly MDS, dated [DATE], reflected he was an [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of type 2 diabetes (varying blood sugar level), dementia (loss of cognition), hypertension (high blood pressure) and a BIMS score of 10 (moderately impaired cognition). Record review of Resident #33 care plan revealed he had anxiety and interfered with Resident #14's care, dated 02/06/25. Interventions included educate resident/family caregivers of the possible outcome(s) of not complying with treatment of care .give clear explanation of all care activities prior to assisting spouse and as they occur during each contact . provide resident with opportunities for choice during care provision. Observation and interview on 04/08/25 at 10:15 AM revealed Resident #14 was lying in bed and Resident #33 was seated in a wheelchair next to her bed. Resident #14 stated there were times that it seemed like staff knew he wanted to be involved in Resident #14's care and sometimes other staff did not know. Resident #33 stated that she agreed and preferred for Resident #33 to assist with her care as much as possible, including when she ate. In an interview on 04/10/25 at 11 AM with Restorative Aide I revealed Resident #14 and Resident #33 ate in their room and Resident #14 preferred for Resident #33 to feed her. In an interview on 04/10/25 at 11:36 AM with the Activity Director revealed Resident #14 preferred to be fed by Resident #33. She stated it was important for Resident #14's preferences to be care planned so that all staff were aware of her preferences and that the MDS Coordinator was responsible for the care plans. In an interview on 04/10/25 at 11:45 AM with RN G revealed Resident #14 preference to be cared for by Resident #33 should be care planned because care plans should be person centered. In an interview on 04/10/25 at 2:24 PM with the MDS Coordinator revealed it was not care planned that Resident #14 preferred Resident #33 to feed her or provide support in activities of daily living. She stated Resident #14's preferences should have been care planned because care plans are supposed to be person centered to ensure resident preferences were honored. She stated that care plans are updated during quarterly reviews and as changes occurred. In an interview on 04/10/25 at 2:50 PM with the Administrator revealed Resident #14's preference for Resident #33 to be involved in her care as much as possible should have been care planned because care plans were supposed to be person centered to ensure resident preferences were honored. Record review of comprehensive care plan policy titled, Resident Assessment Instrument & Care Plan Development, dated reviewed 09/05/2024, reflected .Procedure . 8. The information identified using the MDS and Care Area Assessment process is used to develop an individualize person-centered Care Plan that includes the patient's voice, the patient's goals while residing in the facility and for discharge that assist the patient to attain and/or maintain their highest practicable level of well-being.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #4 and Resident #289) of 8 residents reviewed for ADLs. 1. The facility failed to ensure Resident #4 had her fingernails cleaned and trimmed on 04/08/25 and 04/09/25. 2. The facility failed to ensure Resident #289's nails were cleaned and trimmed on 04/10/25. The facility failed to ensure Resident #289's facial hair was shaved on 04/10/25. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1. Review of Resident #4's face sheet undated reflected Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] with included diagnoses of Heart disease, type 2 diabetes and hypertension. Review of Resident #4's Quarterly MDS dated [DATE] reflected Resident #13 had a primary diagnosis of type 2 diabetes. She had a BIMS of 13 indicating she was cognitively intact. Resident #4 required substantial/maximal assistance with personal hygiene. Review of Resident #4's comprehensive care plan last revised on 11/25/24 reflected Resident #4 has Diabetes. Resident #4 is at risk for falls. Intervention included to assist with ADLs as needed. Review of Resident #4's podiatrist visit documentation dated 02/17/25 reflected Resident #4 had diabetes and podiatrist debrided corn/callous and toe nails on this visit. It did not reflect fingernails were trimmed. It reflected visit as medically necessary but no sooner than 60 days. Observation and interview on 04/08/25 at 11:49 AM revealed Resident #4 lying in her bed with her fingernails in both hands were approximately 0.5 inch in length extending from the tip of her fingers, and dark brown substance underneath the nails. Resident #4 stated she needed her fingernails trimmed and could not recall the last time they were trimmed. She stated no one had asked her to trim her finger nails. She stated she was given bed baths on Monday, Wednesday and Fridays. She stated the CNA had not trimmed her fingernails. Observation on 04/09/25 at 2:57 PM revealed Resident #4's fingernails were approximately 0.5 inch in length extending from the tip of her fingers with a dark brown substance underneath the fingernails. Interview on 04/09/25 at 03:01 PM with CNA P revealed she did not trim the fingernails since Resident #4 was a diabetic. She stated she did give resident bed baths on Mondays, Wednesdays and Fridays on her shift. She stated she had not noticed the fingernails being long. She stated she had not communicated to the nurse about the fingernails being long. She stated nurses were responsible for trimming fingernails for diabetic residents. Interview on 04/09/25 at 03:04 PM LVN B revealed Resident # 4 was a diabetic and the podiatrist was responsible to ensure fingernails were trimmed for Resident #4. She stated Resident #4 did get bed baths on her shift on Mondays, Wednesdays and Fridays. LVN B stated she did not know when the last time Resident #4's fingernails were trimmed. She stated she would have to ask the SW to find out the last time podiatrist came to facility for Resident #4. She stated CNAs should be cleaning Resident #4's fingernails as needed. Interview on 04/09/25 at 3:06 PM with LVN C revealed nurses were responsible to ensure fingernails trimming was completed for diabetic residents including Resident #4. She stated she was not sure the last time Resident #4's fingernails were trimmed. Observation and Interview on 04/09/25 at 3:12 PM with DON revealed Resident #4 had fingernails which needed to be trimmed and cleaned. The DON asked Resident #4 if it was okay for him to trim her fingernails. Resident #4 stated she was a diabetic to the DON and she was okay with him trimming them. The DON stated charge nurses were responsible to ensure Resident #4's fingernails were trimmed. He stated podiatrist did trim fingernails for Resident #4 on visits but they only came out monthly to the facility. He stated he will get the documentation of the last podiatrist visit. He stated the risk to the resident for not getting fingernails cleaned was infection and residents not getting finger nails trimmed could place residents at risk of scratching or cut themselves. The DON stated he will start an in-service with nursing about ensuring fingernails are trimmed. He stated Resident #4's finger nails did seem dirty and needed to be trimmed. He stated he had trimmed Resident #4's fingernails before but it had been a long time. He stated Resident #4 needed to have her fingernails trimmed they were longer. Interview on 04/10/25 at 9:38 AM with SW revealed Resident #4 had seen podiatrist in February 2025. She stated podiatrist only came to facility every 2 months. Follow-up interview on 04/10/25 at 10:47 AM with DON revealed nurses were ultimately responsible for ensuring fingernails trimmed and cleaned for residents. He stated CNAs should be cleaning resident fingernails. He stated he had today started an in-service for CNAs and nurses to ensure resident fingernails trimmed and cleaned. 2. Record review of Resident #289's Face Sheet dated, 04/10/25, reflected a [AGE] year-old woman admitted on [DATE] with diagnoses of enterocolitis due clostridium difficile (inflammatory condition that affects both the small and large intestines), morbid obesity, and muscle weakness. Record review of Resident #289's MDS assessment dated [DATE], reflected Resident #289 had a BIMS 13 indicated Resident #289's cognition was intact. Further review revealed Resident #289 was dependent for showering/bathing and toileting hygiene. Record review of Resident #289's Comprehensive Care Plan, dated 04/03/25, reflected the following: Focus: [Resident #289] ADL assistance and therapy services needed to maintain or attain highest level of function .Interventions/Tasks: Assist with mobility and ADLs as needed. Observation and interview on 04/10/25 at 09:49 AM revealed Resident #289 had facial hair on her chin about an inch long. Resident #289's fingernails on both hands were .05-.07 cm in length extending from the tip of her fingers with dark substance underneath the nails. Resident #289 stated she would like the hair on her chin removed and her fingernails cut. She stated she never wore her fingernails long. She stated no one has asked her if she wanted the facial hair on her chin removed or her fingernails cut. She stated it does not make her feel good with hair on her chin. In an interview on 04/10/25 at 10:12 AM, CNA K stated she did not notice Resident 289's fingernails were long and dirty or that she had facial hair on her chin. CNA K stated Resident #289's fingernails needed to be trimmed and clean as well as the facial hair on her chin shaved. CNA K stated the risk to Resident #289 would be infection and Resident #289 not feeling good about herself. In an interview on 04/10/25 at 10:30 AM, LVN L stated that both nurses and CNAs were responsible for grooming and doing nail care for the residents. She stated that residents should be groomed, and fingernails should be trimmed and cleaned on shower days and as needed. She stated that long and dirty nails could lead to risk of infections. Review of facility's policy Activities of Daily Living dated 12/11/18 and last revised on 02/12/24 reflected The resident will receive assistance as needed to complete activities of daily living (ADLs). Under procedure, .For Fingernail Care, the following procedure will be followed: 1. Ensure fingernails are clean and trimmed to avoid injury and infection .4. Provide privacy and perform nail care, taking care not to trim the skin below the skin line and not to cut the skin. 49837

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 three of eight residents (Resident #60, Resident #32, and Resident #179) reviewed for infection control. 1. The facility failed to ensure CNA D performed hand hygiene during incontinence care for Resident #60 on 04/08/25. 2. The facility failed to ensure LVN E sanitized the glucometer before and after with an EPA approved germicide after performing a FSBS on Resident #32 on 04/08/25. 3. The facility failed to ensure LVN J performed hand hygiene after obtaining a FSBS for Resident #179 on 04/08/25. 4. The facility failed to ensure the Treatment Nurse performed hand hygiene during wound care and incontinence care on Resident #32 on 04/09/25 These failures could place residents at risk for infection and cross contamination. Findings include: 1. Record review of Resident #60's face sheet, dated 04/10/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included infection and inflammatory reaction due to internal right knee prosthesis, (artificial joint), chronic osteomyelitis (inflammation to the bone caused by infection) and diabetes. In an observation on 04/08/25 at 10:45 a.m., revealed CNA D entered Resident #60's room to provide incontinence care. CNA D put on gloves without performing hand hygiene. She unfastened the brief and provided peri-care wiping from front to back and changing the wipes with each stroke. CNA D assisted to resident onto his side, which revealed he had a moderate soft bowel movement. CNA D wiped from front to back until all bowel movement was removed. CNA D removed her gloves and without performing hand hygiene, reached into her pants pocket and retrieved another pair of gloves and put them on. CNA D then applied barrier cream to the resident's buttocks and placed the clean brief under the resident and had him roll back onto his back, where she applied barrier cream on his groin and peri-area. CNA D fastened the brief, removed her gloves, gathered the trash, and then performed hand hygiene. In an interview on 04/08/25 at 10:50 a.m., CNA D stated she was supposed to perform hand hygiene before and after care. Then she stated she should have performed hand hygiene on her hands when she changed her gloves when going from dirty to clean. She stated the risk of not performing hand hygiene was infection and the spread of germs. 2. Record review of Resident #32's face sheet, dated 04/10/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #32 had a diagnosis which included type 2 diabetes mellitus. Observation during medication pass on 04/08/25 at 11:30 a.m. revealed LVN E prepared to obtain fingerstick blood sugar for Resident #32. LVN E pulled a glucometer out of the medication cart and wiped it down with an alcohol prep pad. LVN E entered the resident's room and obtained a fingerstick blood sample. LVN E disposed of the lancet and test strip, and returned to the medication cart where she opened another alcohol prep pad and wiped down the glucometer. In an interview with LVN E on 04/08/25 at 11:35 a.m., she stated she was supposed to wipe the glucometer down with a Sani-wipe (EPA approved germicide) but stated she did not have any on her cart when she was doing the blood sugar checks. LVN E then walked down the hall into a supply room and retrieved a bottle of Sani-wipes and re-cleaned the glucometer. She stated failure to sanitize the glucometer appropriately could result in transmission of blood borne pathogens. 3. Record review of Resident #179's face sheet, dated 04/10/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #179 had a diagnosis which included type 2 diabetes mellitus. During a medication administration observation on 04/08/25 at 11:45 a.m., revealed LVN J obtained a fingerstick blood sample for Resident #179. LVN J disposed of the lancet and test strip and returned to the medication cart. LVN J removed her gloves, re-applied gloves without performing hand hygiene and cleaned the glucometer with a Sani-wipe. LVN J removed her gloves and without performing hand hygiene, opened the medication cart and retrieved the resident's insulin pen. LVN J then attached a needle to the pen, primed the pen and then dialed in 4 units. LVN J performed hand hygiene and re-entered the resident's room and administered the insulin. In an interview with LVN J on 04/08/25 at 11:52 a.m., she stated she was supposed to sanitize her hands after the completion of the FSBS and before giving insulin. She stated she realized she should have sanitized before and after cleaning the glucometer, and prior to retrieving the insulin pen. She stated the risk of was cross contamination. 4. Record review of Resident #32's face sheet, dated 04/10/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #32 had a diagnosis which included pressure ulcer of the sacral region, stage 2. During an observation on 04/09/25 at 01:15 p.m. revealed the Treatment Nurse and CNA D entered Resident #32's room to provide wound care. Both staff performed hand hygiene and put on gowns. The Treatment Nurse opened the resident's brief, and the staff rolled the resident on her side, which revealed a small open area on the resident's sacral area that was almost completely closed. The Treatment Nurse cleaned the wound cleanser and applied Triad paste (helps maintain moist wound healing). The resident's labia was noted to be red. The Treatment Nurse asked Restorative Aide I to ask the Charge Nurse to bring in some Nystatin powder for the red area. The resident began to have a bowel movement. The staff rolled the resident back onto her back to let her finish with the bowel movement. CNA D then provided peri care and catheter care wiping down each groin and down the middle and cleaning the catheter tubing downward and changed the wipe with each stroke. The resident was rolled back onto her side and the Treatment Nurse wiped the anal area from front to back, which resulted in the removal of the triad paste. Once the bowel movement was removed the Treatment Nurse removed her gloves and put on new gloves without performing hand hygiene. The Treatment Nurse cleaned the area of the pressure ulcer with normal saline and re- applied triad paste. The Treatment Nurse stepped aside, LVN E entered the room, performed hand hygiene, and put on gloves and gowns and applied the nystatin powder (used to treat yeast) to the labia area. LVN E and CNA D positioned the clean brief and the mechanical sling under the resident. The resident was rolled back onto her back and the brief was secured. The Treatment Nurse gathered up the trash, removed her gloves and performed hand hygiene. In an interview on 04/09/25 at 01:50 p.m., the Treatment Nurse stated she should have performed hand hygiene when she finished cleaning the resident and before she re-cleaned and treated the wound. She stated the risk of not performing hand hygiene was cross contamination and infection concerns. In an interview with the DON on 04/10/25 at 09:35 a.m., he stated staff were to change their gloves and perform hand hygiene after they performed incontinence care and before applying the clean brief and always before going from clean to dirty, especially during wound care. He stated by not following proper hand hygiene it placed residents at risk of urinary tract infections and increased the risk of wound infection. He stated they had done extensive in-services with the staff on infection control, especially hand hygiene and the use of PPE. He stated in addition they made rounds and watched care to ensure the staff were following correct procedures. He stated the staff had also been trained on the proper sanitizing of glucometers and when to perform hand hygiene during glucose monitoring. He stated alcohol was not an approved germicide for sanitizing glucometers. He stated the staff were to use the EPA approved Sani-wipes to clean the glucometers and staff were to always perform hand hygiene after any procedure, before moving to the next procedure. He stated the risk of not following the proper procedures were cross contamination and potential for the spread of blood borne pathogens. Record review of the facility's policy titled, Cleaning and Disinfection of Non-critical Patient Care Equipment, dated June 2024, reflected .Disinfection should be performed with an EPA-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA-registered disinfectant products must be followed .Intermediate-level disinfection is traditionally defined as destruction of all vegetative bacteria .Given the broader spectrum of activity, intermediate-level disinfection should be considered for non-critical equipment that is visibly contaminated with blood Record review of the facility's policy titled, Hand Hygiene, dated June 2024, reflected, .Associates perform hand hygiene (even if gloves are used) in the following situations .Before and after contact with the resident .After contact with blood, body fluids, or visibly contaminated surfaces .After removing personal protective equipment (e.g., gloves, gown .) .Before performing a procedure such as an aseptic task .dressing care

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of three residents (Resident #32) reviewed for catheter and incontinence care. The facility failed to ensure CNA D and Restorative Aide I maintained the foley catheter drainage bag below Resident #32's bladder while they transferred the resident with a mechanical lift on 04/09/25. This failure could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infections. Findings included: Record review of Resident #32's Admission MDS assessment, dated 03/17/25, reflected an [AGE] year-old female with an admitted [DATE]. Resident #32 had a BIMS of 5 which indicated she was severely cognitively impaired. She required total assistance for ADL care and had a foley catheter and was always incontinent of bowel. Active diagnoses included diabetes (chronic, metabolic disease characterized by elevated levels of blood glucose (or blood sugar), traumatic brain injury (disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury), respiratory failure (condition where there's not enough oxygen or too much carbon dioxide in your body), and neurogenic bladder (disruption in the nervous systems connection to the bladder) Record review of Resident #32's Physician Order Summary, dated 04/10/25, reflected .Keep urinary drainage bag below the level of the bladder . with a start date of 03/13/24. Record review of Resident #32's care plan, initiated on 03/14/25, reflected, The Resident (indwelling) catheter .Goal .Will have no complications related to indwelling catheter use .Interventions .Catheter care every shift In an observation on 04/09/25 at 01:30 p.m. CNA D and LVN E were observed placing Resident #32 on a mechanical lift sling. CNA D unhooked the foley catheter drainage bag from the bed rail and hooked onto the mechanical lift sling. Restorative Aide I raised the lift which placed the catheter drainage bag higher than the resident's bladder. Urine was observed in the tube fluctuating back and forth. Restorative Aide I positioned Resident #32 over the wheelchair, then unhooked the foley drainage bag from the lift sling and placed it on the resident's lap and then lowered the resident into her wheelchair. CNA D then unhooked the sling and LVN E picked up the drainage bag and hooked it onto the wheelchair. In an interview on 04/09/25 at 01:40 p.m. Restorative Aide I stated he usually placed the urinary drainage bag in the resident's lap and stated he thought that was how they were supposed to do it. He stated he knew it was supposed to be below the bladder, but stated he was not very sure how they were supposed to manage the bag during a mechanical transfer. In an interview on 04/09/25 at 01:42 p.m. with CNA D she stated she knew the drainage bag was supposed to be below the bladder, but stated they really had not been shown how to handle the drainage bag while transferring with a mechanical lift. Both CNA D and Restorative Aide I stated if the urinary bag was above the bladder there was a risk of the urine back flowing causing an infection. In an interview on 04/10/25 at 09:35 a.m. with the DON he stated the urinary drainage bag was always supposed to be below the bladder. He stated they teach the staff that, but stated they probably need to add the process of how to handle the drainage bag during a mechanical lift transfer. He stated the risk of having it above the bladder is urinary tract infections. In an interview on 04/10/25 at 04:02 p.m. RN G who is the facilities Infection Preventionist, she stated she educated the staff to always keep the urinary bag below the bladder. She stated she had done education with the staff for residents with mechanical lift transfers which required one of them to hold the drainage bag below the bladder during the transfer. She stated she would have to do some additional education with the staff to ensure they were always keeping the urinary bag below the bladder and keeping it secure during a transfer. She stated the risk for not keeping it below the bladder was the back flow of urine into the bladder which could lead to an infection. Record Review of CNA D's Nurse Aide Proficiency skills check reflected she was competent in the care of indwelling catheters as of 10/31/24. Record Review of Restorative Aide I's Nurse Aide Proficiency skills check off reflected he was competent in the care of indwelling catheters as of 12/07/24. Record review of the facility's policy, Indwelling Urinary Catheter (Foley) Management, dated September 2024, reflected, Maintain unobstructed urine flow .Keep the catheter and collecting tube free from kinking .Keep the collecting bag below the level of the bladder at all times .

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 (Hall E) medication carts reviewed for medication storage. The facility failed to ensure LVN H kept medications secured and the E Hall medication cart locked and/or secured. LVN H failed to ensure medication pill was not loose on the E-Hall medication cart. This failure could place residents at risk of gaining access to unlocked medications that were not prescribed to them. Findings include: During a medication observation on 04/09/25 at 06:20 a.m. revealed LVN H at the medication cart in front of Resident #43's room. A medication cup with a small tan pill was observed on top of the E-Hall medication cart. LVN H stated she was waiting for Resident #43 to finish in the bathroom. LVN H put on gloves and entered Resident #43's room and bathroom and assisted him back to bed. The medication cup with the pill was left on top of the unlocked medication cart out of the sight of the LVN. LVN H returned to the medication cart and pushed the Medication cart to the next room. LVN H pulled Resident #1's medication and entered the room, leaving the medication cart unlocked and out of her sight while in the room administering Resident #1's medications. In an interview on 04/09/25 at 06:35 a.m., LVN H stated she had gotten distracted with Resident #43 when he needed to go to the bathroom. She stated she had punched his protonix (treats acid reflux) out twice and the one in the cup was extra. She stated she should have destroyed the pill. She stated she should never leave medication on top of the cart or leave the medication cart unlocked because anyone could take medication that was not intended for them. In an interview on 04/10/25 at 9:25 a.m. with the DON, he stated if a medication cart was left unlocked a resident or anyone else could get into it and take any of the medication, which could result in a resident taking medication not prescribed for them which could make them sick or cause harm. He stated all the staff were trained on medication storage and the expectation of keeping medication carts locked and secured and were never to leave medication on top of the cart unsecured and if it should have been destroyed instead of placed back into the cart. Record review of the facility's policy, Storage and Expiration Dating of Medications and Biologicals, August 2024, reflected Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for one of nine (Resident #64) residents reviewed for pharmacy services. The facility failed to ensure facility staff re-ordered medications in a timely manner for Resident #64 which resulted in a missed dose of levothyroxine 50 mcg (used to treat low thyroid) on 04/09/25. The facility failed to keep medications secure when LVN H borrowed a medication from another resident to administer to Resident # 64. This failure could place residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition. Findings include: Record review of Resident #64's face sheet, dated 04/10/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #64's 5-day MDS Assessment, dated 02/08/25, reflected he had BIMS score of 13, which indicated he was cognitively intact. The 5-day assessment reflected the resident had diagnoses which included malnutrition and seizure disorder. Record review of Resident #64's Physician order Summary Report, dated 04/10/25, reflected Levothyroxine Sodium Oral Tablet 50 mcg 1 time a day for low thyroid, with a start date of 03/28/25. Record review of Resident #64's MAR for April 2025 reflected on 04/09/25 the 06:00 a.m. administration for Levothyroxine 50 mcg was coded as 7 (which indicated see progress note) by LVN H. There were no other missed doses for April 2025. Record review of Resident #64's progress notes did not reflect any documentation by LVH H for 04/09/25. During a medication observation and interview on 04/09/25 at 06:25 a.m. revealed LVN H at the medication cart in front of Resident #64'sroom. LVN H pulled up the Medication Profile for Resident #64. She looked in the medication cart to obtain the residents Levothyroxine and stated there was none on the cart. She stated she would have to retrieve the medication from the E-Kit. LVN H pushed the Medication cart to the next room. LVN H was never observed going to the medication room to retrieve the Levothyroxine. In an observation and interview on 04/09/25 at 10:00 a.m. with Unit Manager F, revealed the facility had a computer coded pharmacy dispensing unit (E-Kit) for on demand supply of routine medications. Unit Manager F stated they must contact the pharmacy to retrieve information on what was pulled from the system and who pulled it. Unit Manager F contacted their contracted pharmacy and verified no Levothyroxine for Resident #64 was pulled today (04/09/25). In a telephone interview with LVN H on 04/09/25 at 10:05 a.m., LVN H stated she borrowed a Levothyroxine 50 mcg tablet from another resident's medication supply and administered it to Resident #64 before she left. She stated she was running late and had an appointment she needed to get to and just did not go to the other hall where the E-Kit was located to retrieve the necessary medications. She stated she was not sure why the medications had not been re-ordered timely. In an interview with LVN E, charge nurse for the 6 a.m. to 2 p.m. shift, on 04/09/25 at 10:15 a.m. she stated, LVN H had not mentioned anything to her when they counted the medication cart at change of shift about Resident #64's Levothyroxine needing to be ordered. She stated each nurse was responsible to re-order the resident's medication when they had a 7-day supply left. She stated the re-ordering was done through the electronic record and it was as simple as pushing the re-order button in the system. She stated if the medication did not come in on the next day shipment from the pharmacy, they had to call the pharmacy and follow up. She stated Levothyroxine was almost always given by the night shift charge nurse since it was usually ordered to be taken before meals. She stated the night shift charge nurse would be responsible for re-ordering those medications for which they gave routinely. She stated in the event a medication did not get re-ordered or was delayed they always had access to the E-Kit. In an interview with the facility's contracted pharmacy, on 04/10/24 at 8:45 a.m., revealed the facility sent a re-order request to the pharmacy on 04/09/25 for Resident #64's Levothyroxine 50 mcg. The pharmacy representative stated the procedure for any re-order for medications was to submit the request when the resident had 5-7-day supply on hand. In an interview with the DON on 04/10/25 at 09:25 a.m., the DON stated it was never acceptable to borrow a medication from another resident and the staff member would be counseled. He stated there was no excuse for this since they had an E-Kit that had most of the common medications the residents took. He stated the re-ordering process was a very simple process and the staff all knew they were to re-order when a resident had a 7-day supply on hand. He stated whoever administered the medication and saw the 7-day mark was responsible for re-ordering the medication. He stated the staff were responsible for following up with the pharmacy in the event the medication was not delivered. He stated there was no excuse for this. Record review of the facility's policy, Reordering, Changing, and Discontinuing Medication Orders, dated July 2024, reflected Facilities are encouraged to reorder medications electronically or by fax whenever possible .Facility staff should re-order medications using an electronic list of residents and medications due or by use of barcode technology .Facility staff should review the transmitted re-orders for status and potential issues and pharmacy response

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for two of three (Resident #32, and Resident #289) reviewed for respiratory care. 1. The facility failed to ensure LVN E performed hand hygiene during tracheostomy (a surgical opening in the neck providing a direct airway through the trachea) care and failed to maintain sterile technique during tracheostomy care for Resident # 32 on 04/09/25. 2. The facility failed to obtain Physician orders for Resident #289's continuous oxygen with the number of liters to administer. These failures could place residents at risk for respiratory infections, an incorrect amount of oxygen and the risk of lung infections. Findings include: 1. Record review of Resident #32's Admission MDS assessment, dated 03/17/25, reflected an [AGE] year-old female with an admitted [DATE]. Resident #32 had a BIMS of 5, which indicated she was severely cognitively impaired. She required total assistance for ADL care and had a foley catheter and was always incontinent of bowel. Resident #32's active diagnoses included diabetes, traumatic brain injury, respiratory failure, and neurogenic bladder (disruption in the nervous systems connection to the bladder). In Section O-Special Treatments, Procedures, and Programs reflected the resident required tracheostomy care (a surgical opening in the neck providing a direct airway through the trachea), suctioning, and oxygen therapy during the 14 days look back period. Record review of Resident #32's Physician orders summary, dated 01/10/25, reflected Trach care daily with cannula change, with a start date of 03/14/25 Record review of Resident #32's care plan, revised on 03/20/25, reflected .The resident has a tracheostomy related to impaired breathing mechanics, surgery. At risk for dislodging the trach site .Goal .The resident will have clear and equal breath sounds bilaterally through the review date .Interventions .Suction as necessary .Use universal precautions as appropriate An observation on 04/09/25 at 08:35 a.m. revealed LVN E entered Resident #32's room to provide tracheostomy care. LVN E placed paper towels on top of the bedside table and placed the unopened tracheostomy kit on top. She then placed a bottle of unopened sterile normal saline beside the unopened trach kit. LVN E donned a gown and gloves without performing hand hygiene and removed the old stoma dressing from under the trach flange (device that holds the trach secure) and the inner cannula and discarded both into the trash. LVN E then opened the tracheostomy care kit (holds sterile supplies for cleaning tracheostomy), the package held a new disposable trach and opened the bottle of sterile saline. LVN E put on the sterile gloves without performing hand hygiene and removed the sterile drape (used to create a sterile field for tracheostomy cleaning supplies) and placed it on the resident's chest. LVN E reached for the bottle of saline with her right hand and touched the bottle (which was not sterile), then changed to her left hand, and picked up the bottle and poured the saline into the tracheostomy tray to moisten the 4x4 gauze. LVN E took the moistened gauze and cleaned around the stoma and under the trach flange. LVN E stated she messed up and forgot to open a package for the new stoma dressing. LVN E removed her sterile gloves and put on utility gloves without performing hand hygiene and retrieved a package of stoma dressings and a new tracheostomy kit and placed them on the bedside table. LVN E opened the stoma dressing package and the tracheostomy kit. She removed her utility gloves and proceeded to put on the sterile gloves from the kit without performing hand hygiene. LVN E retrieved the stoma dressing and placed it around the stoma and under the trach flange using both hands. LVN E picked up the disposable cannula and re-inserted it into the trach. LVN E removed her gloves and gowns and performed hand hygiene. In an interview with LVN E on 04/09/25 at 09:00 a.m., she stated she was supposed to perform hand hygiene before and after every glove change. She stated she knew the procedure was supposed to be a sterile procedure to reduce the risk of cross contamination. She stated she knew she was supposed to keep her dominant hand sterile and realized she should had picked up the bottle of normal saline with her left hand. She stated she had been checked off on tracheostomy care and even re-watched the video last night. She stated she was so nervous she just forgot to sanitize her hands. In an interview with the DON on 04/10/25 at 09:30 a. m. revealed hand hygiene was to be performed anytime a staff member went from a dirty procedure to a clean procedure. He stated trach care was to be an aseptic/sterile technique. He stated they had a Respiratory therapist who came to the facility weekly and provided hands on training with the staff. He stated they did at bedside training as well as practiced on a mannequin. He stated in addition RN G, who was the infection preventionist, did observations of care with the staff. He stated failure for the staff to follow proper procedures could result in infections. In an interview with RN G on 04/10/25 at 10:10 a.m., she stated she reviewed the skills with the staff, but the Respiratory therapist provided most of the hands-on training for trach care. She stated they taught it as a sterile procedure. She stated she made rounds with the nurses randomly to observe skills and compliance with infection control. She stated hand hygiene was always required after the removal of gloves to prevent the risk of infection. Record review of LVN E skills check list reflected she was skills checked on 07/25/24 and again on 03/12/25 on tracheostomy care. Record review of the facility's policy, Tracheostomy Care' Policy, dated September 2024, reflected .Tracheostomy care will be performed daily and PRN unless otherwise noted by the physician. This procedure should be performed using sterile technique and includes the cleaning of the stoma and neck, cleaning or replacing inner cannula (depending on type of trach tube-disposable or reusable) and replacing the tracheostomy tube holder and drainage sponge .Place the equipment and supplies on a clean table or stand near the patient's bed. Open the tracheostomy care kit using sterile technique. Using sterile technique, pour sterile normal saline solution, sterile water, or other cleaning solution recommended by the manufacturer .into one of the sterile solution containers.If you must replace the disposable inner cannula, open the package containing the new inner cannula while maintain sterile technique .Perform hand hygiene .Put on gown and gloves .Assess the patients respiratory status .Remove the patients tracheostomy dressing, inspect it for drainage, and then discard it .Remove and discard your gloves .Perform hand hygiene .Put on sterile gloves .Using non-dominant hand .unlock the tracheostomy tubes inner cannula by rotating it counterclockwise .Remove the inner cannula .Remove and discard your gloves .Perform hand hygiene .Put on clean gloves .With your dominant hand, moisten a sterile gauze pad with the sterile normal saline solution .then wipe the patients neck under the tracheostomy tube flanges and tracheostomy ties .Dry the area thoroughly with additional sterile gauze pads .Apply a new sterile tracheostomy dressing .Discard used supplies .Remove and discard your, gloves .Perform hand hygiene 2. Record review of Resident #289's face sheet dated 04/10/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #289 had diagnoses which included enterocolitis due clostridium difficile (inflammatory condition that affects both the small and large intestines), acute respiratory failure, morbid obesity, and muscle weakness. Record review of Resident #289's 5-day MDS assessment, dated 04/02/25, reflected Resident #289 had a BIMS of 13, which indicated she was cognitively intact. The MDS did not reflect Resident #289 was on oxygen therapy while at the facility. Record review of Resident #289's Comprehensive Care Plan, dated 04/03/25, reflected the following: Focus: [Resident #289] ADL assistance and therapy services needed to maintain or attain highest level of function .Interventions/Tasks: Assist with mobility and ADLs as needed. There was no indication of Resident's need for Oxygen Therapy. Record review of Resident #289's Physician's Order summary report, dated 04/10/25, reflected no physician's order for oxygen use. Observation and interview on 04/08/25 at 2:16 p.m. revealed Resident #289 was lying in bed on oxygen via nasal cannula with the oxygen concentrator next to her bed. The concentrator was observed on with the oxygen being infused through the nasal cannula. The oxygen concentrator was set to deliver 2 liters per minute. Resident #289 stated she had been receiving oxygen since being admitted to the facility. Interview with LVN L on 04/10/25 at 11:31 a.m. revealed there should have been a physician order for oxygen in place for Resident #289 prior to administering. She stated the risk to Resident #289 would be getting to much or too little oxygen. Interview with the DON on 04/10/25 at 12:06 p.m. revealed he expected Resident #289 to have a physician's order for oxygen and the nurses were responsible for making sure there was one prior to oxygen being administered. He stated his expectation was for every medication and oxygen to have physician orders in place. He stated the risk to Resident #289 was not getting the correct oxygen dose. Record review of the facility's policy, Oxygen Administration, dated September 2024, reflected To ensure that oxygen is administered and stored safely .Respiratory care .The facility must ensure that a resident who needs respiratory care .is provided such care, consistent with professional standards of practice and comprehensive person-centered care plan .Oxygen order should be written for specific liter flow required by the resident 49837

Based on interview and record review, the facility failed to ensure 1 of 1 members of the facility staff were able to demonstrate competency in the provision of skills and techniques necessary to provide quality care as outlined by the comprehensive care plan for 1 of 1 residents reviewed for plans of care. (Resident #1). The facility failed to ensure the staff providing activities of daily living (ADL) care were knowledgeable and competent on the facility's transfer and repositioning policy; Certified Nurse Aide (CNA) A grabbed Resident #1's neck to reposition him in bed, which resulted in the facial grimacing. The noncompliance was identified as past noncompliance (PNC). The facility identified the noncompliance on 9/5/2024 and corrected the noncompliance on 9/9/2024 before the investigation began on 11/7/2024. This deficient practice placed 1 resident with an ADL self-care performance deficit at risk of injury by not receiving care and services in accordance with resident care plans, facility policy, and state professional standards. Findings include: Record Review of Resident #1's Care Plan, dated 9/16/24, revealed Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses of being cognitively impaired (difficulty with thinking, learning, remembering, and making decisions), dementia unspecified severity without behavioral disturbance (a medical condition that causes a person to lose cognitive functioning without behavioral disturbances), psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), mood disturbance and anxiety (mental health condition where there is a disconnect between actual life circumstances and the person's state of mind or feeling), cognition deficit (a person's impaired ability to think, learn, remember, and make decisions), schizoaffective disorder bipolar type (experiences both schizophrenia and a mood disorder, specifically bipolar disorder), major depressive disorder single episode unspecified (a mental condition that's diagnosed when someone has experienced a single depressive episode and no other previous episodes), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), unspecified dementia with behavioral disturbance (a diagnosis for dementia that doesn't have a specific diagnosis and has behavioral disturbances), generalized anxiety disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed), delusional disorders (type of mental health condition in which a person can't tell what's real from what's imagined), adjustment disorder with mixed disturbance of emotions and conduct (adjustment disorder where a person experiences both significant emotional symptoms like anxiety or depression alongside behavioral issues like acting out, aggression, or rule-breaking, all in response to a stressful life event), pain disorder with related psychological factors (a somatoform disorder in which pain is a somatization independent from depression, anxiety or delusion), vascular dementia with behavioral disturbance (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), psychotic disorder with delusions due to known physiological condition (hallucinations or delusions that are caused by another medical disorder), and other speech disturbances (problems creating or forming the speech sounds needed to communicate with others). Record Review of Resident #1's Minimum Data Sheet (MDS), dated [DATE] revealed Resident #1 received a Brief Interview of Mental Status (BIMS) of 99. This indicates that Resident #1 was not able to complete the interview. Record Review of Resident #1's Care Plan, dated 9/16/24, revealed Resident #1 has an ADL self-care performance deficit related to Activity Intolerance, Dementia. Resident #1 Requires assistance with Activities of Daily Living (ADL's) as needed. ADL's Include: - Bed Mobility: The resident is totally dependent on 1-2 staff for repositioning and turning in bed (2-4 hours) and as necessary, - BED MOBILITY: Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; and frequent repositioning. Further review revealed the care plan the family made an allegation of abuse on 9/05/2024. Resident #1 was transferred to a new hall at the family's request and CNA A was suspended. CNA A completed inservice's on transfers and repositioning. The facility took the following actions to correct the non-compliance: Record review of the facility reported incident dated 9/5/2024 revealed the facility self-reported the allegation of abuse. The report stated the resident had no injuries or marks, and there was no reported emotional distress. The report alleged on 9/5/2024 at 8:45 AM, CNA A forcibly grabbed Resident #1's neck to pull him up in the bed before feeding him. The facility notified the physician and family, suspended the alleged perpetrator, assessed resident, conducted staff interviews, resident safe surveys, and conducted abuse prevention Inservice's. Record review of Progress Note dated 9/5/24 revealed a head-to-toe skin assessment was completed on 9/5/24. The wound care nurse performed the daily treatment, no new skin problems were noted, the back and neck area of the skin were normal. Record Review of the Witness Interview / Statement Form dated 9/5/24 written by CNA A, revealed that CNA A stated she entered Resident #1's room around 8:45 AM to assist with breakfast. CNA stated Resident #1 was leaning over to the left side of his bed. CNA A stated she held his shoulders to try to reposition him, but he resisted so CNA A left him leaning to his side. CNA A then went on to start feeding Resident #1 juice and coffee. CNA A also fed Resident #1 eggs, bacon, sausages, and toast. At 9 AM Resident #1's sitter arrived and took over the feeding. Record review of Abuse & Neglect In-service Form dated 9/9/24 revealed that the Director of Nursing performed in-service training to CNA A on 9/5/24. Record review of Safe Survey Forms dated 9/5/24 revealed that Safe Survey interviews with residents at the facility were completed by the Director of Nursing on 9/5/24. The interviews revealed that the residents have not been a victim of abuse and neglect at the facility, the residents were treated with dignity and respect at the facility, and the residents felt that the staff did care about them. Record Review of the Video Recording reviewed on 11/7/24 at 2:12 PM revealed that CNA A grabbed Resident #1 on the left side of his neck while he was leaned over on his left side. This was an attempt to reposition Resident #1 so that he would be sitting up straight in his bed. When CNA A pulled on Resident #1, he grimaced and appeared to be in pain for a moment. Interview on 11/7/24 at 2:01 PM with Familiar Party D revealed that CNA A grabbed Resident #1 by the neck to reposition him. She stated CNA A went into the room and saw Resident #1 leaning to the side. CNA A then immediately grabbed Resident #1 by the neck to move him so that he was sitting up straight. She stated she has a video recording of the incident and t Resident #1 grimaced on the video at the time that he was pulled by the neck. She stated the incident did not cause injury. She thought it was out of laziness and inappropriateness. Attempted Interview on 11/7/24 at 2:45 PM with Resident #1 revealed that Resident #1 was cognitively impaired and not able to verbally communicate effectively. Interview on 11/8/24 at 10:30 AM with the Director of Nursing C revealed that he was aware of the incident involving CNA A and Resident #1. He stated that he understood why the repositioning of Resident #1 by CNA A during his was inappropriate. He stated that Resident #1's family member has complained multiple times about him leaning so the staff felt like it was necessary to reposition him so that he could be sitting up straight. He stated that the family member often made comments such as he is leaning; how could you leave him like that. The staff have been trained to reposition him so that it meets his needs. He stated that after the incident occurred the facility immediately removed CNA A. He also stated that although CNA A has returned to the facility, she does work on Resident #1's hall any longer. He stated the facility performed an in-service on turning and repositioning after this incident occurred. He also stated Resident #1 now required a second person go in to help with positioning and transfers. He stated that CNA A understood why she was being suspended and separated from Resident #1. He stated the staff were also trained to contact somebody else for help if they had questions about repositioning. Director of Nursing C stated If I was by myself, I would use either the sheets or use the hand on his shoulder. Don't go to his neck or head area to reposition. He stated that CNA A should not have grabbed Resident #1 by his neck. The facility did perform an assessment to check for injury. There was no redness. There were no signs or symptoms of pain. Interview on 11/8/24 at 11:00 AM with Administrator B revealed that he was aware of the incident involving CNA A and Resident #1. He stated that the facility performed a self-report and suspended CNA A while the facility performed an investigation. He stated that CNA A performed Inservice training on how to properly perform transfers and repositioning when she returned. He believed that the incident occurred because CNA A was trying to reposition Resident #1 so that he was more comfortable. He stated that the family will complain if they see Resident #1 leaning over in bed. He stated that the family will make comments like why do you leave him leaning. He stated that normally if the resident was at an angle the staff should have laid the resident down to pick him up another way. He claimed that CNA A only pulled on Resident #1's neck one time. The staff stopped after they attempted to reposition him and realized that he was resisting and would not sit up straight. Interview on 11/8/24 at 11:52 AM with CNA A revealed she went into Resident #1's room to perform his breakfast feeding. Resident #1 was leaning sideways in the bed. CNA A stated that she wanted to reposition his head so that he could straighten up. CNA A stated the family always complained about him leaning. CNA A stated Resident #1 can control his head. CNA A stated when she tried to reposition him, she grabbed him by his neck and pulled to straighten him up, it did not work so he went back to his starting position again. CNA A left the resident in that position because she thought that he was comfortable that way. She stated that he was fine. He had no injury. CNA A stated that on the same day the DON called to ask her about the repositioning. Resident #1 has video monitoring in his room. CNA A explained what happened and the facility separated her from Resident #1. The staff performed an Inservice for repositioning. She stated that the DON also said that if the resident was total assistance, the staff need to get two people for repositioning. Get another CNA or nurse. She stated that she was told not to grab anyone by the neck again. Record Review of the Facility Transfer and Reposition Policy revised on 9/19/24, states that while repositioning in bed staff should not pull from head of bed and that manual patient repositioning was dangerous.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure adequate supervision and assistive devices were in place to prevent accidents for three of seven residents reviewed for fractures (Residents (R)3, R4, and R10). All three residents were elderly, demented, at risk for falls or had a history of falls, and exhibited unsafe and/or impulsive behaviors such as trying to get up and walk without assistance (when they required assistance). Each of these residents sustained falls resulting in fractures. The facility failed to provide the necessary level of supervision to ensure their safety and implement individualized interventions in response to their specific risk factors to prevent falls. Findings include: Review of the Fall Management Policy dated 06/04/20 revealed the facility would assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and would identify appropriate interventions to minimize the risk of injury related to falls. The policy indicated, Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. The determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. 1. Review of the Admission Record undated, in the electronic medical record (EMR) under the profile tab, revealed R3 was admitted to the facility on [DATE]. The resident was discharged to the hospital on 08/31/20; she did not return. The resident's closed record was reviewed. Review of the paper History and Physical dated 08/10/21 in the closed record revealed R3 had diagnoses including dementia, anxiety, depression, and [CONDITION(S)]. R3 was residing in a Memory Care assisted living facility when she fell on [DATE] and sustained both left hip and left wrist fractures. R3's hip was surgically repaired and her left wrist was placed in a cast. The resident was discharged to the facility for rehabilitation. R3 was noted to have [CONDITION(S)] and [CONDITION(S)] following the surgery and had a pneumonia that was treated with antibiotic medications in the hospital. Review of the Admission Minimum Data Set (MDS) dated [DATE], in the EMR under the MDS tab, revealed the resident was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) score of two out of 15. R3 had difficulty concentrating on things nearly every day. R3 exhibited no behaviors. R3 required extensive assistance of two persons for bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. R3 did not move from a seated to standing position, walk, turn around while walking or move on or off the toilet during the assessment period. R3 had impaired range of motion (ROM) to the upper extremity on one side and used a wheelchair for mobility. R3 had a fall with fracture in the previous six-month period and a fall since admission to the facility without injury. R3 was 5'5 tall and weighed 123 pounds. Review of the Falls CAA (Care Area Assessment) Worksheet dated 08/19/20 revealed R3 had difficulty maintaining sitting balance and had impaired balance during transitions. The resident was incontinent and had [CONDITION(S)]. Additional risk factors included hip fracture, [CONDITION(S)], infection, cognitive impairment, anxiety, and depression. The problem would be care planned with a goal to minimize risks and for the resident to have no fall related injuries. Review of an Event Note dated 08/07/21 at 1:35 PM, in the EMR under progress notes tab, revealed R3 was found in her room, half on the bed with her upper body lying on the right side of the bed by the window and her knees were on the floor. A Podus boot was on the resident' left foot and a non-skid sock was on the right foot. The call light was in easy reach. The resident was assisted to bed by two staff. She complained of left hip pain and was noted to be very confused. The physician assistant and family were notified and a left hip x-ray was ordered. The x-ray was negative for fracture. Review of a Health Status Note on 8/7/20 at 7:08 PM, in the EMR under the progress notes tab, revealed the resident was, trying to get out of bed constantly, redirected as needed . Will monitor call light in reach Review of a Health Status Note dated 08/08/20 at 11:17 AM, in the EMR under the progress notes tab revealed R3 was, trying to get out of bed constantly. Redirected as needed .Will monitor call light in reach. Review of a Skilled Note dated 08/19/20 at 9:20 AM revealed, Resident tried to get out of bed, staff got her up and transferred to wheelchair, staff assisted with breakfast. Sitting in nurse's station under constant supervision by staff, tried multiple times to get up from wheelchair, redirected. Redirection effective. Review of an Event Note dated 08/24/20 at 10:50 AM, in the EMR under the progress notes tab, revealed a nurse and CNA came out of a room and R3 was lying face down in A hallway with the wheelchair beside the resident, unlocked. R3 had nonskid socks on and the resident was checked for injuries and there was a 1 cm open area at the incision site with scant bleeding. The resident reported she got up and walked. Vitals and neuros completed. The physician, DON and family were notified. Review of a Health Status Note dated 08/25/21 at 11:00 AM, in the EMR under the Progress Notes tab, revealed, awake alert confused sitting at the nurses [sic] station for safety continue try to get out of wheelchair with out calling . Review of a Health Status Note dated 08/31/20 at 11:47 AM, in the EMR under the Progress Notes tab, Wound Doctor requested for this pt. [patient] to have stronger pain medications pain voiced upon wound care round with wound nurse. Resident remains on routine Tylenol. PRN [as needed]. Tylenol given at present as ordered per prn. and [doctor's name] also informed the above situation for possibility to get stronger pain medication. PA [Physician Assistant] informed and new STAT [immediate] x-ray ordered for left hip and family informed. Review of an Event Note dated 08/31/20 at 3:30 PM in the EMR under the progress notes tab, revealed, Late Entry: Note Text: The wound nurse reported to the resident's charge nurse that the patient was complaining of pain to the left hip. the charge nurse then notified the resident's physician. Order received for Left hip/Pelvis X Ray. Resident had a recent fall (8/24/20) but did not have any injuries or complain of pain to the Left hip at the time. The X- ray reported 'there is a fracture dislocation of the left hip joint.' MD and Resident brother, [name] was immediately notified and resident was sent out to the hospital . Although R3 sustained a fall on 08/07/20 and she was noted to be constantly trying to get out of bed or out of the wheelchair when she was unsafe to do so, which was documented on 08/07/20, 08/08/20, and 08/19/20, the facility failed to provide adequate supervision and implement interventions to address this risk factor. Review of the Care Plan dated 08/06/20, in the EMR under the care plan tab, identified a problem of Resident is at risk for falls. The goal was, The resident will not sustain serious injury requiring hospitalization through the review date. Approaches in full were: Assist with ADLs as needed; Call light within reach; Complete fall risk assessment; Mechanical lift; and Orient resident to room. After R3 sustained a fall on 08/07/21 the Care Plan dated 08/07/20, in the EMR under the care plan tab, identified the problem of, The resident has had an actual fall with no injury. Poor communication/comprehension. The goal was, The resident will resume usually activities without further incident through the review date. The interventions were, low bed; neuro-checks as ordered. The care plan was not updated following the fall on 08/24/20. During an interview on 08/11/21 at 9:31 AM, Family member (F)3 stated R3 was mentally incapacitated, was confused, and anxious as well as having [CONDITION(S)]. F3 stated R3 was moved to a room across from the nurse's station and put in a chair after the first fall; however, she got up out of the chair at nursing station, took off walking down the hall, fell and broke her hip again. F3 stated R3 had a history of falls prior to coming to the nursing home. F3 stated when R3 fell on [DATE], the staff did not think there was a fracture and x-rays were taken a couple times following the fall. F3 stated R3 did end up with a fracture and a second hip surgery. F3 stated R3 ended up going back to assisted living and onto hospice after her hospitalization on [DATE]. He stated he had been unable to visit R3 in the facility due to restrictions from COVID. During an interview on 08/10/21 at 2:34 PM, the Director of Rehab (DOR) stated R3 received physical and occupational therapy after being admitted to the facility. The DOR stated R3 -came into the facility following a hip replacement surgery and fractured wrist. The DOR stated the resident was very fidgety and was constantly trying to get up. The DOR stated constant supervision was needed to keep R3 safe. The DOR stated R3 required moderate assist prior to the fall on 08/24/20 and maximum assist after the fall. The DOR stated after 08/25/20, R3 was no longer able to walk, adding that the resident could not verbalize if something was wrong due to cognitive status and alertness barriers. The DOR stated, We talked to her family about increasing supervision. They expect us to. We have those conversations. The DOR stated the facility did not provide one to one supervision for residents. During an interview on 08/12/21 at 10:55 AM, MDS/LVN stated a low bed was implemented following the fall on 08/07/20; however, there were no new interventions implemented after the fall on 08/24/20. When asked about interventions for residents who continually tried to get up but were unsafe such as R3, MDS/LVN stated care plans were developed to put residents closer to the nurses' station or to increase supervision. MDS/LVN stated the facility implemented one to one supervision when the Physician wrote a Physician's order calling for it. During an interview on 08/12/21 at 1:52 PM, the Director of Nursing (DON) stated R3 was at high risk for falls. He stated staff brought the resident to the nursing station and tried to watch her. The DON stated after R3's fall on 08/24/20, there were no apparent injuries. X-rays were obtained on 08/31/20 and the resident had a fracture. The DON stated the facility did not do one to one supervision. He stated they asked the families to help if extra supervision was needed. The DON stated, If the MD writes an order (for one to one supervision), then we have to provide it. He stated the family could not afford to have a sitter. He stated it was the facility's responsibility to provide what the residents needed. During an interview on 08/10/21 at 1:31 PM, LVN1 stated she was on duty when R3 fell on [DATE] fell . LVN1 stated the resident was confused and got out in the middle of the hall, took a walk, and fell down on the floor, indicating there were no witnesses. She stated she got R3 up and checked her over and R3 had no injuries. LVN1 stated R3 thought she could walk but her knees were weak. LVN1 stated she thought it was a normal behavior, R3 trying to get up. LVN1 stated she did not remember interventions except for putting the bed in the low position. LVN1 stated R3 kept trying to get out of bed, even after the fall on 03/24/20. 2. Review of the Admission Record undated, in the EMR under the profile tab, revealed R4 was admitted to the facility on [DATE] after a hospital stay. R4 was discharged on [DATE]; R4's closed record was reviewed. Review of the paper History and Physical dated 11/20/20, in the closed record, revealed R4's active medical problems upon admission consisted of [CONDITION(S)], dementia, [CONDITION(S)] ([CONDITION(S)]), scoliosis, [CONDITION(S)], weakness of the right arm, and restless leg syndrome. R4's insight was impaired; she was not fully oriented. R4 was ambulatory. Review of the paper rehabilitation hospital Patient Discharge Instructions dated 11/18/20, in the closed record revealed the following diagnoses were the primary reason for R4's stay in the hospital: acute [CONDITION(S)] (stroke), [CONDITION(S)], [CONDITION(S)], and visual disturbance. The physical therapy discharge instructions indicated She required a walker for support when walking, needed someone with her for getting in and out of bed, and needed practice using a four wheeled walker. Review of the Admission MDS, dated [DATE], in the EMR under the MDS tab, revealed the BIMS test was not completed; the resident was impaired in memory and severely impaired in decision making. R4 had unclear speech, sometimes made herself understood, but rarely understood others. R4 exhibited continuous inattention, a sign and symptom of [CONDITION(S)]. R4 had trouble concentrating on things; R4 exhibited no behaviors. R4 required limited assistance of one person for bed mobility, transfers, and eating. R4 required extensive assistance of one staff for locomotion off the unit, dressing, and toilet use. R4 required supervision of one person to walk in the room, corridor, and on the unit. R4 was unsteady but could walk and turn around without assistance. R4 was not steady and required staff assistance to stabilize with moving from seated to standing, moving on and off the toilet and surface to surface transfers (transfer between bed and chair or wheelchair). R4 was impaired in upper extremity ROM one side and had experienced one fall with a major injury, Review of the Fall Risk Evaluation dated 11/18/20, in the EMR under the assessment tab, revealed R4 was at risk for falls; risk factors included requiring assistance for elimination, ambulation with problems and need for devices, partial physical support during balance test, age 85 or greater, and some high-risk health conditions and medications. Review of the Baseline Care Plan dated 11/18/20, in the EMR under the assessment tab, revealed R4 was at risk for falls. The goal was for the resident to not sustain serious injury requiring hospitalization . Interventions included assist with ADLs as needed; call light within reach; complete fall risk assessment; mechanical lift; orient resident to room; and ADL assistance and therapy services needed. Review of the Event Note dated 11/24/20 at 9:13 AM, in the EMR under the progress notes tab, revealed at 12:00 AM R4 was sleeping. At 1:15 AM R4 was calling for help. R4 was lying on the floor on her right side near the bed. The call light was not on. The resident refused to be assessed (whole body). R4 was assisted back to bed; she complained of pain in the right shoulder. Tylenol was administered and the on-call physician assist was notified and a Stat x-ray was ordered to the right shoulder. R4 was awake, confused, non-compliant and trying to get up and walk continuously unassisted. X-ray results were positive for a proximal right humerus fracture. A [MEDICATION(S)] (pain medication) patch was applied to the right shoulder, and [MEDICATION(S)] (narcotic pain medication) was prescribed. A right arm sling was applied with non-weight bearing status noted. The family and DON were notified. Review of the paper Provider Investigation Report dated 11/30/20 revealed the incident was reported to the State Survey Agency on 11/24/20 at 9:00 AM. The resident experienced an unwitnessed fall with injury. The resident was not independently ambulatory, not interviewable and did not have the capacity to make informed decisions. The resident had a history of falls. The resident was calling for help and was found sitting on the floor beside her bed. The resident was confused and aphasic and could not say what happened. The resident complained of pain to the right shoulder. The resident was assisted to bed and was sleeping an hour later. The resident's physician was notified and the resident's complaint of right shoulder pain. An order was received for right shoulder x-ray which revealed a minimally displaced acute fracture of the surgical neck of the proximal right humerus. An assessment of range of motion, head to toe skin assessment was done. The resident complained of pain to the right shoulder with movement. The resident was transferred to an orthopedic clinic. A fall risk assessment, pain assessment and incident report were completed. The physician and family were immediately notified. The physician saw the resident on the same day as the incident. Staff interviews were conducted. The investigation summary revealed the resident's fracture was determined to be a result of a fall. Staff interviews revealed the resident attempted to get up and out of the wheelchair or bed unassisted. The resident was seen sleeping at approximately 12:00 AM and then called out at approximately 1:00 AM. The fall likely occurred at or a few minutes prior to 1:00 AM because night staff did not recall hearing any other noises that would indicate a fall prior to the resident calling out at 1:00 AM. Action taken following the fall included in-service on abuse/neglect, in-service on fall prevention measures. An order to schedule an appointment with the orthopedic physician and [MEDICATION(S)] patch to be applied and [MEDICATION(S)] 50 mg 1 tablet every eight hours was prescribed as well as PRN [MEDICATION(S)]. A right arm sling was to be worn at all times and NWB status to the right upper extremity was prescribed. The resident's son was notified. Review of the paper Radiology Interpretation dated 11/24/21 in the investigative file revealed a minimally displaced acute fracture of the surgical neck of the proximal right humerus (arm). Review of the Care Plan dated 11/18/20, in the EMR under the care plan tab, revealed, Resident is at risk for falls with a goal of The resident will not sustain serious injury requiring hospitalization through the review date. Interventions in total were: Assist with ADLs as needed; Call light within reach; Complete fall risk assessment; Mechanical lift; and Orient resident to room. The care plan was not updated with any new interventions after R4's fall with fracture on 11/24/20 or after continuing unsafe behavior of getting up and walking without assistance. Review of Progress Notes after the 11/24/20 fall showed multiple entries of R4 being restless, getting up and walking without assistance and not being redirectable to safe practices: -Review of an Event Note dated 11/25/20, in the EMR under the progress notes tab, revealed, observed walking in the room, reoriented multiple times to use call light for help. -Review of an Event Note dated 11/27/20, in the EMR under the progress notes tab, revealed, Observed walking in the room, reoriented multiple times to use call light for help. -Review of a Skilled Note dated 11/29/20, in the EMR under the progress notes tab, revealed, very high risk for fall noted ambulating in the room by herself . call light in reach will continue to monitor. -Review of a Skilled Note dated 12/02/20, in the EMR under the progress notes tab, revealed, Resident up and down with lot of anxiety, fall risk, redirected as needed . needs assistance to bathroom X 1 assist, care provided as needed call light within reach. - Review of a Skilled Note dated 12/03/20, in the EMR under the progress notes tab, revealed, Resident up and down with lot of anxiety, fall risk, redirected as needed . Care provided as needed call light within reach. -Review of a Skilled Note dated 12/04/20, in the EMR under the progress notes tab, revealed, Screams frequently and tries to get out of wheelchair and walk, redirected and reoriented to use call light for help and let staff to assist with all transfers, frequent monitoring by staff . -Review of a Health Status Note dated 12/04/20, in the EMR under the progress notes tab, revealed, Resident transferred to room 101 (closer to nursing station) at 11:15 AM. - Review of a Health Status Note dated 12/04/20, in the EMR under the progress notes tab, revealed, Resident continues to be observed very difficult to redirect, Resident is so confused and doesn't follow instruction at all when re-directed . Resident continues to be a very high fall risk and being monitored for Risk for fall q (per) shift. -Review of a Skilled Note dated 12/05/20, in the EMR under the progress notes tab, revealed, Resident up and down propelling self in w/c [wheelchair], highly agitated, high fall risk, non-compliant with fall precaution, continue to redirect. Continuously getting out of the w/x walking. -Review of Skilled Notes dated 12/06/20, 12/07/20, 12/08/20, 12/09/20 in the EMR under the progress notes tab, revealed the same text, Resident up and down propelling self with w/c, highly agitated, high fall risk, non-compliant with fall precaution, continue to redirect. Continuously getting out of the w/c walking and going into other resident's rooms. Review of the Discharge Summary Information dated 12/10/20 in the EMR under the assessment tab, revealed R4 was discharged to a group home after completing her course of therapy. R4 required assistance of one person for ADLs and transfers and was to wear a sling to the right upper arm/shoulder at all times. R4 was confused and required redirecting constantly. During an interview on 08/11/21 at 9:37 AM, family member (F)4 stated R4 had been employed full time as realtor, living independently in a two-story home, until she had the stroke. He stated, after that, R4's brain became scrambled. F4 stated R4 was labeled a fall risk in the hospital. F4 stated in the hospital rehabilitation center, R4 was provided a sitter 24 hours a day to keep her safe. F4 stated after 10 days in rehab, R4 had to transfer to a different facility for skilled therapy. F4 stated R4 came to the facility and did not have a person assigned to her (sitter for one-to-one supervision). He stated that shortly after admission, She fell in the middle of the night trying to get to the bathroom and broke her arm . The care for a 24-hour sitter was not covered. F4 stated R4 could not communicate and had trouble asking for help. He stated R4 did not remember where the call button was located, staff showed her but she could not grasp it. F4 stated he asked the facility if they had a sitter for R4 and the bottom line was it was not covered. He stated the facility had not asked him to provide a sitter or to provide the supervision himself. During an interview on 08/10/21 at 2:49 PM, the Director of Rehab (DOR) stated R4 received physical therapy (PT), occupational therapy (OT) and speech therapy (ST) during her stay. The DOR stated R4 was confused, had [CONDITION(S)], was at high fall risk from day one, and was impulsive. The DOR stated when the resident was admitted , she could walk up to 100 feet with minimal assistance (able to use a walker). After the arm fracture, the resident was non-weight bearing on the right arm, but could still walk with hand held assistance; her arm was in a sling. During an interview on 08/10/21 at 12:03 PM, the Social Service Director (SSD) stated R4 was anxious at times, very confused, and hard of hearing. The SSD stated R4 was at risk for falls and all staff watched her. R4 resided in the room next to the nurse's station. The SSD stated F4 was asked if he could provide a sitter; the facility was unable to provide one. A sitter was not provided. During an interview on 08/11/21 at 3:26 PM, the Unit Manager/LVN stated hospitals told the families the facility would provide one to one supervision. She stated residents were watched closely for the first 24 hours following admission due to it being a new environment. The Unit Manager/LVN stated if residents needed increased supervision, the staff tried to bring them to the nursing station and engage them. She stated sometimes the Physician wrote an order for one-to-one supervision but it did not happen often. She stated one to one supervision was provided when ordered by the Physician. During an interview on 08/12/21 at 11:07 AM, MDS/LVN reviewed the care plan and stated she could not find updated interventions to prevent falls for R4 following the fall with fracture on 11/24/20. She stated the only thing she could find under the problem of incontinence was assisting the resident with toileting added on 12/03/20. During an interview on 08/12/21 at 2:10 PM, the DON stated he remembered asking the hospital if they had a sitter when considering admitting R4. He stated he was concerned about taking the resident. He stated it was the practice of the hospital to discontinue the sitter for 72 hours prior to nursing home admission, but that was not enough. He stated, the facility usually had meetings with the hospital and they said a sitter was a precaution and it was not a big deal. The DON stated R4 was active, going around the building back and forth. Staff were dealing with cognitive issues and tried to watch her. He stated, even so, one minute staff looked away and then boom, she fell . 3. 3. Review of the Admission Record undated, in the EMR under the profile tab, revealed R10 was admitted to the facility on [DATE]. Diagnoses at the time included abnormalities of breathing, polyneuropathy, and dementia without behavioral disturbance. Review of the Quarterly MDS dated [DATE], in the EMR under the MDS tab, revealed R10 had a BIMS of 4 out of 10 indicating severe cognitive impairment; she had no behavior. R10 exhibited signs and symptoms of [CONDITION(S)] continuously including inattention and disorganized thinking. R10 required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and hygiene. The resident was unsteady with balance during transitions and walking; the resident was unsteady and only able to stabilize with staff assistance. R10 had one fall since readmission/prior assessment with no injury. Review of the EMR revealed R10 experienced falls on 01/08/21, on 03/06/21, and on 06/01/21, and 06/05/21 and sustained two hip fractures as follows: Review of an Event Note dated 01/08/21 at 1:40 PM, in the EMR under the progress notes tab, revealed, CNA heard the resident calling out loudly for help. Resident [sic] found her sitting up on the floor beside the closet. The CNA immediately notified this nurse, assessment initiated right away, Resident stated I was trying to get to my closet to get my clothes to dress up when I lost balance and fell . small laceration noted on her inner four fingers with some bleeding, able to move Bilateral upper extremity, resident noted to be leaning towards her right side, Resident complained of pain with movement of Left Lower extremity, able to move Right lower extremity. I was trying to get to my closet to get my clothes to dress up when I lost balance and fell Neuro-checks initiated, Resident's MD [medical doctor] notified of the fall. Resident medicated for pain; order received to send resident to the ER [emergency room ] for evaluation. Resident transported to [name of hospital] for evaluation and treatment. Pain medication was helpful upon transfer to the hospital. Review of the History and Physical dated 01/31/21, in the paper chart, revealed R10 was admitted after being sent to the emergency room (ER) on 01/08/21 after a fall in which she sustained a left intertrochanteric fracture (hip fracture). The resident was then transferred back to the facility for rehabilitation. Review of the Care Plan dated 01/26/21, in the EMR under the care plan tab, revealed the focus of, Resident is at risk for falls. The goal was, The resident will not sustain serious injury requiring hospitalization through the next review date. Interventions in full were, Anticipate and meet the resident's needs; Assist with ADLs as needed; Call light within reach; provide adaptive equipment or devices as needed; and PT evaluated and treat as ordered or PRN. Review of an Event Note dated 03/06/21 at 11:30 PM, in the EMR under the progress notes tab revealed, CNA informed the Nurse that patient is on the floor. Nurse went to the room observed patient sitting on the floor nest [sic] to her bed, stated that she got up to use the bathroom and fall [sic], patient did not call for help, bed in low position, call light in place. Heart [sic] to toe assessment done, no injuries noted, able to move her extremities, denies pain at this time. Nurse educate patient to call for help when needed. Neuro check initiated and within normal limit. Assist x 2 staffs [sic] back to bed . supervisor and family [name] notified. No injuries were sustained from this fall. Review of the Care Plan in the EMR under the care plan tab did not include new interventions following this fall. This was verified by MDS/LVN on 08/12/21 at 11:58 AM. Review of an Event Note dated 06/01/21 at 9:07 PM, in the EMR under the progress notes tab revealed, Writer while coming back from the Restroom back to the Nursing station was called upon by Colleague that Resident was found on the floor in her room, Prior to fall while Writer was doing her Rounds on Writer Resumption at the Nursing station at 2:20 pm noted Resident was sitting comfortably on her wheel chair waiting to be served some ice cream and watching TV, Resident when asked if she needed anything then denied, and also denied pain. Resident was unable to describe what she was about doing but kept apologizing back to Writer saying I am so sorry. Resident was already re positioned prior to Writer arrival by Supervisors and Colleague, Writer went ahead to check VS [vital signs], Skin assessed as well on this shift no bruises of skin tear of any form noted, MD called X-ray order received for Bilateral hips and Pelvis which was done around dinner time with result still pending, Daughter called and notified, Neuro checks also initiated . Resident continues to be Non-compliant sometimes with Call light use and tries to self-transfer without waiting for help. Review of the Care Plan in the EMR under the care plan tab did not include new interventions following this fall. This was verified by MDS/LVN on 08/12/21 at 11:58 AM. Review of an Event Note date 06/05/21 at 4:23 PM, in the EMR under the progress notes tab, revealed, Called to the room by the staff and resident observed sitting on the floor near her bed. Resident denies any pain or discomfort upon transfer back to the w/c [wheelchair]. Neuro assessment and vitals completed. Resident unable to say what happened about the fall. Resident's daughter was here earlier to assist this resident with her lunch. Will continue to monitor. Review of an Event Note dated 06/06/21 at 8:17 PM, in the EMR under the progress notes tab revealed, Received report from ongoing nurse that resident had fallen and doctor ordered x rays for her bilateral hips. 10 pm, xray to bilateral hips done awaiting results. Resident sleeping, no moaning or pain reported at this time. 3:30 am called stat xray for results and they said they can't give me results over the phone and that they will fax me results, Results received and read, resident had r [right] hip fracture. Called the on-call agency and left report for a call back from MD, Md called back at 4 am and notified of abnormal xray report. Received an order to send resident to ER for Evaluation. DX r hip fracture. Daughter [name] notified . Resident transferred to ER at 4:45 am. Review of the paper Provider Investigation Report dated 06/08/21 in the investigative file revealed the fall with injury incident was reported to the state on 06/06/21 at 07:50 AM. The incident date was 06/05/21 at 3:30 PM. The resident required extensive assistance under functional ability. The resident was independently ambulatory but not interviewable and had a history of falls. The resident was found sitting on the floor next to her bed by staff and could not[TRUNCATED]