Every finding on record at Marbridge Villa

Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort, which included incorporating the recommendations from the Preadmission Screening and Resident Review level II determination and the Pre-admission Screening and Resident Review evaluation report into a resident's assessment, care planning and transitions of care for one (Resident #1) of six residents reviewed for Pre-admission Screening and Resident Review assessments. The facility failed to provide specialized services to Resident #1 as recommended and agreed upon by the Interdisciplinary Team (IDT). Findings: Record Review of Resident #1 ' s face sheet dated 07/23/2026 reflected the [AGE] year-old male resident was re-admitted to the facility on [DATE] with a diagnosis of Cognitive Communication Deficit (difficulties in communication that arise from impairments in cognitive processes such as attention, memory, perception, and executive function), Cerebral Palsy (is a neurological movement disorder characterized by high muscle tone (spasticity) causing severe stiffness and tightness, primarily affecting the legs more than the arms) and Lennox-Gastaut Syndrome (a complex and severe form of epilepsy that typically develops in children between ages 3 and 5). Record review of Resident #1's annual MDS assessment dated [DATE] reflected he had a BIMS score of 3 and indicates severe cognitive impairment and signaling major difficulties with memory, orientation, and recall. He required dependence on staff for eating, toileting hygiene, showering/bathing and personal hygiene. He required supervision or touching assistance when moving from seated position to standing, from chair or bed to chair transfer or toilet transfer. He required partial to moderate assistance when walking 10 feet on uneven surfaces. He used a manual wheelchair. Record review of Resident #1's Comprehensive Care Plan initiated on 04/26/2026 and last revised on 04/29/2026 reflected Resident #1 has been identified as having PASRR positive status related to an intellectual disability, Cerebral Palsy. His interventions indicated: Resident #1 requires Nursing Facility specialized services of PT, OT and ST to maintain his highest level of practicable well- being. needs assistance to participate in activities due to impaired mobility, impaired vision. Goal is Resident will verbalize desire to attend activities. Interventions: staff will engage Resident # 1 in group activities. Record Review of Resident #1's first PASRR Evaluation dated 03/12/2026 revealed the MHMR Authority of the local county determined he was eligible for PASSRR services due to an Intellectual Disability and a Developmental Disability. Record review of Resident #1's 2nd PASRR evaluation dated 04/22/2026 revealed it was determined that Resident #1 was PASRR positive due to Intellectual Disability and Developmental Disability. Record review of Resident # 1's PASRR Evaluation meeting dated 04/29/2026 revealed he was Medicaid eligible and Specialized Services and a Specialized or Treated Pressure- Reducing Support Surface Mattress were approved. Record review of Resident #1's progress notes dated 04/29/2026 revealed an initial care plan meeting was held for Resident # 1. The resident's family member and the PASRR Habilitation Coordinator were present. It was determined that IDT would continue to monitor and assist. Record review of Resident #1's progress notes dated 07/15/2026 revealed a quarterly care conference was held. The resident's family member was on the phone and the PASRR Habilitation Coordinator was present. Resident #1 was going to be evaluated for PT, OT and ST and he was on current on restorative. During an interview on 07/23/2026 at 9:00 a.m., the ADM stated, This facility is unique in that the facility is for residents who have both a diagnosis of IDD and who also need skilled services. The ADM stated the facility catered to those who were on Medicaid and who were PASRR positive. The ADM stated that the Rehabilitation Manager was responsible for PASRR compliance and she was out on leave when Resident #1 was admitted to the facility. He stated the ST filled in for the Rehabilitation Manager, and she was responsible for the PASRR compliance. The ADM said, The problem here is that people did not get their stuff together and he never was in need of a specialized mattress. He stated the ST was not familiar with how to stop the process in TMHP. The ADM stated, Nothing was delayed for [Resident #1's] care but the facility failed to use the proper channels to cancel the request for a specialized mattress. He stated, staff did not provide the Medicaid requested information in a timely manner. He said the SW was responsible for making first contact with prospective residents and for obtaining the PL1 if it was available.The ADM stated Resident # 1 was admitted to the facility with a known ID and he was PASRR positive. The ADM stated that was notified of Resident # 1's PASRR status. During an interview on 07/23/2026 at 9:20 a.m., the SW stated the specific mission of the facility was to care for residents with ID and who need skilled services. The SW said prescreen all residents, so she knew before they are admitted to the facility of their PASRR status, the facility only took PASRR positive residents or private pay. The SW said it was determined at the IDT meeting 4/29/2026 that a specialized mattress was required for the resident. At that time the referral for the specialized mattress was requested along with PT, OT and ST. She said both the Habilitation Coordinator and herself are responsible for submitting a referral to TMHP portal. The SW stated Resident # 1 was assigned a Habilitation Coordinator as a PASRR Service Coordinator. During an interview on 07/23/2026 at 10:39 a.m., the Rehabilitation Manager stated the facility's process for PASRR as, they did therapy screening before they make a request for PT, OT or ST or for durable medical equipment. It is responsibility to submit the evaluation to TMHP and they tell if that service has been approved or not. If a request is denied, they have a certain amount of time to resubmit the request and to provide proof supporting that need for that request. She stated, she did not make the request on TMHP for services for Resident # 1 and she was on leave when Resident # 1 was admitted . The Rehabilitation Manager stated the request for services and for a specialized mattress was made by ST as she was filling in for her. She stated the ST received a noncompliance request for additional information regarding the need for a specialized mattress. During an interview on 07/23/2026 at 11:44 a.m., the ST stated she was responsible when the Rehabilitation Manager was out on leave and when Resident # 1 was admitted to the facility. She stated, I did not enter any requests on the TMHP site for this resident. I didn't request a mattress. I believe the Rehab Coordinator did that. She stated a request for services or specialized equipment requires them to sign a document confirming the need. She stated the Rehab Coordinator should know who signed for the equipment.The ST stated on 6/17/26, the ADM forwarded an email from the PASRR Compliance unit to her. The ST stated, on 6/19/2026 she sent and an EM to the PASRR Support, and told them, We have re-evaluated the need for this item and have determined that at this time it will no longer be required.Record review on 07/23/2026 of an email titled: PASRR NFSS Compliance Request. The email reflected: within 20 business days following the date that the services are agreed to in the IDT meeting.If the resident is still in your nursing facility, you must submit a request for the PASRR specialized services agreed to during the IDT meeting within 3 business days for therapies and five business days for DMEs or CMWCs of receiving this email (this would be June 24, 2026).Record review on 07/23/2026 of an email dated 06/18/2026 reflected: the SW forwarded an email from PASRR Support, regarding the issue of noncompliance. The email reflected: As a reminder, during the IDT meeting documented on this PCSP form, PASRR Specialized Services DME products were recommended and agreed upon by the SP team. However, our records indicate that no NFSS request has been submitted for this individual (no paperwork was submitted.) During an interview on 07/23/2026 at 1:28 p.m., Habilitation Coordinator stated that she was aware that in the IDT meeting on 4/29/2026 everyone agreed that Resident # 1 would benefit from a specialized mattress. She stated that the Therapy Manager was usually responsible for requesting services on the portal, but the ST was filling in for her at the time Resident # 1 was being evaluated. She stated the SW was responsible for adjusting the information on the portal and said, I entered the information regarding my position. During an interview on 07/23/2026 @ 2:05 p.m., QM stated that she was with the PASRR compliance unit. She said, This facility was out of compliance regarding [Resident # 1's] PASRR timeline of 5 days. She stated, On 6/17/2026 I wrote to the administrator they were already out of compliance. On 6/26/2026 I sent a follow-up email to administrator and I received no response until 7/15/2026. They sent the needed information that explained that the resident no longer requires the requested DME. Record review of policy:admission Criteria And PASRR- dated 2001, revision date of March 2019.Policy StatementOur facility admits only residents who's medical and nursing care needs can be met.The objective of our admission criteria policy is to:provide uniform criteria for admitting residents to the facility. 6. Residents are admitted to this facility if their needs can be met adequately by the facility. 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders per the Medicaid Pre-admission Screening and Resident review (PASRR) Process. a. The facility conducts a Level I PASRR screen for all potential admissions regardless of payer source, to determine if the individual meets the criteria for an MD, ID or other related disorders. 2. The Social worker is responsible for making referral to the appropriate state- designated authority. c. upon completion of the Level II evaluation, the state PASRR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. e. the Interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential residents that are outlined in the evaluation. f. Once a decision is made, the state PASRR representative, the potential resident and his or her representative are notified.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services.The facility failed to ensure food was properly labeled and dated in the main cooler and freezer. This deficient practice could place residents at risk for health complications and foodborne illnesses.An observation on 7/07/2026 at 9:05 AM revealed a bag of 12 pressed flour tortillas that were stored without the required labeling and date marking. An observation on 7/7/2026 at 9:06 AM revealed a silver pan of unknown food that was stored without the required labeling and date marking. An observation on 7/7/2026 at 9:06 AM revealed a bottle of sweet Chilli sauce that was stored without the required labeling and date marking. An observation on 7/7/2026, at 9:07 AM revealed a large bag of spinach that was stored without the required labeling and date marking.An observation on 7/7/2026 at 9:07 AM revealed a large silver pan of macaroni salad that was stored without the required labeling and date marking.An observation on 7/7/2026 at 9:07 AM revealed a large frozen package of single serve bread that was stored without the required labeling and date marking.An observation on 7/7/2026 at 9:08 AM revealed a small package of bread that was stored without the required labeling and date marking.An observation on 7/7/2026 at 9:09 AM revealed a frozen package of hot link sausage that was stored without the required labeling and date marking.In an interview on 7/9/2026 at 10:22 AM, DA F stated food items should be labeled when they were opened and when he did it, he included the open date, expiration date, and initials. To determine what date to write on the container or package he stated for items like milk he labeled the item for 4-5 days, then it was his responsibility to check daily for items that must be discarded. He stated the facility currently used the first in first out system to ensure older food were used before newer items arrived. He stated if food was not properly labeled and dated residents could become sick. In an interview on 07/09/2026 at 10:37 AM, DA G stated food items should be labeled when they were opened. When asked what information should be included on the label, she stated the date, item name, and expiration date. She stated the facility used the first in first out method to ensure items were discarded by their expiration date. She stated she was required to take yearly training, and if items were not labeled and dated properly residents could be exposed to sickness or illness. In an interview on 07/09/2026 at 10:46AM, the DSM stated it was her expectation all items in the kitchen were labeled and dated. She expected the label would include the date, item name, initials, expiration date, and throw out date. She stated the facility used a standard guideline of three to five days especially for dairy to determine the date. She stated her staff used a first-in-first out sticker and were required to rotate items to ensure older items were used before newer items. She stated she was trained in food and nutrition. She stated if food items were not properly labeled and dated residents could become ill.Record review of the facility's policy titled, Food Storage, dated 2023, reflected:12. leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2022 Federal Food Code. (Also see policy on Use of Leftovers later in this chapter.) Check state regulations as some states may allow shorter time frames for the use of leftovers.

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 2 of 2 residents (Resident #7 and Resident #79) reviewed for infection prevention. 1. The facility failed to ensure CNA C was following the proper infection control protocols while providing incontinent care with Foley catheter to Resident #7. 2. The facility failed to ensure Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols were implemented when LVN A and MA D provided wound care for Resident #79. 3. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when LVN B and LVN E provided wound care for Resident #79. These deficient practices could place residents at risk for cross contamination and the spread of infection. Finding included:1. Record review of Resident #7's, undated, face sheet reflected a [AGE] year-old male with an admission date of 12/16/2026. Resident #7 had diagnoses which included urinary tract infection, site not specified (an infection but is not pinpointed if it is in the bladder or kidneys), presence of urogenital implants (medical devices or artificial materials placed within the urinary organs or genitals), urinary retention (inability to fully empty a bladder), unspecified Intellectual Disability (clinical diagnosis given to individuals over the age of five when a standard, comprehensive assessment of intellectual functioning cannot be properly completed), benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland that commonly causes lower urinary tract symptoms in aging men), cognitive communication deficit (difficulties with communication caused by disrupted thinking skills rather than a primary speech or language impairment).Record review of Resident #7's quarterly MDS assessment, dated 04/29/2026, reflected no BIMS score indicated. The MDS reflected Resident #7's cognitive skills for daily decision making were moderately impaired. Resident #7 needed substantial/maximal assistance with toileting hygiene and showering/bathing. Resident #7 required intermittent catheterization and he was frequently incontinent.Record review of Resident #7's, undated, care plan reflected a Focus which included: Enhanced Barrier Precautions r/t Colostomy, Foley, GT Interventions included: Maintain enhanced barrier precautions as outline in nursing home policy.Focus also included: Alteration in bladder function requiring an indwelling catheter r/t Urine Retention.Interventions included: Catheter: Resident # 7 has 16FR/10cc Foley Catheter. Position catheter bag and tubing below the level of the bladderand away from entrance room door. Foley catheter care q shift related to presence of urogenital implants. Monitor and document intake and output as per facility policy. Monitor for s/sx of discomfort on urination and frequency. Monitor/record/report to MD for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.Record review of Resident #7's order summary report reflected:Change Foley catheter and drainage bag each monthon the 22nd. 16FR/10cc every night shift starting on the 22nd and ending on the 22nd every month relatedto other Retention of Urine. Start date: 02/22/2026Foley catheter care q shift. every shift related to presence of urogenital implants, other retention of urine. Start date: 01/23/2026.Record urine output every shift for monitoring. Start date: 01/23/2026.During observation of care on 07/07/2026 at 3:00 p.m. revealed Resident # 7's room had an EBP sign on his door; PPE was available inside of Resident #7's room. CNA C entered Resident #7's room without sanitizing her hands; she put PPE on. She closed the window blinds in the room and assisted Resident #7 from his wheelchair to the bed. Resident #7's Foley bag was leaking urine on the floor. CNA C wiped the urine on the floor using paper towels. CNA C tossed the paper towels saturated with urine in the bathroom's trash can. She washed her hands and donned (putting on) disposable gloves. CNA C pulled down Resident #7's pants and released the tabs on both sides of the incontinence briefs and tucked the briefs under the resident's body. CNA C pulled out approximately 7-8 sheets of the wipes out of the wipes' container and placed them next to the left side of the resident's body on the bed. CNA C performed incontinent care using one cleaning wipe for one swipe, front to back and placed dirty wipes between the resident's legs. CNA C did not clean resident's Foley catheter. CNA C assisted Resident #7 to turn to his left side, where the resident was facing CNA C. She removed the dirty gloves and without sanitizing her hands she donned clean gloves. CNA C cleaned the resident's right side of his buttocks. CNA C did not clean Resident #7's left side buttocks and his anal area. CNA C removed her gloves and put on new gloves; she removed the resident's dirty briefs and the dirty wipes she left between the resident's legs. CNA C applied new briefs to the resident, pulled the resident's pants up and assisted him to his wheelchair. CNA C removed her gown, gathered trash, removed her gloves and exited the resident's room. CNA C did not wash her hands after providing incontinent care for the high contact resident. CNA C did not sanitize her hands after exiting Resident #7's room. 2. Record review of Resident #79's, undated, face sheet reflected a 55-years-old male with an original admission date 02/14/2014 and with admission date 10/24/2019. Resident #79 had diagnoses which included expressive language disorder (communication condition where an individual struggles to convey thoughts, ideas, or feelings through spoken or written language), hemiplegia (complete paralysis) and hemiparesis (weakness) on the left side of the body result from damage to the right side of the brain due to a cerebral infarction (stroke), cognitive communication deficit (difficulty with speech or interaction stemming from disrupted brain functions like memory, attention, or executive function, rather than a primary language or physical speech impairment), need for assistance with personal care (assistance with personal care includes help with Activities of Daily Living (ADLs) such as bathing, dressing, grooming, toileting, and mobility assist).Record review of Resident #79's quarterly MDS assessment, dated 05/17/2026, reflected a BIMS score of 07, which indicated severe cognitive impairment. Resident #79 was dependent on helper for toileting hygiene, lower body dressing, putting on/taking off footwear.Record review of Resident #79's, undated, care plan reflected a Focus which included: Resident #79 has actual impairment to skin integrity r/t: Left Heel Open Blister Opened 11/18/25.This problem area included the following interventions: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration to MD.Resident # 79's care plan also reflected a Focus which included: Activities deficit: r/t cognitive impairment, episodes of confusion, impaired decision making, impaired mobility, unclear speech.This problem area included the following interventions: Engage resident in group activities. Will monitor level of participation. Activity Staff. Involve Resident #79 in making own schedule/sequencing of activities. Activity StaffResident #79 needs assistance to participate in activities, both encouragement and transportation. Will communicate with related staff about specific needs concerning activities &events. Will offer calendar of activities and events.Record review of Resident #79 order summary report reflected: Wound care order/left foot posterior: Cleanse area with normal saline, gently pat dry with gauze, apply xeroform (cut to size of wound bed), cover with foam and secure with tape. Wound care should be completed daily and PRN soiled/dislodged. Every evening shift for Skin Care/Prevent skin breakdown Complete wound care after showers onMWF. Start date: 07/01/2026. Resident #79 requires Enhanced Barrier Precautions. Every shift.: Start date: 06/19/2026.During observation of wound care on 07/07/2026 at 3:00 p.m. revealed Resident #79's room had an EBP sign on his door; PPE was available inside of Resident #79's room. LVN A and CMA D entered Resident # 79's room without sanitizing their hands and putting gowns on. LVN A and CMA D donned (putting on) disposable gloves without washing their hands. LVN A sanitized the surface of the over bed table, she put a piece of white paper on the top of the table and then she placed a small plastic tray with wound care supplies on the top of it. CMA D assisted Resident # 79 to position on his bed and lifted Resident #79's left leg for easy access to the wound on his heel area. LVN A proceeded to remove resident's wound dressing without removing her gloves and performing hand hygiene. LVN A started preparing the wound supplies by opening them and placing them on white paper without removing her gloves and performing proper hand hygiene. LVN A removed her gloves and sanitized her hands before she started cleaning the resident's wound area with normal saline. She used three gauzes with normal saline for each wipe. LVN A applied new dressing on the resident's heel without removing her gloves. She put Resident #79's pressure-reliving boots on his feet. LVN A and CMA D removed their gloves and discarded them into the trash can. LVN A and CMA D did not wash their hands after removing gloves. LVN A took a small plastic tray with the remaining wound care supplies and scissors and exited the resident's room. LVN A placed the plastic tray with reusable wound care supplies inside of the treatment cart without disinfecting the tray and reusable wound care supplies. LVN A and CMA D did not wash their hands with soap and water or sanitize their hands with hand sanitizer after existing the Resident #79's room.Observation on 07/08/2026 at 10:38 AM, revealed there was a sign which indicated Enhanced Barrier Precautions on the door to Resident #79's room. There was a supply of PPE available inside of the room at the door. LVN A and LVN E had their gloves on but did not wear a gown while providing wound care for high contact resident.During an interview on 07/09/26 at 9:31 a.m., LVN A she stated she had her infection control training during onboarding to this job about 2 months ago. She stated the infection control training covered performing proper hand hygiene, wearing PPEs while providing care to the residents with Foley catheters, wounds, G-tubes in the EBP rooms. She stated it was her mistake that she did not put on a gown while providing wound care to Resident #79 in the EBP room yesterday. She stated she thought the resident's wound had to be big to require wearing a gown for wound care. She stated she was not aware wearing gown was required for any skin opening that required dressing. LVN A stated that not following enhanced barrier precaution protocol while providing wound care for high contact resident could potentially spread infection and cause other residents to get sick.During an interview on 07/09/26 at 9:38 a.m. with LVN H, she stated her last infection control in service training was sometime back in February or March. She stated training covered hand hygiene protocols, different types of room precautions, including rooms in EBP and what PPEs to be used when cared for the residents in EBP rooms. LVN H stated she did not put a gown on while changing Resident #79's wound dressing because she thought the EBP sign on the door was for his roommate who had g-tube in place. She stated she thought since Resident #79's wound was healed it was not required to wear a gown during the dressing change. She stated she found out the facility policy stated wearing PPEs was required for any skin opening that needed a dressing.During an interview on 07/09/2026 at 11:07 a.m. with CNA C, she stated she had been working at the facility for over 20 years. She stated she was trained on incontinent care and infection control; she stated her last incontinent care training was in January of this year. CNA C stated it was hands on and paperwork training. CNA C stated when providing incontinent care for a male with Foley bag CNAs were expected to use one wipe for one swipe; first to wipe the head part of penis, then pull the skin down and clean it. She could not recall if she cleaned Resident #7's Foley catheter. She stated she did not sanitize the floor after wiping off the urine on the floor because there were no satanizing wipes in the room. CNA C stated that she could not recall putting dirty wipes between Resident #7's legs. CNA C stated that she did clean the resident's Foley catheter. CNA C stated she did not sanitize her hands between gloves because she did not have the hand sanitizer in the room. She stated not following the proper hand hygiene and incontinent care procedures could affect residents badly, they could get bacteria and UTIs and they could get really sick. During an interview on 07/09/26 at 1:21 p.m. with the DON, she stated her last infection control was on HHS' website; it covered different types of rooms' precautions, proper hand hygiene protocols. She stated staff were expected to sanitize their hands before going to the residents' rooms and right after coming out of the residents' rooms. The DON stated staff must wash hands before starting and after providing care for high contact residents. She stated the EBP signs on the residents' doors were to indicate if it was for the residents' bed A or the resident's bed B. The DON stated staff were expected to follow proper hand hygiene during providing residents' care and to wear PPE while providing care for the residents with wounds, Foley bags and g-tubes. She stated while providing incontinent care for the residents staff were expected to use one wipe for one swipe and then toss the dirty wipe into the trash can and not leave it between the resident's legs. The DON stated it was not acceptable to pull out multiple wipes and place them next to the resident's body to be used for incontinent care because it was an infection control issue. She stated when incontinent care was provided for a male resident with a Foley catheter staff were expected to wipe the Foley catheter away from the insertion site at the penis to remove any germs. She stated not providing proper incontinent care to the residents could potentially cause UTIs. The DON stated any urine spills on the floor were to be properly handled following infection control protocol; paper towels to soak up the urine and then the purple wipes to disinfect the area. Not following infection control protocol may spread infection among residents and staff.During an interview on 07/09/26 at 1:21 p.m. with the ADON, she stated she provided infection control training for the facility staff. Infection control training and in services covered hand hygiene, wound care, incontinent care, prevention of viruses, types of precautions and what PPE to be used. She stated staff were expected to use one wipe for one stroke and throw the used wipe into the trash can. She stated clean wipes must be pulled out of the wipes' container one at a time, not multiple clean wipes to be placed at the resident's body and to be used for incontinent care. The ADON stated staff were to sanitize their hands after removing gloves and before putting on new gloves while providing care for the residents in EBP rooms. She stated during incontinent care for the male resident with Foley catheter, staff were expected to clean the Foley catheter away from the insertion site at the penis to prevent infection problems and potential UTIs. The ADON stated any urine on the floor must be cleaned by using paper towels and then disinfected by using wipes from the containers with a purple top. ADON stated she started educating staff in wound care procedures for the residents in EBP rooms. Her understanding was PPEs were used only for the residents with chronic wounds. She stated staff were expected to wear PPE when providing care for the residents with skin dressings. The ADON stated staff expected to wash their hands and put on gloves before applying a new dressing on the residents' wounds. The ADON stated reusable wound care supplies must be sanitized before they returned to the treatment cart.During an interview on 07/09/26 at 1:33 p.m. with the ADM, he stated he had been working at the facility for 11 years. He stated he was trained in the infection control, this was HHS required training which covered hand hygiene, spread of infection, and how to monitor and prevent spread of infection. The ADM stated staff were expected to follow proper hand hygiene procedures and to sanitize their hands before going to the residents' rooms and right after leaving the rooms. The ADM stated staff were expected to follow the EBP protocol and to wear PPE when providing care to the residents in EBP rooms; not following the infection control protocols could potentially lead to the spread of infection among the residents.Attempted telephone interview with LVN A on 07/08/2026 was unsuccessful. A voicemail was left requesting a return call. During an interview on 07/09/26 at 2:26 p.m. with MA D, she stated she did not wear a gown while providing wound care to Resident #79 on 07/07/2026. She stated the EBP sign on the resident's door was for Resident 79's roommate who had a g-tube. MA D stated she was assisting LVN A by holding Resident 79's leg for easy access to his wound and she did not provide the actual wound care. She stated staff were expected to sanitize hands before entering the residents' rooms and after exiting the rooms. She stated hand washing and putting new gloves on was required before applying new wound dressing to prevent cross contamination. Record review of the facility's policy titled, Catheter Care, Urinary with revision Date: August 2022 reflected: Steps in the procedure:Routine Perineal Hygiene2. Wash and dry your hands thoroughly.5. Put on gloves.6. Provide privacy.For a male resident:h. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.m. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks.23. Wash and dry your hands thoroughly.Record review of the facility's policy titled, Enhanced Barrier Precautions, with revision date 12/2024, reflected: Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include:j. wound care (any skin opening requiring a dressing).Record review of the facility policy titled, Wound Care, with revision date: 04/2026, reflected: Clean the wound:1. Apply clean gloves.2. Place a piece of gauze over the wound, leaving the margins of intact skin exposed.3. Clean the area around the wound usually covered by the dressing, tape, or gauze with antiseptic or soap and water.4. Remove dry gauze from the wound5. Clean and apply treatments as ordered.6. Apply appropriate dressing. [NAME] tape with initials, date, and time and apply to dressing.7. Remove the disposable cloth next to the resident and discard into the designated container.8. Discard disposable items into the designated container.9. Place all soiled laundry, linen, towels, and washcloths into the soiled laundry container.10. Remove disposable gloves and discard into designated container.11. Perform hand hygiene.12. Reposition the bed covers.13. Make the resident comfortable. Use supportive devices as instructed.14. Place the call light within easy reach of the resident.15. Use clean field saturated with alcohol to wipe overbed table.16. Return the overbed table to its proper position.17. Wipe reusable supplies with alcohol as indicated (i.e., outsides of containers that were touched by unclean hands, scissor blades, etc.). Return reusable supplies to resident's drawer in treatment cart.

Based on observation, interview and record review the facility failed to ensure the resident had the right to personal privacy including accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups for 1 of 2 residents (Resident #7) reviewed for privacy. The facility failed to ensure CNA C provided privacy by drawing the privacy curtain during incontinent care for Resident #7. This failure could place residents at risk of feeling embarrassed, diminish the residents' quality of life and not having resident rights acknowledged. Findings Included: Record review of Resident #7's, undated, face sheet reflected a 69-years-old male with an admission date of 12/16/2026. Resident #7 had diagnoses which included urinary tract infection, site not specified (an infection but is not pinpointed if it is in the bladder or kidneys), presence of urogenital implants (medical devices or artificial materials placed within the urinary organs or genitals), urinary retention (inability to fully empty a bladder), unspecified Intellectual Disability (clinical diagnosis given to individuals over the age of five when a standard, comprehensive assessment of intellectual functioning cannot be properly completed), benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland that commonly causes lower urinary tract symptoms in aging men), cognitive communication deficit (difficulties with communication caused by disrupted thinking skills rather than a primary speech or language impairment). Record review of Resident #7's quarterly MDS assessment, dated 04/29/2026, reflected no BIMS score was indicated. Resident #7's cognitive skills for daily decision making were moderately impaired. Resident #7 needed substantial/maximal assistance with toileting hygiene and showering/bathing. Resident #7 required intermittent catheterization and he was frequently incontinent. Record review of Resident #7's, undated, care plan reflected a Focus which included: Enhanced Barrier Precautions r/t Colostomy, Foley, GT Interventions included: Maintain enhanced barrier precautions as outline in nursing home policy. Focus also included: Alteration in bladder function requiring an indwelling catheter r/t Urine Retention. Interventions included: Catheter: [Resident # 7] has 16FR/10cc Foley Catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Foley catheter care q shift related to presence of urogenital implants. Monitor and document intake and output as per facility policy. Monitor for s/sx of discomfort on urination and frequency. Monitor/record/report to MD for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Record review of Resident #7's order summary report reflected the following: Change Foley catheter and drainage bag each month on the 22nd. 16FR/10cc every night shift starting on the 22nd and ending on the 22nd every month related to other Retention of Urine. Start date: 02/22/2026 Foley catheter care q shift. every shift related to presence of urogenital implants, other retention of urine. Start date: 01/23/2026. Record urine output every shift for monitoring. Start date: 01/23/2026. During an observation of perineal care with indwelling catheter on 07/07/2026 at 2:30 p.m., CNA C was providing incontinent care to Resident #7. CNA C did not pull the privacy curtain therefore exposing Resident #7 who was nude from the waist down. Resident #7's roommate Resident #63 was in room, and he was drawing pictures during the incontinent care. During an interview on 07/09/2026 at 11:07 a.m. with CNA C, she stated Resident #7's roommate Resident #63 was in the room while she was providing incontinent care to Resident #7. She stated Resident #63 was coloring pictures. She stated Resident #63 could not speak but it could make him uncomfortable when seeing his roommate exposed during the incontinent care. CNA C stated that she forgot to pull Resident #7's privacy curtain. CNA C stated Resident #7 could be embarrassed and upset when other people see his private body parts. During an interview on 07/09/26 at 1:21 p.m. with the DON, she stated staff were expected to pull the privacy curtains while providing care to the residents because it was a dignity issue. Residents could get embarrassed and upset. During an interview on 07/09/26 at 1:21 p.m. with the ADON, she stated staff were expected to provide privacy by pulling the privacy curtains while providing any care for the residents. She stated it was very important because it was dignity of the residents. Record review of the facility's policy titled Catheter Care, Urinary, with revision Date: August 2022, reflected: Routine Perineal Hygiene 6. Provide privacy.

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 of 3 residents (Resident #17) for incontinence and catheter. The facility failed to ensure CNA C cleaned Resident #7's penis around the catheter while providing incontinent care on 07/07/2026. This failure could place residents at risk of urinary tract infection.Findings included: Record review of Resident #7's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included urinary tract infection, presence of urogenital implants (surgically placed medical devices aiding urination and the urinary system), retention of urine, metabolic encephalopathy (condition where the brain does not function normally due to a chemical imbalance), microcephaly (rare condition in which the head is smaller than normal at birth due to lack of brain development), intellectual disabilities, cognitive communication deficit (trouble communicating due to cognitive impairment), and benign prostatic hyperplasia (enlarged prostate causing urinary symptoms). Record review of Resident #7's quarterly MDS assessment, dated 06/15/2026, reflected a BIMS score of 03, which indicated severe cognitive impairment. Resident #7 had an indwelling catheter and required substantial/maximal assistance with bathing (the resident does not toilet in the traditional sense due to the catheter, but bathing applies to the care required to ensure cleanliness of his catheter). Record review of Resident #7's care plan, dated 03/17/2026, reflected the following: FOCUSAlteration In Bladder:Indwelling CaterterR/T Urine RetentionGOAL (Resident #7) will have adequateurinary output during next90days (Resident #7) will show no s/sx ofUrinary infection through reviewdate.INTERVENTIONS CATHETER: (Resident #7) has 16FR/10cc Foley Catheter. Position catheter bag andtubing below the level of the bladder and away from entrance room door. Foley catheter care q shift.every shift related to presence of urogenital implants Monitor and document intake and output as per facility policy. Monitor for s/sx of discomfort on urination and frequency. Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine,cloudiness, no output, deepening of urine color, increased pulse, increased temp,Urinary frequency, foul smelling urine, fever, chills, altered mental status, change inbehavior, change in eating patterns. During observation of care in Resident #7's room on 07/07/2026 at 3:00 p.m., CNA C washed her hands and donned (putting on) disposable gloves. CNA C pulled down Resident #7's pants and released the tabs on both sides of the incontinence briefs and tucked the briefs under the resident's body. CNA C pulled out approximately 7-8 sheets of the wipes out of the wipes' container and placed them next to the left side of the resident's body on the bed. CNA C did not clean the penis around resident's Foley catheter. CNA C applied new briefs to the resident, pulled the resident's pants up and assisted him to his wheelchair. During an interview on 07/09/2026 at 11:07 a.m. with CNA C, she stated she had worked at the facility for over 20 years. CNA C stated when providing incontinent care for a male with Foley bag, CNAs were expected to use one wipe for one swipe; first to wipe the head part of the penis, then pull the skin down and clean it. She could not recall if she cleaned Resident #7's Foley catheter. She stated not following the proper hand hygiene and incontinent care procedures could affect residents badly, they could get bacteria and UTIs and they could get really sick. During an interview on 07/09/26 at 1:21 p.m., the DON, she stated when incontinent care was provided for a male resident with Foley catheter staff were expected to wipe the Foley catheter away from the insertion site at the penis to remove any germs. She stated not providing proper incontinent care to the residents could potentially cause UTIs. Not following infection control protocol may spread infection among residents and staff. During an interview on 07/09/26 at 1:21 p.m., the ADON stated during incontinent care for the male resident with a Foley catheter, staff were expected to clean the Foley catheter away from the insertion site at the penis to prevent infection problems and potential UTIs. Record review of the facility's policy titled, Catheter Care, Urinary, with revision Date: August 2022, reflected: Steps in the procedure:Routine Perineal Hygiene2. Wash and dry your hands thoroughly.5. Put on gloves.6. Provide privacy.For a male resident:h. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.m. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks.23. Wash and dry your hands thoroughly.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. The facility failed to ensure CK A and DM were holding cold foods below the danger zone temperature of 41 degrees Fahrenheit and below. The facility failed to ensure CK A checked food temperatures and recorded temperatures correctly. The facility failed to ensure CK A and DM periodically monitored throughout the meal service to ensure proper cold holding temperatures are maintained for the macaroni salad. The facility failed to ensure functioning of reach in refrigerator and temperature at 41 degrees Fahrenheit and below. This failure could place residents who were served from the kitchen at risk for consuming contaminated food, and/or developing foodborne illnesses. Findings included: Observation on 05/28/2025 at 10:54 AM, revealed CK A preparing lunch and placing deep stainless steel steam table pans of food on the warming table and checking temperatures of cooked food. Observation on 05/28/2025 at 10:57 AM, revealed the reach in refrigerator temperature was reading 55 degrees. Observation and interview on 05/28/2025 at 10:57 AM, revealed CK A checking temperatures for the cold macaroni salad he pulled out of the reach in refrigerator. The level 4 - pureed macaroni salad temperature read 48 degrees, the level 5 - minced & moist macaroni salad temperature read 55 degrees, and the level 7 - regular macaroni salad temperature read 48 degrees. He stated the cold food temperatures should be under 40 degrees and he was going to bring down the temperatures of the 3 deep steam table pans of macaroni salad by placing in an ice bath and returning to the reach in refrigerator. Observation and interview on 05/28/2025 at 11:37 AM, revealed CK A began plating lunch trays. To the right side of CK A was a large deep container filled with ice and (3) deep dish containers of macaroni salad. Surveyor requested for CK A to recheck the macaroni salad temperatures before serving. The level 4 - pureed macaroni salad temperature read 38 degrees, the level 5 - minced & moist macaroni salad temperature read 48 degrees, and the level 7 - regular macaroni salad temperature read 38 degrees. He stated he did not understand why the level 5 - minced & moist macaroni salad temperature had not dropped under 40 degrees and placed it back on ice. Observation and interview on 05/28/2025 at 11:46 AM, revealed CK A returning to food plating. Surveyor again asked that the macaroni salad temperatures be checked, specifically the level 5 - minced & moist macaroni salad. The temperature was checked for a 3rd time and the level 5 - minced & moist macaroni salad now was reading 42.06 degrees, which remained in the danger zone. CK A stated the temperature went down and surveyor asked what he was going to do with the macaroni salad. CK A stopped food plating and left the line and went to the back area to discuss the issue with his manager. CK A returned to the tray line and began food plating and serving the level 5 - minced & moist macaroni salad that was above the appropriate cold temperature. In an interview on 5/28/2025 at 3:27 PM, CK A stated he prepares breakfast and lunch for the facility. He stated he's been employed one year at this facility. He secured his food safe certification roughly 2 years back. He stated he last received in-person training this past December 2024 and topics included hand hygiene practices and wearing hairnets. He stated proper hygiene is necessary to avoid cross contamination as this could cause the residents to become ill. He stated the food temperatures should also be followed. He stated chicken temperatures should be 165 degrees and above, fish should be 145 degrees and above, steak should be 160 degrees and above, boiling vegetables should reach 180 degrees and above, the steam table and holding temperatures for cooked food should be between 140 to 160 degrees and holding at 160 degrees. He stated if any foods are under 160 degrees and in the danger zone, he would put them back in the oven or stove to cook longer and reach appropriate cooked temperatures. He stated that cold foods should be below 40 degrees and if above this temperature it is in the danger zone. He stated that if the temperature is above 40 degrees for more than 45 - 60 minutes this would make the food no good to serve and it would have to be tossed out and remade or substituted for something similar. He stated he began preparing the macaroni salad at 7:00 AM. He stated the truck made a delivery today between 6 AM and 7 AM and the macaroni salad was already cold. He stated the macaroni salad is premade and he does not need to do anything to it but prepare puree and mince & moist levels and serve. He stated he began the puree and minced & moist process at 7:00 AM and returned the deep dish filled with macaroni salad back to the refrigerator about 20 minutes later. When asked about serving the macaroni salad that had produced (3) temperature checks above the danger zone to the residents during lunch service he stated he should not have served the macaroni salad. He stated residents could become ill and die if they were to become sick from this practice. He stated he understands he did not do the right thing and he sees this now. He stated one of the dietary aids cleaned out the refrigerator this morning and the temperature rose, and stated he was not sure how long she kept the doors open while she cleaned it but believes this is what may have caused the temperature of the cold foods to rise. In an observation and interview on 05/28/2025 at 3:45 PM, revealed CK B was checking temperatures for dinner foods: meats, vegetables, and starch, which were all within appropriate temperatures. She stated she had been employed one year at this facility. She was knowledgeable of hand hygiene, cooking temperatures, and serving portions. She stated she had received kitchen training from her manager and the dietitian over the last year. She stated that cold food holding temperature is 40 degrees and below and anything above this temperature is considered the danger zone and would get placed in a cold ice bucket to bring down to an appropriate temperature for safety. She stated if holding temperatures of a food are in the danger zone for long period of time, she would not serve it and ask her manager to switch out for something similar. She stated that if temperatures are in the danger zone bacteria can form and residents could get sick. She stated the best practice is to notify her manager and toss it in the trash and substitute the food with something similar. In an interview on 05/28/2025 at 4:14 PM, the DSM stated she had been employed at this facility one year. She stated she recently obtained her dietician certification and is now transitioning to the clinical side for the facility. She stated there is a full-time dedicated kitchen manager who focuses on the operations side of the kitchen and provides the dietary aides and cooks one-on-one training, staff meetings, ordering, and scheduling. She stated she has provided staff training on cooking temperatures, temperature logs, holding temperatures, and the danger zone for food items not in appropriate temperatures. She stated the cooking temperatures are 155-165 degrees for meats, 140 degrees and above is the holding temperature on the warmer for serving, and the cold food items should be below 41 degrees. She stated that food items above 41 degrees for more than one hour is considered the danger zone. She stated she would toss the food item out and substitute it with something similar and document the substitute log. She stated the holding time is up to 4 hours on the warmer. She stated that temperature logs are maintained by the cook and foods are checked in the morning, noon, and evening meals. She stated that if this practice is not followed it can cause bacteria and this can cause harm and be detrimental to a resident's health. She stated the cleaning schedules are followed by dietary staff on a regular basis and equipment and refrigerators require less time to clean. She stated the cleaning time for the refrigerator would have been no more than 15-20 minutes. She stated that if she would have known all the facts of the macaroni salad that was shared with her during the interview she would have thrown out the product and replaced it with something similar. She then stated the hold temperatures are 4 hours or less if above the danger zone and stated this information was in her training and should be in the manual. In an interview on 05/28/2025 at 4:14 PM, the RDLD a third-party consultant stated she provided consultation services to the dietary staff 2-3 times per month if needed; however, her focus is more on the clinical side. She stated she had provided dietary staff training on cooking temperatures, temperature logs, holding temperatures, and the danger zone for food items. She stated the cooking temperatures are 155-165 degrees for meats, 140 degrees and above is the holding temperature on the warmer for serving, and the cold food items should be below 41 degrees. She stated that if this practice is not followed it can cause bacteria and this can cause harm and be detrimental to a resident's health. She stated that cooks are knowledgeable of checking food temperatures and stated had she had additional information regarding the temperature checks with temperatures above the danger zone, knowledge of food being taken out of the refrigerator with above danger zone temperatures she would have directed the cook to toss out and make something similar. In an interview on 05/28/2025 at 4:20 PM, the DM interrupted the interview in progress with surveyor and RDLD and stated that the macaroni salad was already delivered the prior week and was already cold. She stated it was not delivered today and cook was mistaken with information. The product should have maintained an appropriate temperature and there would be no reason as to it being above 41 degrees. In an interview on 5/29/2025 at 1:56 PM, the DM stated she had been employed for three years at this facility. She stated all staff are responsible for checking refrigerator temperatures, cooks are responsible for checking food temperatures and documenting on the specific logs. She was knowledgeable of food temperatures and holding temperatures. She stated the expectation is for the cooks to check each item to be served and to document the temperature on the log before line service. She stated each level of a food item is to be documented on the log to keep an accurate account of temperatures. She stated she provides the monthly training during monthly meetings, and additional in-services take place during Monday morning meetings; however, these are not documented. She stated these Monday meetings also include any feedback from staff, residents, changes to ingredients, if anything needs to be worked on in the kitchen. She stated the cooks have been trained that if a food item is not hot enough and at the appropriate temperature before meal service to take it off the line and put it in the oven. She stated if the food item is not cold enough the expectation is for the cook to place in an ice bath and put back in the refrigerator to hold temp even if on the service line. She stated that if the temperature is not coming down to the appropriate temperatures, she would direct the cooks to toss it in the trash and replace it with another similar food item. She stated the impact to residents can be food borne illness and can give residents stomach problems, diarrhea, and vomiting. When asked about the macaroni salad that remained in the danger zone during yesterday's lunch service, she stated that the cook notified her and she instructed him to put the macaroni salads into 2 separate deep warming pans and into an ice bath to help cool faster, to continue monitoring the food on the line, and temping the service. She stated that she gave the cook the directions to serve the food as she did not believe it was in the danger zone for more than 4 hours. She stated that the cook continued to check the temperatures while monitoring and the diced & moist macaroni salad was cooling down but stated that he did not document this in the log. She stated that the cook made an error, and he notified her at the end of his shift that he did not document the correct temperatures for the foods that were above the danger zone and only documented once prior to meal service and he documented that the macaroni salad was at an appropriate temperature. She stated the cook did not document on the log as to what occurred with the macaroni salad, and he did not correctly notate the temperature he observed, and he was counseled on this. She stated that she did advise him not to do this in the future and that she would be training her dietary staff to document each item being temped from each level. Record review of Diet Type Report, dated 5/29/2025 revealed 20 residents are on level 5 minced & moist, diet texture and would have been served the macaroni salad with temperatures above the danger zone of 41 degrees. Record review of written statement by DSM, dated 5/28/2025 reflected, upon internal review, we acknowledge that this specific instance may have reflected a brief, isolated deviation from standard protocol. Per this policy corrective action was initiated by kitchen manager and was cooled i.e. ice bath consistently stirring to improve circulation of temperature .The remaining item trended down but remained at approximately 42 degrees. Record review of Policy and Procedure Manual, dated 2023 revealed: 7. Food Temperatures for Meal Service a. Check to be sure the staff takes food temperatures correctly and records temperatures. b. Teach staff what to do if temperatures are in the Temperature Danger Zone. Be sure temperatures are taken again, halfway through tray line to assure safety. Record review of Staff Meeting, dated 12/28/2024 revealed cooks were in-serviced on temp logs, timeline, and preparing minced & moist and puree foods. Record review of food temperature log dated 5/28/2025 revealed CKA documented lunch food items as one single food item. CKA documented the macaroni salad end preparation temperature of 36 degrees and tray line temperature of 40 degrees noting it was below the temperature danger zone. There was no entry for the corrective action column of the temperature log. Record review of [NAME] Timeline, not dated revealed: cooks are directed to, 6:40 AM temp logs; 11:05 AM temp logs.

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 4 of 8 residents (Resident #8, Resident #27, Resident #53, and Resident #57) reviewed for infection control. 1. During pericare, CNA J folded and reused a disposable wipe when cleaning the groin and penis for Resident #27. 2. MA G did not conduct hand hygiene after preparing medications and prior to administering the medications for Resident #53 and Resident #57. 3. LVN I failed to ensure supplies that were to be used on multiple residents was not placed on a dirty surface in a resident's room for Resident #8. These failures could place residents at risk of transmission of disease and infection. Findings included: 1. Record review of Resident #27's admission record, dated 05/29/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #27 had diagnoses which included: dysphagia (difficulty swallowing), moderate intellectual disabilities (a condition where someone has an average mental age of 6 to 9 years), spastic quadriplegic cerebral palsy (a conditions that affects movement and posture caused by brain damage before birth), thrombocytopenia (a condition characterized by a low platelet count and may cause easy bruising and/or prolonged bleeding), and malignant neoplasm of descended right testis (testicular cancer). Record review of Resident #27's Quarterly MDS, dated [DATE], reflected a BIMS score 04, which indicated severe cognitive impairment. Record review of Resident #27's care plan, dated 05/22/2025, reflected: Focus: Incontinence of Bowel & Bladder: r/t impaired mobility, cognitive deficit, physical limitations with Goals that included: No infection and Interventions that included: Provide good perineal care . Observation on 05/28/2025 at 03:16 PM, revealed CNA J performing pericare on Resident #27. CNA J used a disposable wipe to wipe the left groin from front to back, then folded the wipe and wiped the penis. CNA J then threw the wipe away, obtained a new wipe and cleaned the right groin from front to back then folded the wipe and used it to clean the pubic mound (area above the base of the penis), then tossed the wipe in the trash. 2. Record review of Resident #53's admission record, dated 05/29/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #53 had diagnoses which included: unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain), other impulse disorders (a group of behavioral conditions that involve an inability to control impulses and behaviors), and generalized anxiety disorder (a condition characterized by persistent and excessive worry about everyday issues). Record review of Resident #53's Quarterly MDS, dated [DATE], reflected a BIMS score 04, which indicated severe cognitive impairment. Record review of Resident #53's care plan, dated 05/08/2025, reflected: Focus: Medication Administration: Medications whole with water with Goals: will have no complications from medication administration throughout the 90 days. Observation on 05/29/2025 at 07:03 AM, revealed MA G performed hand sanitization, prepared medications appropriately, then locked the cart, grabbed the cup of medication and a cup of water, approached Resident #53, and administered the medication as ordered without performing hand hygiene after touching the surfaces of the medication cart and prior to administering the medication to Resident #53. 3. Record review of Resident #57's admission record, dated 05/29/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #57 had diagnoses which included: personal history of pneumonia (a history of an infection in the lungs), hypertensive heart disease without heart failure (a heart condition caused by long-term high blood pressure, which can lead to changes in the heart's structure and function), thrombophilia (a condition that makes your blood more likely to for clots), dysphagia (difficulty swallowing), generalized anxiety disorder (a condition characterized by persistent and excessive worry about everyday issues), and chronic kidney disease stage 2 (a condition that mildly affects the kidneys ability to filter out toxins). Record review of Resident #57's Comprehensive MDS, dated [DATE], reflected a BIMS score 04, which indicated severe cognitive impairment. Record review of Resident #57's care plan, dated 03/21/2025, reflected: Focus included: Medication Administration: Medications whole with pudding/applesauce with Goal: will have no complications from medication administration throughout the 90 days. Observation on 05/29/2025 at 07:09 AM, revealed MA G performed hand sanitization, prepared medications, while attempting to place a Vitamin D3 tab in a medication cup, it fell on the top of the medication cart. MA G used a glove to pick up the tablet and used ungloved hand to lift trash can lid while using gloved hand to place tablet in trash can. MA G then place a Vitamin D3 tablet in medication cup, returned bottle to cart, then locked the cart, grabbed the cup of medication and a cup of water, approached Resident #57, and administered the medication as ordered without performing hand hygiene after touching the surfaces of the medication cart and trash can and prior to administering the medication to Resident #57. 3. Record review of Resident #8's admission record, dated 05/29/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #8 had diagnoses which included: hyperlipidemia (high cholesterol), essential hypertension (high blood pressure), major depressive disorder (persistent feeling of sadness and loss of interest), moderate intellectual disabilities (a condition where someone has an average mental age of 6 to 9 years), peripheral vascular disease (decreased blood circulation to the legs), and type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar). Record review of Resident #8's Quarterly MDS, dated [DATE], reflected a BIMS score 02, which indicated severe cognitive impairment. Record review of Resident #8's care plan, dated 04/17/2025, reflected: Focus: Enhanced Barrier Precautions: r/t wound with Interventions that included: Maintain enhanced barrier precautions as outline in nursing home policy. Observation on 05/29/2025 at 10:49 AM, revealed LVN I gathered supplies for wound care for Resident #8 into a basket. She proceeded to take all gathered supplies, including a roll of paper tape, into the room. LVN I performed hand hygiene and put on gown and gloves for enhanced barrier precautions. She then set the basket on the bed next to Resident #8's leg and proceeded to perform wound care. After cleaning and applying new dressing to the wound on Resident #8's right calf, LVN I took the roll of paper tape out of the basket, tore a piece of tape off the roll, and set the roll of tape on the bed next to Resident #8. After securing the wrapped gauze around Resident #8's right calf, LVN I gathered the roll of tape off the bed and placed in the basket and placed basket on counter in room. She then took off her gown and gloves and washed her hands, retrieved basket, and returned to nurses' medication cart. In an interview and observation on 05/29/2025 at 11:08 AM, LVN I stated the roll of paper tape should not have been taken into the room with the Resident #8 and set it on the bed. She stated they are supposed to tear a piece of tape off the roll and leave the roll of tape in the medication cart. She stated she was going to throw the roll of tape away and observation revealed LVN I threw the roll of paper tape in the trashcan attached to LVN I's medication cart. LVN I stated using the roll of paper tape on a different resident since it had been on Resident #8's bed could cause transfer of bacteria from one resident to another and could cause an infection. In an interview on 05/29/2025 at 11:30 AM, MA F stated she had worked for the facility for about 30 years. She stated that she had been trained on infection control, that included hand hygiene and how to use the proper personal protective equipment, in April 2025. MA F stated it was policy to wash or sanitize hands before and after providing direct care to a resident. She stated hands should be sanitized before dispensing medications and after administering them to the resident. MA F stated she didn't think hands needed to be sanitized after dispensing the medication and before administering the medication. She stated the ADON monitored hand hygiene about every 3 months. MA F stated by not performing some form of hand hygiene at the appropriate times then the residents could get sick by spreading germs from one resident to another resident. In an interview on 05/29/2025 at 11:39 AM, CNA J stated she had been trained on infection control about a month ago. She stated the training discussed the personal protective equipment needed for residents with enhanced barrier precautions. CNA J stated she had not received training on the proper use of disposable wipes. She stated that in her training they used wash basins and wash cloths, and it was appropriate to fold the washcloths and use them again to clean. CNA J stated that by using a disposable wipe and folding it to use again it could possibly cause an increased risk of infection. In an interview on 05/29/2025 at 11:58 AM, MA K stated she had worked at the facility for 13 years. She was trained on infection control in 2024 and the training covered hand hygiene, how to use personal protective equipment to avoid cross contamination, and enhanced barrier precautions. She stated that hand hygiene needed to be done before and after entering a resident's room to provide care to a resident. MA K stated hand hygiene needed to be performed before dispensing medication and after giving the medication to the resident. She stated it did not need to be performed after gathering medication and before administering the medication to the resident. MA K stated all staff were responsible for monitoring hand hygiene and the ADON and DON were often on the floor walking around the halls monitoring for proper hand hygiene. MA K stated not using proper hand hygiene could make residents sick by spreading germs and cross contamination. She stated that when providing pericare on a resident, she did not think wet wipes could be folded and used again. MA K stated it's a one and done and to throw away the wipe once used and get a new wipe, but she did not provide pericare often. She said she thought the DON would be the person responsible for monitoring pericare to ensure it was done correctly but did not know how often. In an interview on 05/29/2025 at 12:46 PM, MA G stated she had worked at the facility for about 10 years. She stated she was trained on infection control last month and it covered hand hygiene. MA G stated hand hygiene should be performed before dispensing medication and after administering medication to the resident. She stated she didn't think it was necessary to performed between dispensing the medication and administering the medication to the resident. She stated hand hygiene was monitored by all manager as they performed their walking rounds. She stated by not performing hand hygiene at the appropriate times then germs could be passed from one resident to another and make the residents sick. In an interview on 05/29/2025 at 01:11 PM, the DON stated she had received training on infection control. She stated she received specialized training on infection control in residents with disabilities. The DON stated it was her expectations for staff to perform some sort of hand hygiene, whether it be hand washing or hand sanitizing, before entering a resident's room, after leaving a resident's room, before and after performing any type of direct care to a resident, and when moving from a dirty to a clean field when performing direct patient care. The DON stated that hands are to be sanitized before dispensing medications, before administering medication and after administering medication during medication pass. She stated it was the responsibility of the person providing any care to the resident to ensure they are performing hand hygiene at the appropriate times. The DON stated the weekend RN supervisor was responsible for performing random weekly hand hygiene audits. She stated if hand hygiene is not performed at the appropriate time, then staff could spread infections from one resident to another. The DON stated when performing pericare on a resident it is her expectation for staff to use the disposable wipe one time then throw the wipe away and obtain a new wipe. She stated by using a disposable wipe, folding it, and using it again it increased the risk of a urinary tract infection in the resident. The DON stated staff were required to perform check offs twice prior to working independently then staff had to perform the skill check off again annually to ensure competency. The DON stated that any resident who had a need for wound care that required tape should have their own roll of tape that was kept in a bag with the resident's name labeled on it. She stated if a roll of tape was placed on a dirty surface in a resident's room, then placed back in the nurses' medication cart, it could spread germs to other things in the cart. In an interview on 05/29/2025 at 01:41 PM, the ADM state he had received training on infection control in January 2024. He stated he expected staff to perform hand hygiene before providing personal care to the residents, with glove changes, before serving meal trays. He stated he thought hands should be sanitized before, after and maybe in the middle of a medication pass though that was more of a clinical question and he wasn't sure. He stated he was responsible for everything in the building but deferred the monitoring of hand hygiene to the DON and the ADON. The ADM stated the DON and ADON performed checkoffs regularly though it was unsure of the exact timeframe. He stated by not performing hand hygiene at the appropriate times, the residents could be at a higher risk of infection. The ADM stated disposable wipes should be used only one time then thrown away. He stated he relied on the DON and the ADON to monitor skills checkoffs for pericare performed by the staff. He stated there was not a policy related to the use of disposable wipes when performing pericare. The ADM stated he was unsure of the process for using paper tape on residents, but the roll of tape shouldn't be placed on a resident's bed then placed back in the nurses' medication cart. He stated if tape was set on a resident's bed, then used on a different resident that could be an infection control issue. Record review of the facility's policy titled Handwashing/Hand Hygiene, dated 2001 and revised 10/2023, reflected, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretations and Implementation 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors . Indications for Hand Hygiene 1. Hand hygiene is indicated: a. immediately before touching a resident; . Record review of the facility's policy title Wound care, dated 2001 and revised 10/2010, reflected, Purpose The purpose of this procedure is to provide guidelines for the care of wounds to promote healing . Steps in the Procedure . 22. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart .

Based on observation, interviews, and record reviews the facility failed to ensure personal privacy for 2 of 3 residents (Resident #8 and Resident #56) reviewed for privacy while receiving care. 1. The facility failed to ensure the privacy of Resident #56 by not closing the door or pulling the privacy curtain during administration of enteral formula through a PEG tube. 2. The facility failed to ensure the privacy of Resident #8 by not closing the blinds on the window or pulling the privacy curtain during wound care. This failure could place residents at risk of loss of privacy and dignity. Findings included: 1. Record review of Resident #56's admission record, dated 05/29/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #56 had diagnoses which included: thrombocytopenia (a condition characterized by a low platelet count and may cause easy bruising and/or prolonged bleeding), aphasia (a language disorder that affects communication), dysphagia (difficulty with swallowing), post traumatic seizures (a seizure disorder that occurs when the brain experiences damage from physical trauma), personal history of traumatic brain injury (a sudden injury that causes damage to the brain), and major depressive disorder (A period of at least two weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities, and had a majority of specified symptoms, such as problems with sleep, eating, energy, concentration, or self-worth). Record review of Resident #56's Quarterly MDS, dated [DATE], reflected a BIMS score 99, which indicated resident was unable to complete the assessment. Section C- Cognitive Patterns reflected resident had memory problems for both short-term and long-term memory. Record review of Resident #56's care plan, dated 04/11/2025, reflected: Focus: [Resident #56] and his Responsible Party will be educated on their Resident Right's as residents of a Long-Term Care Facility with Interventions that included: Resident and/or the Legal Guardian/Responsible Party is given a copy of the Resident's Rights upon admission. Observation on 05/29/2025 at 08:48 AM, revealed Resident #56 sitting up in specialized wheelchair. LVN H approached resident and explained procedure for administering enteral formula through the PEG tube to Resident #56. LVN H left door open and privacy curtain open when she exposed Resident #56's abdomen to assess PEG tube placement and administer formula through PEG tube. During the assessment and administration of formula, Resident #56's roommate remained in the room and one unknown female resident sat in a wheelchair at the doorway to Resident #56's room. In an interview on 05/29/2025 at 08:54 AM, LVN H stated privacy, such as closing the door and pulling the curtain, should be provided to residents when assessing and administering anything through a PEG tube. She stated she forgot to provide privacy while providing care to Resident #56. LVN H stated that all staff monitored to ensure residents were receiving appropriate privacy when needed. She stated if [Resident #56] was more alert, then it might embarrass him if privacy was not provided appropriately. 2. Record review of Resident #8's admission record, dated 05/29/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #8 had diagnoses which included: hyperlipidemia (high cholesterol), essential hypertension (high blood pressure), major depressive disorder (persistent feeling of sadness and loss of interest), moderate intellectual disabilities (a condition where someone has an average mental age of 6 to 9 years), peripheral vascular disease (decreased blood circulation to the legs), and type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar). Record review of Resident #8's Quarterly MDS, dated [DATE], reflected a BIMS score 02, which indicated severe cognitive impairment. Record review of Resident #8's care plan, dated 04/17/2025, reflected: Focus: [Resident #8] and her Responsible Party will be educated on their Resident Right's as residents of a Long-Term Care Facility with Interventions that included: Resident and/or the Legal Guardian/Responsible Party is given a copy of the Resident's Rights upon admission. Observation on 05/29/2025 at 10:49 AM, revealed Resident #8 lying in bed covered with a blanket. LVN I uncovered Resident #8's legs to provide wound care to the right calf without closing the blinds to the window that led to the front circle drive or pulling the privacy curtain closed. In an interview on 05/29/2025 at 11:08 AM, LVN I stated she should have pulled the privacy curtain at the foot of the bed and closed the blinds to ensure privacy and dignity to Resident #8. She stated she was not sure how ensuring privacy for the residents was monitored. She stated by not ensuring privacy was provided it could affect the self-esteem of the resident. In an interview on 05/29/2025 at 11:30 AM, MA F stated she had been trained on resident rights in 04/2025. She stated the policy was to close the door and pull the curtain closed when providing patient care in a resident's room. MA F stated it was the responsibility of the person providing care to provide privacy to the resident. She stated not providing privacy to a resident in their room while providing care to them could make the resident feel bad or embarrassed. She stated the ADON monitored about every 3 months to ensure residents were provided privacy. In an interview on 05/29/2025 at 11:58 AM, MA K stated she had been trained on resident rights. MA K stated the training covered providing privacy for residents during pericare, wound care, or any care when the body is exposed. She stated when providing patient care in a resident's room, the door should be closed, and the curtain should be pulled to provide privacy. MA K stated, the staff member providing resident care was responsible for ensuring residents had privacy and the nurse that worked that hall was monitoring to ensure privacy was provided daily. She stated the resident could feel bad, exposed, or embarrassed if they did not have privacy when care was provided. In an interview on 05/29/2025 at 01:11 PM, the DON stated she had been trained on resident rights within the last 6 months. She stated it was her expectation that privacy, like closing the door and blinds and pulling the privacy curtain closed, was provided to all residents when care was provided. The DON stated the staff member providing the care to the resident was responsible for ensuring privacy was provided. She stated that the floor nurses were responsible for monitoring this every day when they perform their walking rounds. The DON stated a resident could become fearful or anxious if privacy was not provided. In an interview on 05/29/2025 at 01:41 PM, the ADM stated he had received training on resident rights. He stated his expectations for providing privacy to residents was to pull the curtain closed and close the door when providing care to the resident in their room. He stated he was ultimately responsible for everything in the building, but he defers that to the DON. He stated he was unsure how it was monitored. The ADM stated it might cause some embarrassment to the resident if privacy was not provided. He stated it was a dignity thing. Record review of facility policy titled Resident Rights, dated 2001 and last revised 02/2021, reflected: Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . t. privacy and confidentiality; .

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 (D/E Hall) medication room reviewed for pharmacy services. The facility failed to ensure expired medication and medical supplies were removed from D/E-halls medication storage room. This failure could place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose, inaccurate results, and/or contamination from expired supplies. Findings included: During an observation on 05/29/2025 at 07:58 AM, with the ADON revealed a bottle of omeprazole 20mg with an expiration date of 01/2025, a bottle of omeprazole 20mg with an expiration date of 03/2025, 10 BioSign Flu A+B tests with an expiration date of 07/31/2024, a sterile CleanWipe foam swab with an expiration date of 11/2023, a gray top vacutainer (blood collection device for labs) with an expiration date of 05/31/2024, and a gray top vacutainer with an expiration date of 08/31/2024. In an interview on 05/29/2025 at 08:25 AM, the ADON stated the medication and supplies found were expired. She stated if an expired medication was given to a resident, the medication may not be as effective or may cause an unintended adverse reaction. She stated she was not sure who was responsible for checking the medication room for expired medications and supplies. In an interview on 05/29/2025 at 11:58 AM, with MA K stated she had worked at the facility for 13 years. She stated medication aides was responsible for checking the medication room on Hall D/E for expired medications and supplies, but she did not know how often. She stated that nursing management should be following up once a month to ensure there are no expired medications or supplies. She stated that tests could be inaccurate if supplies were expired, and the resident might not receive the correct dosage of medication or not achieve the desired effect if the medication was expired. In an interview on 05/29/2025 at 12:46 PM, MA G stated she had worked at the facility for 10 years. She stated the medication aide that is assigned to the hall is responsible for checking for expired medications and supplies in the respective medication rooms once a month. MA G stated she thought nursing management followed up behind the medication aids to ensure all expired medications and supplies were removed from inventory. She stated if expired medications or supplies were used on the residents then it could be dangerous by causing an adverse reaction to the medication or an infection could occur due to contamination, or even false results could occur. In an interview on 05/29/2025 at 01:11 PM, the DON stated she had worked at the facility for 6 years. She stated the central supply person stocked the medication rooms weekly with over-the-counter medications and was responsible for ensuring the over-the-counter medications were not expired. She stated a medication technician consultant performed an audit every 3 months to ensure all expired medications were removed from inventory. The DON stated the nurse managers were responsible for performing a quick survey of the medication rooms weekly. She stated if expired medications or supplies were used for residents then they might have an adverse effect. In an interview on 05/29/2025 at 01:41 PM, the ADM stated he had worked at the facility for almost 10 years. He stated he was ultimately responsible for everything that occurs in the building, but the DON was responsible for ensuring all expired supplies and medications were removed from inventory in the medication rooms, but he was unsure how often it was reviewed. He stated if expired medications and supplies were used for residents then it could cause an adverse reaction to the medication or false readings in supplies. Record review of facility policy titled Medication Labeling and Storage, dated 2001 and revised last 02/2023, reflected Policy Statement The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation Medication Storage . 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items .

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services. The facility failed to ensure the food was safely stored in the freezer and the pantry. This failure could place residents at risk of being served food that could had been crossed-contaminated, frost bitten, and foodborne illness. Findings included: Dry pantry observation on 04/09/2024 at 8:55am revealed an undated plastic container of Fiber. Dry pantry observation on 04/09/2024 at 9:00am revealed an opened bag powered milk, exposed to open air, and not sealed. Refrigerator observation on 04/09/2024 at 8:59am revealed a box of mushrooms in the refrigerator, exposed to open air and not sealed. Kitchen observation on 04/09/2024 at 8:46am revealed a cell phone in a pink protective case sitting on the rolling cart next to the prep table , directly across from the kitchen entry doorway. Kitchen observation on 04/09/2024 at 8:51am revealed a cloudy, chunky, brown liquid substance in the drain receptacle of the ice machine nearest to the steam table. Kitchen observation on 04/09/2024 at 8:53am revealed a greasy substance, food crumbs and other unidentifiable particles on the bottom shelf of the prep table where the spices and bottled sauces were stored. Pantry observation on 4/09/2024 at 8:57am revealed two small containers of Chicken Flavored Base sitting on top of a large 5-gallon bucket of Ultra San sanitation product. Pantry observation on 04/09/2024 at 8:57am revealed individual sized yellow packets of artificial sweetener, a Styrofoam cup, and other unidentifiable debris on the floor in the dry storage pantry, between the defrost refrigerator and a stack of boxes. Kitchen observation on 04/09/2024 at 9:05am revealed debris and trash, multiple divided plates, bowls, bubble cups, drinking glasses and multiple disposable containers under steam table. Kitchen observation on 04/09/2024 at 9:05am revealed cloudy, greasy water that contained food particles such as an Asian dumpling, a green bean and a French fry in the three wells of the steam table. Kitchen observation on 04/10/2024 at 11:37am revealed a cell phone, a smart watch, keys and an unopened can of soda on the rolling blue cart beside steam table. On top of the cart contained plastic bags with bread and serving trays. Kitchen observation on 04/10/2024 at 11:38am revealed a cloudy, chunky liquid substance in the drain receptacle of the ice machine nearest to the steam table. Appears to be the same liquid that was present yesterday. Kitchen observation on 04/11/2024 at 9:06am revealed a cell phone, keys, key fob, and a facility name tag. There was a pan of food sitting on the rolling tray. Kitchen observation on 04/11/2024 at 9:06am revealed on opened energy drink sitting next to a loaf of bread on a rolling cart. Kitchen observation on 04/11/2024 at 10:27am revealed debris and trash, multiple divided plates, bowls, bubble cups, drinking glasses and multiple disposable containers under steam table. Kitchen observation on 04/11/2024 at 11:20am revealed two kitchen staff wearing earbuds and one cell phone was ringing in the kitchen. The location of the cell phone was not identified, and kitchen staff ignored the ringing. Kitchen observation on 04/11/2024 at 12:31pm revealed small pieces of breakfast bacon and egg particles on the steam table, while lunch was served. Interview on 04/11/2024 at 2:30pm with the DA revealed she was trained by the KS. She said the kitchen cleaning checklists should be updated every day and all kitchen staff were responsible for this task. She confirmed she has read the policy on Kitchen Sanitation. She said she felt like the kitchen was clean. She said personal items are kept on the wall in the hallway, between the kitchen and the dry storage. She said this is important for sanitation purposes. She said items in the refrigerator should be stored in the container with the lid on top. She said all kitchen staff are responsible for ensuring all food items are safely stored and have an open date, to prevent the potential for bugs and other debris getting into the food. She said not storing food items properly could get the resident's sick. Interview on 04/11/2024 at 2:40pm with the KS revealed she was trained by her last company. She said cleaning checklists should be completed daily and she was aware the cleaning checklists had not been updated since the State had entered the facility. She said whoever complete d the cleaning task is responsible for documenting on the cleaning checklist. She said she read the Kitchen Sanitation policy when she was hired by the facility. She said her expectation is for things to be cleaned when something was dirty. Regarding cleanliness, she said, Currently, the kitchen could be better. She said that staff's personal items should be kept in the hallway, or her the supervisor's office. She said it is important to keep the kitchen free of personal items to prevent cross contamination with the food area. She said, staff are not allowed to wear ear buds in the kitchen due to safety regulations . Regarding the ice machine by the steam table, she said, It does not drain well. Maintenance has looked at it and it is a gravity issue. It is a non-functional ice machine and must be manually loaded with ice. I put Bleach in it at night. She said the steam wells should have been cleaned every day, usually by the night shift. She said food items should be sealed and closed with an opened and discard by date. She said the cooks and aides on each shift are required to label and date their own items that they prepared. She said it is important for food to be sealed and stored properly because it guaranteess freshness and nothing breeds bacteria that could cause food poisoning, spread contagion, cross contamination, and food allergies. Interview on 04/11/2024 at 2:50pm with the DM revealed that she held a Food Kitchen Managers Certification, she is an RD, and had classes in food management and production while in school. She said all kitchen staff are required to complete the cleaning checklist after they complete that task. She said she read the policy on Kitchen Sanitation when she was hired. When asked if the kitchen cleanliness met her expectations, she replied, For daily production measures, yes. That is always our highest priority. We cover our basics, cleaning all food and kitchen prep areas thoroughly. One area of focus in which we could improve, would be getting on your knees, cleaning the floors, etc. She said personal items should be kept in the hallway, on the hooks or on the fridge. She said it is important to keep the kitchen prep and line free of personal items to reduce cross contamination, safety and the correct level of cleanliness and it is not acceptable for staff to wear earbuds in the kitchen. She said staff knows not to wear earbuds in the kitchen. Regarding the ice machine near the steam table, she said, One or two times a week we empty the container. It's not hooked up to drain. Regarding the steam table wells, she said, That's a less frequent task, the cooks check off on that, one to two times a week. Regarding proper storage of food items, she said, Raw meat should be on bottom, anything with dripping juices on bottom, fresh produce on top, everything sealed in original packaging, or sealed with saran wrap or in a Ziplock. That is the responsibility of whoever opened the item. She said proper storage is important to prevent cross contamination with other foods and prevent foodborne illness, compromised immune systems in this population, insects, and foodborne intoxication. Interview on 04/11/2024 at 3:10pm with the RD revealed that the cooks and aides were responsible for updating the cleaning checklists when they complete a task. She said she has read the policy on Kitchen Sanitation, and she thinks if it is dirty, it should be cleaned. She said the kitchen does not meet her expectation for cleanliness. She said staff should keep personal items in the hallway or the mangers office. She said it is important to keep personal items out of the kitchen to prevent cross contamination. She does not like to see kitchen staff wearing earbuds, but I do see them when they are doing certain chores, like washing dishes. She said the ice machine drain pan should be dumped and cleaned every day. She said staff should label, date, and store items properly to ensure freshness and make sure the oldest items are used first. Interview on 04/11/2024 at 3:50pm with the ADM revealed his concern was constant turnover of kitchen staff. He was aware the kitchen is not as clean as it should be. He said he believes feeding the residents is the highest priority and the kitchen prep areas are clean and sterile. He said, The kitchen staff have to prioritize their duties, and no one is going hungry or has become ill. Review of the facility's Sanitization Policy revised November 2022) revealed the following: Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation: 1. All kitchens, kitchen areas and dining areas are kept clean, free of debris and protected from rodents and insects. 10. I0ce machines and storage containers are drained, cleaned, and sanitized per manufacturer's instructions. Review of the facility's Food Receiving and Storage policy revised November 2022 revealed the following: Policy Statement: Foods shall be received and stored in a manner that complies with food handling practices. Policy Interpretation and Implementation: Refrigerated/Frozen Storage, 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). 9. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with resident rights, that include measurable objectives and time frames to meet resident's mental and psychosocial needs for 1 of 4 residents (Resident #39) reviewed for care plans. The facility failed to update Resident #39's care plan to reflect current needs for heel protectors to be worn at all times. This failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being. Findings included: Review of Resident #39's Face Sheet dated 04/10/2024 revealed a 56 Record review of Resident #80's face-sheet dated 04/09/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: other skin changes (changes in your skin can be clues that there's an internal issue with your health), severe intellectual disabilities (a condition in which your brain doesn't develop properly or function normally), and peripheral vascular disease (the reduce circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel). Record review of Resident # 39's Quarterly MDS Assessment, dated 02/26/2024, reflected Resident #39 was never/ rarely understood and was not capable of completing the BIMS questions. His cognitive patterns were assessed by the staff. Resident #39 had poor short- and long-term memory recall. His decision-making abilities was severely impaired. Resident #39 was dependent on staff for all his ADL's. Resident #39 was also assessed to be at risk for developing pressure ulcers/ injuries. Resident #39's MDS also reflected he required a pressure reducing device for chair and for his bed. Record review of Resident #39's Comprehensive Care Plan, dated 03/14/2024, reflected Resident #39 had alteration in skin integrity related to incontinence, physical limitations, and cognitive impairment. Interventions: monitor skin during showers for any areas of redness or excoriation and report to nurse. Off load (using a pillow or wedge under the calf to leave the foot suspended above the mattress) bilateral heels at all times. Resident #39 had ADL self-care deficit related to severe cognitive deficits. Resident #39 was also assessed to require total assistance with dressing, personal hygiene, toileting, and shower. He required 2-person Hoyer lift for transfers. Record review of Resident #39's Physician Order for the month of 04/2024 reflected a physician order dated 04/10/2024 wear heel protectors at all times; offload right heel when in bed. In an interview and record review on 04/10/2024, LVN C stated Resident #39 had an official physician order in the electronic medical record on 04/10/2024. She viewed Resident #39's physician order and care plan during the interview. She stated on the care plan, it reflected Resident #39 was to offload his heels when in bed. LVN C also stated the care plan date was 03/14/2024 and it was the most current care plan. She stated the care plan was completed prior to the new physician order dated 04/10/2024 for Resident # 39's heel protectors to be used at all times. She stated Resident #39's care plan had an intervention of offloading heels. However, this was different than wearing heel protectors. LVN C stated the interventions for the staff to follow required to be very specific. LVN C stated anytime there was a change in a resident care or any new order for any device the residents' care plan was expected to be updated. She reviewed Resident #39's care plan during the interview and stated the care plan was not updated to reflect the new physician order for the resident to have heel protectors on his feet. She stated care plan said to offload his heels but the care plan was written prior to him developing the red area on his right heel and offloading was not the same as wearing heel protector. She stated someone would probably update the care plan to reflect he needed heel protectors. She stated someone in the nurse administration department would review Resident #39's care plan and add the heel protectors to the care plan. LVN C also stated it was the MDS Nurse, the DON or the ADON revised the care plan. In an interview and /record review on 04/11/2024 at 9:30 AM, CNA F stated there was a form in Resident #39's room explaining the care he required. She stated the CNAs referred to the form for any changes in Resident #39's care. CNA F stated LVN E gave her report that morning about Resident #39 and to place heel protectors on him at all times. She stated if she saw offloading heels at all times documented, she would not know exactly what it meant. She stated she would need further guidance from the nurse to ensure she knew what to do if she saw the residents' heels needed to be offloaded. CNA F stated if she saw heel protectors on any of Resident #39's forms, she would know exactly what to do and she would place heel protectors on his feet. In an interview and record review on 04/11/2024 at 8:40 AM, the Director of Nurses stated as she was reviewing the Resident #39's care plan during the interview the interventions was not revised to reflect he was to wear heel protectors at all times. She stated the last care plan was revised on 3/14/2024 and the new physician order for heel protectors was dated 04/10/2024. She stated, in the perfect world the care plan would be revised. She also stated the care plan was the record the staff referred to when developing person center care for each resident. She stated offloading heels was on the care plan and that was when staff would use pillows under residents' feet. She stated again in a perfect world the care plan would be revised. In an interview on 04/11/2024 at 3:25 PM, the Administrator stated the care plan for Resident #39 did not reflect specific heel protectors on the care plan. He stated the care plan had offloading and he believed offloading and heel protectors was the same thing but he was not a nurse. He also stated he was not going to discuss the potential negative outcome of a resident not wearing heel protectors because he was not a nurse. Record review of the facility's policy on Goals and Objectives, Care Plans dated 2009 reflected objectives were entered on the resident's care plan so that all disciplines have access to such information and were able to report whether or not the desired outcome were being achieved. Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence.

Based on observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of eight residents (Resident # 40 and Resident # 63) reviewed for quality of life. The facility failed to ensure Resident #40 and Resident #63's nails were cleaned. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Record review of Resident # 40 Face Sheet dated 04/11/2024 reflected Resident #40 was admitted on [DATE] with diagnosis of muscle weakness (lack of strength in muscles), mild intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently), and age-related osteoporosis without current pathological fracture (reduce bone mass). Record review of Resident #40's Quarterly MDS Assessment, dated 02/26/2024, reflected resident was rarely/never understood. The staff completed Resident #40's cognitive status. Resident #40 was assessed to have poor short- and long-term memory recall. She was also assessed to have poor decision-making ability. Resident #40 was dependent on staff for all ADLS including personal hygiene. Resident #40 did not reject care. Record review of Resident #40's Comprehensive Care Plan dated 01/18/2024 reflected Resident #40 had an ADL self-care deficit related to general weaknesses, and cognitive deficits. Intervention: Explain to Resident #40 all care being given to her. Observation and Interview on 04/09/2024 at 1:19 PM Resident #40 had a blackish/brownish hard substance underneath the nails on her fore finger and middle finger on her left hand and underneath the nails on her middle finger and ring finger on her right hand. Resident #40 was not interview able. Record review of Resident # 63's Face Sheet dated 04/11/2024 reflected Resident #63 was admitted to the facility on [DATE] with diagnosis of: down syndrome (a condition in which a person has an extra chromosome or an extra piece of a chromosome), dementia in other diseases classified elsewhere, unspecified severity (lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement), and delusional disorders ( unshakeable belief in something that is not true). Record review of Resident #63's Quarterly MDS dated [DATE] reflected Resident #63 rarely/ never understood others. Her cognitive assessment was completed by staff. She was assessed to have poor short- and long-term memory recall and her decision-making ability was severely impaired. Resident required assistance with all ADLs. Record review of Resident #63's Comprehensive Care Plan dated 03/07/2024 reflected Resident #63 had ADL self-care deficit related to cognitive deficits. Care plan reflected Resident #63's ADL needs will be met. Observation and Interview on 04/09/2024 at 1:11 PM Resident #63's middle and forefinger nails on her right had had blackish/brownish hard substance underneath the nails. Resident #63 was not interview able. In an interview on 04/11/2024 at 9:15 AM, LVN E stated the nurses and CNAs were responsible for nail care. She stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. LVN E stated it was the CNA's responsibility to clean and trim all other residents' nails. She stated the CNAs reported to nurses of any diabetic resident's nails to be cleaned. She stated the nurses' made rounds and checked residents, with diabetic nails. She also stated the Cans usually did nail care when residents received a shower or as needed. She stated if anyone observed a brownish and/or blackish substance underneath residents nails the nursing staff were expected to clean the resident's nails or ask the appropriate nurse to complete the nail care. She stated the blackish/ brownish substance possibility may had feces or any type of bacteria underneath the resident's nails. LVN E stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. She also stated a resident may become dehydrated and may require to be transfer to hospital for further medical assessment. She stated she had been in- serviced on nail care and infection control. She stated she was not aware of Resident #40 or Resident #63 refusing nail care. In an interview on 04/11/2024 at 9:30 AM, CNA F stated CNAs were responsible for nail care unless a resident was a diabetic. She stated the CNAs usually trimmed and cleaned nails during showers. She stated the nails could be cleaned or trimmed by nurses or CNAs as needed. CNA F stated the nursing staff was expected to clean and trim residents' nails immediately if there was a blackish substance underneath the residents' nails and/ or if their nails needed to be trimmed. CNA F stated the blackish substance may be fecal matter underneath the residents' nails. She stated if a resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues or any type of intestinal issues. She stated there was a possibility a Resident may need to be assessed at the emergency room if they became severely ill. She stated she gave care to Resident #40 and Resident #63, and with her experience they did not refuse nail care. In an interview on 04/11/2024 at 10:40 AM, the Director of Nurses stated it was the nurse's responsibility to trim/clean residents with a diagnosis of diabetes. She stated CNAs were expected to give nail care to other residents during showers or as needed. She stated if a resident had blackish substance underneath the nails and the resident ingested the substance there was a possibility the resident may become ill such as: vomiting or diarrhea. Director of Nurses stated if staff saw a blackish substance underneath a resident's nails, he expected the nails to be cleaned immediately. She stated only nurses were assigned to trim or clean residents nails with a diagnosis of diabetes. In an interview on 04/11/2024 at 3:25 AM, the Administrator stated nail care was overseen by nurses and the CNAs assisted with nail care directed by the nurse. He stated the nurses were expected to keep the residents' nails trimmed, cleaned, and filed. He stated he was not a nurse and could not speculate what may happen to a resident if the resident ingested some type of bacteria. Record review of the facility's policy on Fingernails/Toenails, dated February 2018, reflected nail care included daily cleaning and regular trimming. Clean the nail bed and keep the nails trimmed, and to prevent infections.

Based on observation, interview, and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development of pressure ulcers for one of three (Resident # 39) reviewed for pressure ulcers. The facility failed to ensure Resident #39 received his physician ordered heel protectors at all times. This failure could place residents at risk for developing a pressure ulcer leading to pain, discomfort, and potential infections. Findings included: Review of Resident #39's Face Sheet dated 04/10/2024 revealed a 56 -year-old male admitted to the facility on [DATE]. His diagnoses included: other skin changes (changes in your skin can be clues that there's an internal issue with your health), severe intellectual disabilities (a condition in which your brain doesn't develop properly or function normally), and peripheral vascular disease (the reduce circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel). Record review of Resident # 39's Quarterly MDS Assessment, dated 02/26/2024, reflected Resident #39 was never/ rarely understood and was not capable of completing the BIMS questions. His cognitive patterns were assessed by the staff. Resident #39 had poor short- and long-term memory recall. His decision-making abilities were severely impaired. Resident #39 was dependent on staff for all his ADL's. Resident #39 was also assessed to be at risk for developing pressure ulcers/ injuries. Resident #39's MDS also reflected he required a pressure reducing device for chair and for his bed. Record review of Resident #39's Comprehensive Care Plan, dated 03/14/2024, reflected Resident #39 had alteration in skin integrity related to incontinence, physical limitations, and cognitive impairment. Interventions: monitor skin during showers for any areas of redness or excoriation and report to nurse. Off load (using a pillow or wedge under the calf to leave the foot suspended above the mattress) bilateral heels at all times. Resident #39 had ADL self-care deficit related to severe cognitive deficits. Resident #39 was also assessed to require total assistance with dressing, personal hygiene, toileting, and shower. He required 2-person mechanical lift for transfers. Record review of Resident #39's Physician Order for dated 04/10/2024 reflected for the resident to wear heel protectors at all times; offload right heel when in bed. Record review of Resident #39's skin assessment dated on 04/03/2024 reflected Resident #39 had pressure on his bilateral heels (no measurements on the skin assessments). Record review of Resident #39's Nurse Practitioners notes dated 04/11/2024 reflected Resident #39 was seen on 04/09/2024. Resident #39's chief complaint was reports of redness to bilateral heels. Right heel medial aspect with approximately 2.5 x .2.5 purplish slightly blanchable area to heel. Assessment/Plan: Pressure injury of heel- suspect pressure related. Add heel protector booties at all times. Offload Right heel when in bed. Pressure Ulcer of unspecified heel, unspecified stage. Signed by Nurse Practitioner. Record review of Resident #39's skin assessment dated [DATE] reflected Resident #39 did not have any skin concerns. Record review of Resident #39's skin assessment dated [DATE] revealed Resident #39 did not have any skin concerns. Record review of Resident #39's skin assessment dated on 03/30/2024 revealed Resident #39 did not have any skin concerns on his right heel. Record review of Resident #39's skin assessment dated on 04/03/2024 revealed Resident #39 had pressure (sore) on his bilateral heels. Record review of Resident #39's skin assessment dated on 04/11/2024 revealed Resident #39 had pressure (sore) on his right heel with measurement 1.7 cm x 1.3 cm. Observation on 04/10/2024 at 10:30 AM revealed Resident #39 was in the common tv area in his specialized wheelchair. Resident #39 was not wearing heel protectors. In an interview on 04/10/2024 at 10:45 AM, CNA D stated she received report from LVN C during report at the beginning of her shift on 04/10/2024 to ensure Resident #39 was wearing his heel protectors when out of bed and to ensure he had pillows underneath his heels when he was in bed. She stated when she assisted Resident #39 out of his room to the common tv area, she forgot to place the heel protectors on his feet. CNA D stated the heel protectors was available in Resident #39's room. She stated if he did not wear his heel protectors, the areas on right heel may develop into a wound. CNA D stated the heel protectors were used to prevent him having a pressure wound. In an interview/record review on 04/10/2024 at 11:05 AM, LVN C stated the Nurse Practitioner was at the facility on 04/09/2024 and checked Resident #39's heels. She stated a verbal order was given to her from the Nurse Practitioner to place heel protectors on Resident #39's heels to prevent pressure ulcer to his right heel. She stated she thought she documented about the order in the nurses notes or the physician orders. LVN C viewed the physician orders and the nurses note during the interview. She stated she did receive a verbal order to place heel protectors on Resident # 39's heels on 04/09/2024 but she did not document this order. LVN C stated the order was entered into the electronic medical record on 04/10/2024. She stated the staff had been offloading Resident #39's heels when he was in bed. She stated offloading heels and placing heel protectors on the heels were two different interventions. She stated offloading heels was an intervention of placing a pillow underneath the residents' feet. LVN C stated it had to be very specific when placing heel protectors on residents' feet to prevent skin breakdown. She stated he had been wearing heel protectors on 04/09/2024 due to the Nurse Practitioner gave her a verbal order to place the heel protectors on his feet. LVN C stated Resident #39 was expected to have heel protectors on when he was in the common area on 04/10/2024. She stated she gave report to the CNAs to place heel protectors on Resident #39 heels when he was out of bed and to offload his heels when he was in bed by using a pillow. In an interview/observation on 04/11/2024 at 9:15 AM, LVN E stated she worked with Agency and this was the first day she had worked at the facility in a few months. She stated Resident #39 was required to wear heel protectors related to a small new area on his right heel. LVN E also stated he was to wear heel protectors at all times. She stated the heel protectors was better for him than offloading his heels with a pillow. She stated the night nurse (she couldn't remember the nurse's name) gave her report on 04/11/2024 when she came to the nurse's desk at the beginning of her shift. LVN E stated the night nurse told her in report Resident #39 was offloading his heels on a pillow and now he had a new order to wear heel protectors. LVN E stated she discussed this information with the CNAs after she received her report from the nurse on night shift. LVN E stated Resident #36 did have heel protectors on his feet when she made rounds on 04/11/2024. LVN E stated Resident #39 was in his room and when entered Resident #39's room he was wearing heel protectors while he was in bed. LVN E stated the heel protectors were to be worn at all times in bed and out of bed. She stated the heel protectors was a different intervention than offloading heels on a pillow. In an interview on 04/11/2024 at 9:30 AM, CNA F stated she was informed Resident #39 was expected to wear heel protectors when out of bed, during the morning report when she began her shift on Resident #39. She stated she was informed Resident #36 was expected to wear heel protectors when in bed and out of bed. She stated this was a new order for this week. She stated prior to this week, the staff was placing pillows underneath his feet and he was not wearing heel protectors. In an interview on 04/11/2024 at 10:40 AM, the Director of Nurses stated there was a new order on 04/10/2024 for Resident #39 to wear heel protectors. She stated if Resident #39 was sitting in the common area on 04/10/2024, he was expected to be wearing heel protectors. The Director of Nurses stated when a resident had a red area on heel the intervention of wearing heel protectors was prevent the area from developing into a wound/pressure ulcer. She stated the staff was expected to place heel protectors on Resident #39. In an interview on 04/11/2024 at 3:25 PM, the Administrator stated if there was an order for Resident #39 to wear heel protectors, he expected the heel protectors to be on resident per physician order. He stated he could not respond to the question of what possibly may occur to the resident if he did not wear heel protectors. He stated he was not a nurse. Record review of the facility's policy on Support Surface Guidelines, dated 2011, reflected support surfaces were to promote comfort for all bed, chairbound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction.

Based on observations, interviews, and record review, the facility failed to maintain an Infection Control Program designed to ensure hand hygiene procedures were followed by contract staff in the direct care of one of four residents (Resident # 80) reviewed for infection control in that: 1. The facility failed to ensure the Hospice Nurse LVN B sanitized or wash her hands after touching contaminated items while feeding of Resident #80. 2. The facility failed to ensure the Hospice Nurse did not touch Resident #80 tip of straw and side of Resident #80's mouth. These failures could place residents at risk of cross contamination which could result in physical illness. Findings include: Record review of Resident #80's face-sheet dated 04/09/2024 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (parts of the brain that control thought, memory, and language), diseases of lips (can make it difficult to eat, drink, or even smile. Cold sores cause by bacteria can be a common symptom), anxiety disorder (mental disorder that causes constant fear and worry), Down's syndrome (a condition in which a baby is born with an extra chromosome 21. The extra chromosome is associate with delays in the child's mental and physical development, as well as increased as an increased for health problems. Record review of Resident # 80's Significant Change MDS Assessment, dated 02/14/2024, reflected Resident #80 was never/ rarely understood and was not capable of completing the BIMS questions. Her cognitive patterns were assessed by the staff. Resident #80 had poor short- and long-term memory recall. Resident #80 required for the staff to do more than half the effort with feeding. Record review of Resident #80's Comprehensive Care Plan reflected Resident #80, dated 02/22/2024, reflected she had ADL self-care deficit related to decreased cognitive status. Intervention: Eating- assist resident to the dining room, set up meals and provide verbal cueing as needed. Resident was assessed to require hospice services related to Alzheimer's disease (parts of the brain that control thought, memory, and language). Intervention: will maintain communication between hospice and the caregivers of facility to meet the needs of the resident. Observation on 04/09/2024 at 12:05 PM- 12:10 PM, the Hospice nurse (LVN) B was feeding Resident #80 in the dining area on D hall. During feeding, Hospice LVN B placed the palm and fingers of her right hand at the top of her ponytail and went to the end of the ponytail. Her ponytail was approximately at her shoulders. After this, she touched the handles and back of Resident #80's wheelchair. She also touched Resident #80's clothing. Hospice LVN B did not sanitize or wash her hands and began to give Resident #80 her protein shake. When she picked up the protein shake, she placed the tip of her forefinger on her right hand on the tip of the straw and placed that portion into Resident #80's mouth. When she was holding the protein shake, the tip of her ring finger of her right hand touched Resident #80's left side of her mouth. The Hospice Nurse LVN B picked up the spoon from the bowl of chocolate pudding and touched the inside of the bowl with her middle and ring finger on her right hand and fed Resident #80. In an interview on 04/09/2024 at 12:25 PM Hospice LVN B stated she sanitized her hands when she was in the hall walking toward the dining area. She stated she placed her bag on the floor and sanitized her hands again. Hospice LVN B stated when she began to feed Resident #80, she grabbed her ponytail with her right hand and run her fingers and palm of her hand through her hair. She also stated she touched Resident #80's wheelchair and clothing. She stated her hair, Resident #80's clothing and wheelchair would not be considered sanitized. She stated there was a possibility that bacteria were on Resident #80's clothing and wheelchair. She also stated her hair had hair products and possibly bacteria. Hospice LVN B stated she did not wash or sanitize her hands while feeding resident and after she touched these items (wheelchair, clothes, and hair). She stated she was to follow proper hygiene protocol when feeding or giving any type of care to a resident in the facility. She also stated there was a potential she may have cross contaminated the straw used for Resident #80 when she placed her fingers on the tip of the straw and when she placed fingers on her right hand by residents' mouth during feeding. Hospice LVN B stated there was a possibility of Resident #80 ingested bacteria from her fingers on her right hand the resident my become physically ill with a stomach issue and may have symptom of vomiting. She stated she had been in -serviced by the Hospice Agency she worked for on infection control and hand hygiene. She stated all nurses learned, in nursing school, proper hand hygiene when giving any type of care including feeding someone. She stated she made a mistake and she should have sanitized or washed her hands when feeding Resident #80 and she did not follow proper hand hygiene protocol. In an interview on 04/09/2024 at 1:20 PM, the Director of Nurses stated the hospice nurse was to follow proper hand hygiene when giving care to residents in the facility. She stated any nurse giving care whether it was a nurse employed at the facility or a nurse from another agency such as hospice giving care to a resident in this facility, were all to follow proper hand hygiene. She stated if the hospice nurse touched her own hair, touched Resident #81's wheelchair and clothes, she was expected to wash her hands prior to feeding Resident #80. She stated hand hygiene is basic nursing training. The Director of Nurses also stated any nurse learned proper hand hygiene protocol in nursing school and whenever given infection control in-service. She stated if a nurse touched anything considered contaminated was to wash or sanitize their hands immediately prior to given any care to a resident including feeding. She stated the hospice nurse did not practice good hand hygiene. In an interview on 04/10/2024 at 11:05 AM, LVN C stated any hospice staff who came into the facility to give care to any residents was expected to follow nursing protocol of hand hygiene. She stated she was in the dining room when Hospice Nurse LVN B was feeding Resident #80. She stated she was feeding another resident and was not watching Hospice Nurse LVN B. She stated if Hospice Nurse LVN B did not sanitize or wash her hands after touching her hair, someone else's clothing and parts of a wheelchair and continued to feed Resident #80, she did not follow nursing protocol of hand hygiene. She stated hand hygiene is what every nurse learns in nursing school and it is a part of the infection control protocol at every facility and agency. She also stated if Resident #80 ingested bacteria from Hospice LVN B's hands, Resident #80 possibly could become ill with any type of stomach issues. In an interview on 04/10/2024 at 1:04 PM, Director of Quality Assurance RN /BSN stated Hospice Nurse LVN B was required to follow the infection control protocol. She also stated hand hygiene for nurses was a standard protocol. She stated if a nurse had contaminated hands and gave any type of care to a resident , the nurse was expected to wash or sanitize their hands immediately before continuing care. She also stated this included feeding a resident. Director of Quality Assurance stated Hospice Nurse LVN B did not practice proper hand hygiene when feeding Resident #80 at the facility. She stated hand hygiene in-service was given to all nursing staff including Hospice Nurse LVN B. She also stated it was a possibility resident may become physically ill such as: the flu, respiratory issues, and a lot of different physical illnesses. Director of Quality Assurance RN/ BSN stated it deepened on the bacteria. In an interview on 04/11/2024 at 3:25 PM, the Administrator stated Hospice Nurse LVN B was expected to follow hand hygiene protocol when in the facility. He stated he was not a nurse and did not know all the specifics of what possibility could happen to Resident #80. He also stated hand hygiene protocol was expected to be known to all nurses who went to nursing school. Record review of the facility's policy on Hospice Program, dated 07/2017, reflected the facility staff (clinical nurse manager) provided orientation on the policies and procedures of the facility. Record review of the facility's Policy on Hand Hygiene in the Dining Room, not dated, reflected It is the policy of [FACILITY] to make every effort to prevent the spread of infection in the facility. In complying with this policy, we will make every effort to ensure that hand hygiene is practiced by all staff while in the dining room serving trays or assisting resident with eating. hand hygiene is to be considered high priority when working in the dining room. If in doubt of the need as to perform hand hygiene, remember it cannot be done too frequently.

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 reviewed for sanitation. 1. The DSM failed to ensure all items in the kitchen were labeled, dated, and discarded prior to their expiration date. 2. The DSM failed to ensure all personnel food items were stored separate from resident food items. 3. The DM failed to properly sanitize the thermometer probe when taking the temperature of food items. Findings included: Observations of the reach-in refrigerator on 3/06/2023 from 9:13 a.m. - 9:24 a.m. revealed the following: At 9:13 a.m., the reach-in refrigerator contained 12 bags of yellow unidentifiable substance unlabeled and undated. At 9:15 a.m., the reach-in refrigerator contained five foam containers of unidentifiable substance unlabeled and undated. At 9:16 a.m., the reach-in refrigerator contained three small foam containers of unidentifiable substance unlabeled and undated. At 9:17 a.m., the reach-in refrigerator contained a foam container, undated and labeled with the DSM's name. At 9:23 a.m., the reach-in refrigerator contained a bag of shredded carrots with a best-if-used-by date of 1/30/2023. The carrots appeared browned and had a foul odor. At 9:24 a.m., the reach-in refrigerator contained three sandwiches labeled PBH dated 2/26/2023. During an interview on 3/06/2023 at 9:30 a.m., the DM stated all items in the refrigerator should be labeled and dated. The DM stated the yellow substance was egg and usually they put it in a container with a label. The DM stated the items in the foam containers were parfait and whipped topping. The DM stated all items in the refrigerator needed to be labeled and dated. The DM stated all leftovers were discarded after seven days, the sandwiches were eight days old, and she would discard them. The DM stated the facility followed best-if-used-by dates and stated she would not serve the shredded carrots. The DM stated the foam container labeled with the DSM's name was the DSM's meal from the day prior. The DM stated the kitchen had a separate cooler for employee food items. An observation on 3/07/2023 at 10:46 a.m. revealed six bulk bins labeled sugar, rice, thickener powder, powdered milk, flour, and jasmine rice. These bins were labeled but not dated. Observations on 3/07/2023 from 11:10 a.m. - 11:20 a.m. revealed the DM took the temperatures of seven food items on the steam table and used a white rag to wipe the thermometer probe between each food item. During an interview on 3/07/2023 at 11:20 a.m., the DM stated no she had not sanitized the thermometer probe in between temping the food items because she had dipped the towel in sanitizer solution prior to temping the food items. The DM stated the kitchen did not have disposable sanitizer wipes. During an interview on 3/07/2023 at 3:17 p.m., the RDN stated the kitchen's policy on labeling and dating refrigerated items included the use of FIFO and stated staff labeled everything when it came in. The RDN stated it was not necessary to date bulk bin items as long as the container did not appear old and crusted. The RDN stated she would question it if it looked that way but stated the kitchen's stuff always looked fresh. The RDN then stated all food items needed a label and a date. The RDN stated she instructed kitchen staff to get rid of old produce if it looked wilted or was spotting and stated yes she would have expected staff to discard a bag of shredded carrots with a foul odor and a best-if-used-by date of over one month ago. The RDN stated the DM and the DSM inventoried the kitchen once or twice a week to identify and discard old food items. The RDN stated leftover food items such as sandwiches needed to be discarded after seven days. The RDN stated staff should use alcohol sanitizer wipes to sanitize the thermometer probe between temping different food items. The RDN stated that was how she trained staff to take food temperatures. The RDN stated the kitchen had sanitizer wipes and she expected them to use them. The RDN stated personal food items could be kept in the personal fridge or in the DSM's office. The RDN stated no that personal food items should not be kept in the reach-in refrigerator. The RDN stated all kitchen staff had been trained on food storage and sanitation through obtaining their Texas food handlers license upon hire. The RDN stated herself as well as the DM and DSM completed in-service trainings with staff on food storage and sanitation. The RDN stated she monitored the kitchen by completing monthly sanitation audits. The RDN stated she was in the kitchen a couple times a month and she would do a walk-through and make observations of tray line and the dining room. The RDN stated the kitchen was monitored daily by either the DM or DSM. The RDN stated they monitored the kitchen by going through to make sure items were labeled, dated, and covered. The RDN stated if policies on food storage and sanitation were not followed, there could be potential for foodborne illness. During an interview on 3/08/2023 at 4:01 p.m., the ADM stated the kitchen's policy on food storage included covering, labeling and dating food items. The ADM stated leftovers should be tossed. The ADM stated old produce with a best-if-used-by date of over a month ago should have been thrown away already. The ADM stated there was a personal refrigerator where employee's personal food items should be stored. The ADM stated yes that all items removed from their original package should have a label and a date. The ADM stated he did not know what the facility's policy was on sanitizing thermometer probes when temping food but stated it should be sanitized appropriately in between. The ADM stated all kitchen staff were trained on food storage and sanitation through obtaining their certification and through in-service trainings. The ADM stated the DSM, the RDN and himself monitored the kitchen by making frequent rounds. The ADM stated the RDN monitored the kitchen via visits at least once a month, by completing a report, and through communication with the ADM about how things were going in the kitchen. The ADM stated he was in the kitchen twice a week to make sure there was not anything out of hand. The ADM stated if food storage policies were not followed, someone could get sick and if sanitation policies were not followed, infections could spread. A record review of the facility's policy titled Taking Accurate Temperatures using Metal Stem Thermometers dated 2021 reflected the following: Thermometers should be sanitized according to manufacturer's instructions. Bimetallic thermometers may be sanitized using a dish machine or three sink method. In between uses at one meal, an alcohol swab may be used to sanitize. (use a new swab for each sanitizing.) A record review of the facility's policy titled Food Storage dated 2021 reflected the following: Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contamination or cross contamination. Procedure: 8. Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated. 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2017 Federal Food Code. 13. Refrigerated food storage: f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. h. Refrigerated foods should be stored upon delivery and careful rotation procedures should be followed. A record review of the facility's undated policy titled Policy for Personnel Food Items reflected that employee's personal food items were to be stored in a mini fridge located in the hallway near the kitchen or in the DSM's office. A record review of the RDN's monthly sanitation audit titled Food Safety and Sanitation Checklist dated 2/28/2023 reflected no that the facility did not identify food not stored in its original container by its proper name and out of date leftovers x 4-5. A record review of the FDA's 2017 Food Code reflected the following: Objective 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. Food-contact surfaces and equipment used for time/temperature control for safety foods should be cleaned as needed throughout the day but must be cleaned no less than every 4 hours to prevent the growth of microorganisms on those surfaces. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

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 24 residents (Residents #55, 57, and 76) and one of four medication carts reviewed for infection control. 1. Resident #55 scratched herself in the perineal area multiple times resulting in soiled hands and fingers, and she touched people and things in the common area without intervention from staff. 2. LVN A stored and locked her used scrub-top in the drawer of a medication cart that contains medications and treatment supplies. 3. LVN C assisted both Residents #57 and 76 with eating, using the same hand, and did not perform hand hygiene between them. These failures placed residents at risk of transmission of infectious diseases. Findings included: Review of the undated face sheet for Resident #55 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of pruritus (itchiness), chronic gingivitis, irritable bowel syndrome, slow transit constipation, diarrhea, impacted cerumen, hypothyroidism, Alzheimer's disease with early onset, intellectual disabilities, gastroesophageal reflux disease, down syndrome, Reynaud's syndrome without gangrene (a condition in which body overreacts to certain situations causing cold and numbness in the hands and feet.), anorexia, major depressive disorder, impulse disorder, and insomnia. Review of the quarterly MDS for Resident #55 dated 02/07/23 reflected a BIMS score of 99, indicating a severe cognitive impairment. It reflected Resident #55 required the extensive assistance of one staff member with personal hygiene. Review of the care plan for Resident #55 dated 08/03/22 reflected the following: Bowel and bladder incontinence r/t cognitive deficits. Resident will not have any direct complications from incontinence such as skin problems. Assist w/ incontinent care as indicated. Encourage self-care wiping and give resident praise for doing so. Observation and interview on 03/07/23 between 12:29 PM and 02:15 PM revealed Resident #55 walking all around the common area on the DE side of the facility, frequently reaching her hands into the front and back of her pants and underwear and scratching. In between scratching inside her pants, she touched multiple surfaces including the back of several chairs, a medication cart, the overbed table CNAs used while entering their charting notes, staff members' hands and shoulders, and a toy car belonging to another resident. kissing staff on the hand. LVN D assisted Resident #55 with reapplying an arm sling, and Resident #55 put her hands on the sling, on LVN D's hands, and on LVN D's shoulder. Immediately after this, LVN D went into the nurse's station and began working on the computer. She did not perform hand hygiene. At 01:34 PM, Resident #55 again reached into the back side of her pants, scratched, withdrew, looked at, and smelled her hand, and said Ew! Her hand was covered in a brown substance, and she showed it to the surveyor, who asked loudly if she wanted to show any of the staff present. LVN D, LVN E, and MA F were each within four feet when this occurred, but none of them acknowledged the situation. MA F walked past Resident #55, and Resident #55 reached out to her and touched her arm as she walked by. Resident #55 continued to touch other things around the area, including her own face and the inside of her nose. MA F went to a sink behind the nurse's station and washed her hands. Shortly after, LVN E washed her hands in the same sink. At 01:38 PM, LVN D came out from behind the nurse's station and donned gloves. LVN D stated she was about to clean her medication cart. When asked why she had not performed hand hygiene since assisting Resident #55 with her arm sling, LVN D stated she thought she had and pulled a small bottle of hand alcohol-based hand run out of her pocket. When asked if she noticed that Resident #55 had been reaching her hands in her pants and touching things, LVN D stated, Yes, she does that. We try to redirect her. LVN D stated she should perform hand hygiene after assisting any resident with care, including the reapplication of a sling, and she should have assisted Resident #55 with hand hygiene often after she scratched inside her pants. When asked if she had received any specific training on how to address Resident #55's behavior, LVN D stated she was sure that the behavior was in Resident #55's care plan. During an interview on 03/07/23 at 02:19 PM, the ADON stated she had witnessed Resident #55 scratching herself under her underwear, and this was a fairly common behavior for her due to her resistance to care and activities of daily living. The ADON stated the staff should be taking her to the bathroom to sanitize her hands if they witness the behavior. When asked how the staff knew to respond to the behavior that way, she stated they had infection control in-services. The ADON stated there had been no in-servicing specific to Resident #55, but because of the nature of the material that came out on her hands when she digs and scratches under her pants, her hands needed to be sanitized every time she did it. The ADON stated she thought there was a behavioral care plan for Resident #55, but the only thing she saw was the care plan item about being resistant to care with ADLs. The ADON stated the staff should have known what to do, though, because it was common sense for infection control. During an interview on 03/08/23 at 03:13 PM, the DON stated hand hygiene for someone who has touched or dug under their underwear was common sense. She stated treating the behavior for Resident #55 presents with a unique challenge, because people with downs syndrome who develop dementia are extremely difficult to redirect. The DON stated she knew the staff washed Resident #55's hands when they provided assistance with toileting. The DON stated she did not think they had a specific intervention for Resident #55 but that any time someone is soiled the staff needed to clean them. The DON stated Resident #55 walking around touching things in the common area was hazardous due to being an infection control issue, and the area in which she had been doing that should have had a deep clean. During an interview on 03/08/23 at 04:02 PM, the ADM stated they had to monitor sanitation all over the building and needed to monitor someone like Resident #55 very closely to make sure they did not have an infection control issue. He stated the hard part about residents with Downs syndrome who have dementia is they will be up and out and all over the place and trying to keep up with her will sometimes succeed and not others. The ADM stated if they saw her touching something she should not have touched with soiled hands, they should be intervening immediately. The Adm stated the problem often was that staff got nervous while surveyors were watching and failed to do what they normally would. Review of facility policy dated August 2019 and titled Cleaning and Disinfection oc Environmental Surfaces reflected the following: Housekeeping surfaces (e.g. floors, table tops) will be cleaned on a regular basis, when spills occur, and when the surfaces are visibly soiled. Environmental services will be disinfected or clean on a regular basis (e.g. daily), three times per week, and when surfaces are visibly soiled. Spills of blood and other potentially infectious materials will promptly be cleaned and decontaminated. 2. During an observation on 03/06/2023 at 10.30 AM revealed the storage of a green colored slightly faded scrub- top in the bottom drawer of a medication cart in the medication room situated at Hall A of the facility. There were wound care supplies, compound benzoin tincture swab sticks, oxygen tubing, sanitary pads, liquid medications in bottles and gastrotomy care supplies were in that drawer. LVN A was assisting the investigator by opening the drawers of the cart one by one for medication storage inspection. The scrub was found above the medications and treatment supplies in the bottom drawer, in plain without any package or wrap. LVN A removed the scrub immediately from the drawer and stated she regrets for storing it in the med cart. During an interview on 03/06/23 at 10.45 AM LVN A stated the scrub owned by her and should not have stored in the med cart after the use. When asked about the adverse result of storing used scrub with medications, LVN A stated the scrub could contaminate the medications and treatment supplies stored in the med cart and helps to spread diseases. During an interview on 03/07/23 at 3:00 PM ADON stated the med cart was exclusively for storing medications and treatment items and should not be used for storing any other materials like food or clothes. She stated this was necessary to minimize spreading diseases through cross contamination. During an interview on 03/08/23 at 2:00 PM DON stated no materials other than medications and treatment items should be there in the med cart. She stated used clothes stored in a med cart could contaminate the medications in the cart and this compromises infection control efforts. Review on 03/08/23 of the facility policy Storage of Medications dated November 2020 reflected: The facility stores all drugs and biologicals in a safe, secure, and orderly manner . . 3.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . 3. A record review of Resident #57's Resident Dashboard dated 03/08/23 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of mild intellectual abilities, hypertension (high blood pressure), hyperlipidemia (high cholesterol), legal blindness, gastro-esophageal reflux disease (acid reflux), dysphagia (difficulty swallowing), schizoaffective disorder (mental condition causing delusions), major depressive disorder (depression), bipolar disorder (extreme mood swings), and repeated falls. A record review of Resident #57's MDS assessment dated [DATE] reflected she was unable to complete a BIMS assessment. A review of Section G (Functional Status) reflected Resident #57 required supervision and a one-person physical assist with eating. A record review of Resident #57's care plan last revised on 01/29/23 reflected she had ADL self-care deficit related to physical limitations and eyesight, and required meal set up, verbalized placement of food on table and verbal cueing as needed. A record review of Resident #76's Resident Dashboard dated 03/08/23 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of muscle weakness, unspecified convulsions, severe intellectual disabilities, irritable bowel syndrome, and epilepsy (nervous system disorder). A record review of Resident #76's MDS assessment dated [DATE] reflected she was unable to complete a BIMS assessment. A review of Section G (Functional Status) reflected Resident #76 was totally dependent on staff and required a one-person physical assist with eating. A record review of Resident #76's care plan last revised on 01/28/23 reflected she had ADL self-care deficit related to altered cognitive status, cerebral palsy, and autistic disorder. Resident #76's care plan reflected she needed to be spoon fed all meals. An observation on 03/06/23 at 11:58 AM revealed LVN C was sitting between Resident #76 and Resident #57 in the dining room. LVN C was observed feeding Resident #76. Resident #57 was observed to be having trouble feeding herself, LVN C began feeding her with the same hand she used to feed Resident #76. LVN C went back and forth three times between feeding Resident #76 and Resident #57 without using hand hygiene in between. During an interview on 03/06/23 at 12:04 PM, LVN C stated she did not use hand hygiene in between feeding Resident #76 and Resident #57 because she did not believe it was cross-contamination since she did not touch the resident themselves. LVN C stated Resident #57 usually ate on her own but that day she needed help. LVN C then stated she should have used hand hygiene in between. During an interview on 03/07/23 at 02:31 PM the ADON stated she expected staff to sanitize their hands in between feeding different residents. The ADON stated all staff were trained on proper hand hygiene upon hire. When asked what potential negative resident impact there could be if staff did not practice proper hand hygiene when feeding residents, the ADON stated, they are exchanging different bacteria when changing from one resident to another. During an interview on 03/08/23 at 3:20 PM, the DON stated the facility's policy on hand hygiene during meal assistance included that staff were to perform hand hygiene between each resident. The DON stated yes that hands should be sanitized between feeding one resident and another. The DON stated staff were trained during orientation on proper hand hygiene during meal service. The DON stated herself, the ADON, and other management personnel monitored for compliance of proper hand hygiene by completing audits with staff. The DON stated if the facility's policy on hand hygiene during meal service were not followed, it would be an infection control issue. During an interview on 03/08/23 at 04:01 PM, the ADM stated staff should perform hand hygiene between feeding multiple residents. The ADM stated all staff were trained on this upon hire. The ADM stated typically the nurse managers monitored staff to ensure they used proper hand hygiene. When asked what potential negative resident impact there could be if the facility's policy on hand hygiene in the dining room were not followed, the ADM stated, it is not best practice, it is not the right thing to do, and there was not an infection that came out of it. A record review of the facility's orientation checklist titled Employee Onboarding Checklist reflected LVN C was trained on the facility's policy on hand hygiene in the dining room on 02/08/23. LVN C signed a statement reflecting she understood the policy for hand hygiene in the dining room. A record review of the facility's undated policy titled Hand Hygiene in the Dining Room reflected the following: It is the policy of (facility name) to make every effort to prevent the spread of infection in the facility. In complying with this policy, we will make every effort to ensure that hand hygiene is practiced by all staff while in the dining room serving trays or assisting residents with eating. Policy Interpretation and Implementation: 6. If you are assisting a resident to eat, hand hygiene must be done prior to the beginning of the actual feeding or assistance. 7. You may feed two residents at the same time as long as you maintain a clean hand that is dedicated to touching only the silverware, plate or glassware of each resident. If you touch either resident with your dedicated hand, you must perform hand hygiene before you resume feeding or assisting the resident. 8. If you move from a resident at one table to a resident at another table to begin feeding or assisting, you must perform hand hygiene before assisting the new resident. 9. Hand hygiene is to be considered high priority when working in the dining room. If in doubt of the need as to perform hand hygiene, remember it cannot be done too frequently.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 12 of 14 resident rooms (rooms for Residents ##3, 6, 12, 14, 15, 19, 35, 40, 42, 43, 50, 51, 52, 55, 64, 65, 66. 67, 72, 74, 75, and 81) reviewed for physical environment. The air conditioning units in rooms for Residents #3, 6, 12, 14, 15, 19, 35, 40, 42, 43, 50, 51, 52, 55, 64, 65, 74, 75, and 81 were covered with a black and grey substance, and the units in rooms for Residents #52, 64, 65, 66, and 67 were broken and/or not securely fastened to the wall. This failure placed residents at risk of respiratory illness, infection, and injury by accident. Findings included: Review of the undated face sheet for Resident #66 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and seasonal allergic rhinitis. Review of the undated face sheet for Resident #67 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and seasonal allergic rhinitis. During observation and interview on 03/06/23 beginning at 09:42 AM, Resident #67 was sitting in his wheelchair in the doorway of his room. He stated his air conditioner was broken and pointed to a unit under the window and near his roommate's bed. He roommate, Resident #66, sat in his wheelchair approximately three feet from the AC, with a peg tube attached and operating, and did not respond to efforts to communicate with him. The AC unit was coming away from the wall, the filters were jammed and would not slide back into the unit. The unit's air output grill was covered with a thick grey and black substance. Review of the undated face sheet for Resident #15 reflected an [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and seasonal allergic rhinitis. Review of the undated face sheet for Resident #6 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of chronic respiratory failure, chronic bronchitis, intellectual disabilities, and allergic rhinitis. Observation on 03/07/23 at 11:43 AM revealed the AC unit's air output grill in #6 and 15's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #81 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and seasonal allergic rhinitis. Review of the undated face sheet for Resident #75 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and history of infections of the central nervous system. Observation on 03/07/23 at 11:45 AM revealed the AC unit's air output grill in #75 and 81's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #42 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of allergic rhinitis due to pollen and intellectual disabilities. Review of the undated face sheet for Resident #64 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of seasonal allergic rhinitis. Observation on 03/07/23 at 11:46 AM revealed the AC unit's air output grill in #52 and 64's room was covered with a thick grey and black substance. It was also cracked and pulling away from the wall. Review of the undated face sheet for Resident #55 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnosis of intellectual disabilities. Observation on 03/07/23 at 11:47 AM revealed the AC unit's air output grill in #55's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #12 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and seasonal allergic rhinitis. Review of the undated face sheet for Resident #51 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and allergic rhinitis. Observation on 03/07/23 at 11:48 AM revealed the AC unit's air output grill in #12 and 51's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #43 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of allergic and intellectual disabilities. Review of the undated face sheet for Resident #50 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of allergic rhinitis. Observation on 03/07/23 at 11:49 AM revealed the AC unit's air output grill in #43 and 50's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #72 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and seasonal allergic rhinitis. Observation on 03/07/23 at 11:52 AM revealed the AC unit's air output grill in #74's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #3 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of obstructive sleep apnea and allergic rhinitis. Review of the undated face sheet for Resident #14 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of obstructive sleep apnea. Observation on 03/07/23 at 11:53 AM revealed the AC unit's air output grill in #3 and 14's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #40 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of allergic rhinitis due to pollen and intellectual disabilities. Review of the undated face sheet for Resident #42 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of seasonal allergic rhinitis and intellectual disabilities. Observation on 03/07/23 at 11:54 AM revealed the AC unit's air output grill in #40 and 42's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #35 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of allergic rhinitis due to pollen, seasonal allergic rhinitis, and intellectual disabilities. Review of the undated face sheet for Resident #19 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of snoring and intellectual disabilities. Observation on 03/07/23 at 11:55 AM revealed the AC unit's air output grill in #19 and 35's room was covered with a thick grey and black substance. Review of the undated face sheet for Resident #65 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of allergic rhinitis and intellectual disabilities. Observation on 03/07/23 at 11:56 AM revealed the AC unit's air output grill in #65's room was covered with a thick grey and black substance. The Ac unit was pulling away from the wall and left a gap in the drywall behind it. During an interview on 03/07/23 at 11:52 AM, HK G stated the maintenance department was responsible for cleaning the AC units. HK G stated she had noticed the grey and black substance on the AC units, but she did not know who to tell. HK G stated she thought someone from the maintenance department cleaned the units sometimes but did not know of any schedule. During an interview on 03/07/23 at 01:53 PM, the MAINT stated he was the director for the entire campus, which included two assisted living facilities and an independent living facility. He stated the position of maintenance director for this facility was vacant, but someone was scheduled to start the following day (03/08/23). He stated he also employed a dedicated HVAC specialist for the whole campus, but that position was also vacant. his team cleaned the AC filters monthly, but he was not aware how long it had been since the unit's air output grills had been cleaned. The MAINT stated the ideal service times for the AC units when they would be fully inspected was quarterly, but he had not had a had a full time HVAC service person since June 2022, and a new one would finally start on 03/14/23. After walking through the rooms and viewing the AC units, the MAINT stated the ACs pulling away from the wall were a safety hazard, and the grey black substance was probably a form of mildew and was not healthy for anyone to be breathing in. During an interview on 03/07/23 at 2:51 PM, the ADM stated he knew there was a general schedule they maintained of cleaning out the AC unit filters. The ADM stated they were without a permanent maintenance person just for their facility, but when they had one, he had cleaned the filters at least twice a month. When asked if he expected the staff who cleaned the filters to also notice if there was debris or grime in the air output grate, he stated it would depend on what it looked like, but he hoped that staff would take care of it. He stated he had not done any specific training or given guidance on this issue, but it was common sense that if there was mold, mildew, or other mess it should be cleaned. During an interview on 03/08/23 at 03:21 PM, the DON stated mildew in the air output grate could cause harm or discomfort to a resident. She stated the main concern would be respiratory issues in a room where that was the condition. Review of facility policy dated February 2021 and titled Homelike Environment reflected the following: Policy Statement- Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation- 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility, they reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary, and orderly environment. Review of facility policy dated December 2009 and titled Maintenance service shall be provided to all areas of the building, grounds, and equipment. 1.The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2.Functions of maintenance personnel include, but are not limited to: d. Maintaining the heat/cooling system, plumbing, fixtures, wiring, etc., in good working order i. Providing routinely scheduled maintenance service to all areas j. Others that may become necessary or appropriate.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of eight residents (Resident #55) reviewed for care plans. Resident #55 scratched herself in the perineal area multiple times resulting in soiled hands and fingers, and she touched people and things in the common area without intervention from staff, and this was not included in a behavioral care plan. This failure placed residents at risk of not attaining their higest practicable well-being. Findings included: Review of the undated face sheet for Resident #55 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of pruritus (itchiness), chronic gingivitis, irritable bowel syndrome, slow transit constipation, diarrhea, impacted cerumen, hypothyroidism, Alzheimer's disease with early onset, intellectual disabilities, gastroesophageal reflux disease, down syndrome, Reynaud's syndrome without gangrene (a condition in which body overreacts to certain situations causing cold and numbness in the hands and feet.), anorexia, major depressive disorder, impulse disorder, and insomnia. Review of the quarterly MDS for Resident #55 dated 02/07/23 reflected a BIMS score of 99, indicating a severe cognitive impairment. It reflected Resident #55 required the extensive assistance of one staff member with personal hygiene. Review of the care plan for Resident #55 dated 08/03/22 reflected the following: Bowel and bladder incontinence r/t cognitive deficits. Resident will not have any direct complications from incontinence such as skin problems. Assist w/ incontinent care as indicated. Encourage self-care wiping and give resident praise for doing so. Observation and interview on 03/07/23 between 12:29 PM and 02:15 PM revealed Resident #55 walking all around the common area on the DE side of the facility, frequently reaching her hands into the front and back of her pants and underwear and scratching. In between scratching inside her pants, she touched multiple surfaces including the back of several chairs, a medication cart, the overbed table CNAs used while entering their charting notes, staff members' hands and shoulders, and a toy car belonging to another resident. kissing staff on the hand. LVN D assisted Resident #55 with reapplying an arm sling, and Resident #55 put her hands on the sling, on LVN D's hands, and on LVN D's shoulder. Immediately after this, LVN D went into the nurse's station and began working on the computer. She did not perform hand hygiene. At 01:34 PM, Resident #55 again reached into the back side of her pants, scratched, withdrew, looked at, and smelled her hand, and said Ew! Her hand was covered in a brown substance, and she showed it to the surveyor, who asked loudly if she wanted to show any of the staff present. LVN D, LVN E, and MA F were each within four feet when this occurred, but none of them acknowledged the situation. MA F walked past Resident #55, and Resident #55 reached out to her and touched her arm as she walked by. Resident #55 continued to touch other things around the area, including her own face and the inside of her nose. MA F went to a sink behind the nurse's station and washed her hands. Shortly after, LVN E washed her hands in the same sink. At 01:38 PM, LVN D came out from behind the nurse's station and donned gloves. LVN D stated she was about to clean her medication cart. When asked why she had not performed hand hygiene since assisting Resident #55 with her arm sling, LVN D stated she thought she had and pulled a small bottle of hand alcohol-based hand run out of her pocket. When asked if she noticed that Resident #55 had been reaching her hands in her pants and touching things, LVN D stated, Yes, she does that. We try to redirect her. LVN D stated she should perform hand hygiene after assisting any resident with care, including the reapplication of a sling, and she should have assisted Resident #55 with hand hygiene often after she scratched inside her pants. When asked if she had received any specific training on how to address Resident #55's behavior, LVN D stated she was sure that the behavior was in Resident #55's care plan. During an interview on 03/07/23 at 02:19 PM, the ADON stated she had witnessed Resident #55 scratching herself under her underwear, and this was a fairly common behavior for her due to her resistance to care and activities of daily living. The ADON stated the staff should be taking her to the bathroom to sanitize her hands if they witness the behavior. When asked how the staff knew to respond to the behavior that way, she stated they had infection control in-services. The ADON stated there had been no in-servicing specific to Resident #55, but because of the nature of the material that came out on her hands when she digs and scratches under her pants, her hands needed to be sanitized every time she did it. The ADON stated she thought there was a behavioral care plan for Resident #55, but the only thing she saw was the care plan item about being resistant to care with ADLs. The ADON stated the staff should have known what to do, though, because it was common sense for infection control. During an interview on 03/08/23 at 03:13 PM, the DON stated hand hygiene for someone who has touched or dug under their underwear was common sense. She stated treating the behavior for Resident #55 presents with a unique challenge, because people with downs syndrome who develop dementia are extremely difficult to redirect. The DON stated she knew the staff washed Resident #55's hands when they provided assistance with toileting. The DON stated she did not think they had a specific intervention for Resident #55 but that any time someone is soiled the staff needed to clean them. The DON stated Resident #55 walking around touching things in the common area was hazardous due to being an infection control issue, and the area in which she had been doing that should have had a deep clean. During an interview on 03/08/23 at 04:02 PM, the ADM stated they had to monitor sanitation all over the building and needed to monitor someone like Resident #55 very closely to make sure they did not have an infection control issue. He stated the hard part about residents with Downs syndrome who have dementia is they will be up and out and all over the place and trying to keep up with her will sometimes succeed and not others. The ADM stated if they saw her touching something she should not have touched with soiled hands, they should be intervening immediately. The Adm stated the problem often was that staff got nervous while surveyors were watching and failed to do what they normally would.

Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Residents #5) reviewed for pressure ulcers. 1. The facility failed to ensure the provider treatment plan for Resident #5 was implemented. 2. The facility did not provide wound care as ordered by the provider for Resident #5. These failures placed residents at risk of pain, worsening of wounds and wound infection. Findings included: Record review of Resident #5's Face Sheet dated 03/07/23 reflected Resident #5 was a [AGE] year-old male, and he was admitted to the facility on [DATE]. Resident #5 had diagnoses of Dysphagia (difficult to swallow), Parkinsonism, Chronic pain, Deficiency of B and D vitamins, Allergic rhinitis due to pollen, Epilepsy, Constipation, Intellectual disabilities, Muscle Weakness, Need for assistance with personal care, Psychosis, Pain in left Foot, Pain in left knee and Pressure-induced deep tissue damage of left heel. Record review of Resident #5's MDS assessment dated [DATE] reflected Resident #5 had slurred or mumbled words and limited ability to make concrete requests. Resident #5 also had a BIMS score of 11, indicated Resident #5 had moderate cognitive impairment. He required to have full staff performance every time during entire 7-day period. Resident #5 was incontinent for both bowel and bladder. The MDS assessment indicated Resident #5 had one or more unhealed pressure ulcers/injuries and treatment included pressure reducing device for chair and bed and pressure ulcer/injury care. Record review of Resident #5's Care Plan dated 02/03/23 reflected no statement of any pressure ulcer. Record review of Resident #5's weekly skin assessment dated [DATE] reflected Resident #5 had left heel wound measuring 3cm L x 2cm W x 0cm D with clear drainage. Resident informed he had a burning sensation from that. Resident#5's left toe had a blackish colored spot above the toenail measuring 1cm L x 1cm W x 0 cm D. Record review on 03/7/23 of the evaluation of the wounds of Resident #5 on 2/22/22 at 1:53pm by APRN, stated: Wound #1, Date of onset: 2/22/23, Location: left heel (2 areas), Description: Medial Area:1.5cm x 1.4cm and 0.8cm x0.7 cm. Etiology: DTI, Treatment plan: change treatment to: Apply skin prep and cover with sock. Continue booties. Wound #2, Location: left great toe. Description: Proximal Area:0.8cm x0.6 cm. Etiology: DTI. Treatment plan: change treatment to: Apply skin prep and cover with sock. Apply booties. Record review of clinical physician's order on 03/07/23 dated 02/22/23 at 1:07pm by APRN, stated: Left heel wound: Apply skin prep and cover with sock. Record review of clinical physician's order on 03/07/23 dated 03/07/23 at 1:12pm by APRN, stated Left great toe DTI: Apply skin prep and cover with sock. The treatment order on 02/22/23 at 1:07pm for Resident#5's wound on his left heel was as per the treatment plan dated 02/22/23, however, the treatment order on 03/07/23 at 1:12pm for Resident #5's left great toe was ordered 13 days after the completion of wound evaluation and treatment plan dated 02/22/23. Record review of February,2023 TAR on 03/07/23 at 01:18pm stated: Left heel wound: Apply skin prep and cover with sock every evening shift for Left heel wound, -Start Date-02/24/2023, 1400. Record review of March,2023 TAR on 03/7/23 at 1.28 pm stated: 1.Left heel wound: Apply skin prep and cover with sock every evening shift for Left heel wound, -Start Date-02/24/2023, 1400 2.Left great toe DTI: Apply skin prep and cover with sock. Every evening shifts. -Start Date-03/07/2023 1400. Record review on 03/07/2023 at 11.30am of the TAR reflected that as on 03/07/2023, 11.30am there were no evidence of any treatment provided as per the order to Resident#5's wounds starting from 02/24/2023, as per the order. Observation of Resident #5's wound dressing on 03/07/23 at 11:30 AM revealed Resident #5's left heel wound had redness without any secretion and the left toe wound was visible as a red spot without any secretion. An interview with LVN B on 03/07/23 at 11:30 am, LVN B stated she was not aware of the pressure ulcer treatment for Resident #5. LVN B said she was aware of the order for Witch Hazel Liquid (medicinal ointment) that was applied on 3/7/23 to Resident#5's face, neck, behind ears topically. This was provided every day as per the order. When asked about the adherence to TAR orders, LVN B stated it was mandatory that the treatments had to be provided by nurses as per the directions in the treatment order in the TAR. During an interview on 03/07/23 at 2.00pm the ADON stated that LVN B reported to her about the issue of the omission of wound treatment. ADON stated both orders for treatment were placed only on 03/07/23 by the APRN. She added that the facility had a new APRN who started few weeks ago and getting used to the system. When the investigator asked about the treatment order by APRN on 02/22/23 for the wound treatment for the left heel that was transcribed into the TAR clearly stating to commence from 02/24/23, ADON said most likely there was a software glitch in the EMR and transcribed the commencement date wrongly. When asked about the compliance by the nurses to the treatment order, ADON stated the nurses should strictly follow the treatment order in the TAR. During the interview on 03/08/23 at 2:30 pm the DON stated the nurses and MAs must follow the MAR and TAR while providing treatments and administering medications. DON stated the APRN did not place the orders for the treatments and that was the reason for not providing the treatment. When the investigator showed the treatment order for left heel wound on TAR scheduled to start from 02/24/23, DON stated that the commencement date on the TAR was wrong and most likely there was some issue with the EMR software. When asked about the risk of such software issues, she stated there was high risk of not getting very important medications and treatments to the residents on time if the EMR was malfunctioning. DON stated this was the first time happening like this. During the interview on 03/08/23 at 2pm the APRN stated she was new to the facility and settling in with the system at the facility. When asked about the treatment orders for the pressure ulcers of Resident#5, she stated on 02/22/23 after her wound evaluation she made a treatment plan, and not a treatment order. When the investigator asked when there was a treatment order for the wound on the heel, based on the treatment plan on 02/22/23, why there was not an order for the wound on the toe on 02/22/23 itself but only 13 days after on 03/07/23, though both of them had treatment plan on 02/22/23, APRN said she was not familiar with the EMR and might not have entered properly. During the interview on 03/08/23 at 3.30pm, the ADM stated the clinical aspects were taken care by DON and he was in charge of the administration. When the investigator asked about the accuracy and reliability of the EMR system, he stated it was a very reliable software and never heard of any complaints. He said, in case if any issues there, that could be immediately resolved with the support of the readily available EMR software technicians. He added, the facility never had any concerns about the reliability and accuracy of the system. The ADM stated there was no specific policy and procedure for medication administration and the nurses supposed to follow the standard clinical rules for medication administration and treatment.

Based on interview and record review the facility failed to make prompt efforts to resolve grievances for five (CR #1, CR #2, CR #3, CR #4, and CR #5) of twenty confidential residents reviewed for grievances, in that: The facility failed to resolve grievances for CR #1, CR #2, CR #3, CR #4, and CR #5 and establish a policy to ensure a system was in place to provide residents with a written decision or response regarding grievances. This failure placed the residents at risk for unresolved grievances and a decreased quality of life. The findings included: During a confidential interview on 1/5/22 at 10:15 AM with twenty Confidential Residents, CR #1, CR #2, CR #3, CR #4, and CR #5 expressed the following grievances: CR #1 - Items are taken out of her closet such as clothes, bedspread, and her pillow CR#2 - Missing clothes CR#3 - Down comforter is missing CR#4 - Half of his DVD collection is missing CR#5 - Several missing blouses The residents stated they had expressed their missing items to staff members, but they never hear back. None of these residents knew what a grievance form was, or if there was a grievance process. They all stated they had their names written on their items. During an interview on 1/5/22 at 1:20 PM with the SW, she stated she had only worked at the facility for a week, so she was not sure how they had been doing their grievance process before her. She stated that in her experience, any complaints made by a resident or family member would be written on a grievance form and given to the appropriate manager. She stated the family member or resident that reported the complaint should always receive a written response. She stated if a resident alleged, she was missing a blouse and it was unable to be located, a grievance form should be completed to start the process of an investigation. During an interview on 1/6/22 at 9:43 AM with LVN C, she stated if a resident notified her of an item of theirs that was missing, she stated she would look in their room for the item and would also notify the laundry department. She stated she would also write a note on the dashboard (resident EMR system) but was not sure if that would create a grievance form. During an interview on 1/6/22 at 9:46 AM with CNA B, she stated if a resident is missing clothing, she would notify the laundry department. She stated she assumed they would complete a grievance form. During an interview on 1/6/22 at 9:50 AM with a LA F, she stated if it was clothing that was reported missing, she would first check the resident's closet to see if it was misplaced. She stated she would also inform the Housekeeping Supervisor. During an interview on 1/6/22 at 9:55 AM with the HSKS, she stated if there was a piece of clothing that a resident was missing and she could not locate it, she would notify the Social Worker. She stated she did not know where a grievance form would be located. During an interview on 1/6/22 at 10:00 AM with AD G, she stated she takes the resident council meeting notes, types them up, and sends them to the managers. She stated she does not get a verbal or written response from the managers. She stated if she does not receive the same complaint again, she figured it was resolved. During an interview on 1/6/22 at 12:23 PM with the ADM, he stated his expectations on grievances was that they use the grievance process when something could not be immediately resolved. He stated as for a missing piece of laundry, they could be found pretty easily. He stated if it went for a couple of days without being found, then that was a different story. When asked what could be a potential negative outcome for the residents if they felt their grievances or concerns were not being responded to, he stated he had never been told the residents felt like they were not getting responses. Review of the facility's grievance form log reflected two grievances documented from the past year, 1/21 - 1/22, neither of which were regarding missing items. Review of the facility's Resident Council Minutes, dated 10/28/21 reflected the following grievances made by residents: - Still missing shirt with beadwork on shoulders - Missing brown shirt with vertical stripes - Missing black socks that stretch all the way to the knee - Missing pair of black jeans Review of the facility's Resident Council Minutes, dated 11/24/21, reflected the following grievances made by residents: - Still missing dark gray blouse with beadwork on the shoulders - Missing blue blazer Review of the facility's Grievances/Complaints Policy, revised April 2017, reflected the following: Policy Statement: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff . The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Policy Interpretation and Implementation 1. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. . 7. The administrator has delegated the responsibility of grievance and/or complaint investigation to the grievance officer who is the Facility Social Worker. 8. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint.

Based on interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. Certified Nursing Assistant (CNA) A attempted to transfer Resident #1 on her own from the chair to her bed. Resident #1 required a two (2) person transfer. Resident #1 and CNA A fell during this transfer resulting in a displaced distal femoral fracture of Resident #1's right leg. This deficient practice could place 19 residents who require the assistance of two (2) staff members for transfers at risk for injuries and decreased quality of life due to improper transferring techniques. Findings include: Review of Resident #1's face sheet reflected a [AGE] year old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] reflected a score of 13 of 15 (a score of 13-15 indicating cognitively intact) for the Brief Interview for Mental Status (BIMS) for Cognitive Status. The MDS also indicated [DIAGNOSES REDACTED]. Review of Resident #1's care plan dated 09/18/13 reflected that Resident #1 has a high risk for falls related to gait problems and the use of psychoactive drugs. The interventions for falls include that staff should transfer Resident #1 using a Hoyer lift transfer with two (2) person assistance, place her call light in reach, keep her bed in the low position, be educated on the importance of a two (2) person Hoyer lift transfer, and remind the resident to wait until her wheelchair is behind her to sit down. Resident #1 is also care planned as being resistive to care and experiencing fear of falling and pain related to her previous hip injuries and her [DIAGNOSES REDACTED]. Interventions to preventing fractures include gentle lifting and maneuvering of resident, follow weight bearing precautions to right leg as ordered, using two (2) person Hoyer lift transfers to transfer the resident, and using a draw sheet to reposition the resident while she is in bed. Review of the incident report regarding Resident #1 dated 09/05/13 at 7:50 pm reflected that "resident fell forward on to CNA while transferring. Resident yelling and screaming the whole time, resisting care. Resident assessed and transferred back to bed." The physician and family were notified. The final disposition was to use the Hoyer lift for transfers. Review of the incident report regarding Resident #1 dated 09/08/13 at 7:00 am reflected that "swelling and bruising noted to resident's right leg with multiple bruises behind the right knee. Redness and swelling from right knee to ankle. Warm to touch." An x-ray was ordered. Review of mobile x-ray impression for Resident #1 dated 09/08/13 reflected right femur: "Impression: Displaced distal femoral fracture." Review of the Provider Investigation Report regarding Resident #1 dated 09/12/13 reflected "Provider Response: After the discovery of bruising around the resident's right knee on 09/08/13 by CNA putting TED hose on the resident, the charge nurse was immediately notified. The LVN assessed the resident, ordered an x-ray, informed the doctor, rp (responsible party), administrator, and DON. After a positive right displaced distal femoral fracture was reported, the resident was sent to a (local medical center) for treatment on 09/08/13. After the Administrator and DON were informed of the fracture, myself, and the DON arrived at the facility with the hour to investigate. During the investigation, statements were gathered from staff. It was discovered that the fall on 09/05/13 by the resident during the transfer, occurred with only one CNA transferring the resident not two. The resident was a two person transfer according to the transfer status [REDACTED]. The CNA, (CNA A) who was involved in the failed transfer was interviewed and another more detailed statement was taken regarding the 09/05/13 incident. She had not been to work since 09/05/13 and was suspended upon her return to work on 09/08/13 before her shift began. On 09/09/13, in-services on abuse and neglect specifically as it related to transfers continued and competency checks offs of all CNAs began. CNA (A) remained suspended until her termination on 09/13/13." "Investigation Summary:..No signs or symptoms of a fracture were observed prior to 09/08/13. However, no other incidents occurred after the 09/05/13 transfer incident....On multiple occasions CNA (A) had in-services regarding where to locate the transfer status of the resident and the importance of adhering to this status. In her statement, she acknowledges she knew (Resident #1) was a two person transfer but failed to follow this status." "Provider Action Taken Post-Investigation: All CNAs had competency check offs regarding resident transfers. All CNA's, CMA's, and LVN's have had in-services on Abuse/Neglect as it specifically relates to resident transfer status. CNA (A) was terminated from her position. Resident (#1) readmitted to the facility with a soft leg splint." The provider investigation report also included copies of CNA A's corrective action forms indicating her suspension and subsequent termination, Resident #1's face sheet, x-ray results, incident reports from 09/05/13 and 09/08/13 involving Resident #1, Resident #1's post fall assessment, a written statement from CNA A, and written statements from other staff members who have worked with Resident #1 and/or CNA A. During an interview on 09/26/13 at 10:13 am, Licensed Vocational Nurse (LVN) E stated that even before Resident #1's fracture, she required two (2) person assistance with transfers. During an interview on 09/26/13 at 10:24 am, CNA F stated that information regarding transfer status of residents is on a list located at the nurses' station. He stated that there is also information in the resident's room in their cabinet and in the shower room. During a telephone interview on 09/26/13 at 11:32 am, CNA A stated that on the day of the incident (09/05/13), she attempted to transfer Resident #1 by herself with a gait belt. CNA A stated that she knew that Resident #1 required the assistance of two (2) people with transfers. She stated that as she stood Resident #1 up from the chair, the resident's weight shifted forward and the resident fell on top of CNA A and they both fell to the floor. CNA A stated that from the legs down, the resident's body was on the floor, while the rest of the resident's body fell on top of CNA A. CNA A stated that about 3 or 4 other CNAs have transferred Resident #1 by themselves. CNA A also stated that she had transferred Resident #1 by herself because there were 14 to 15 residents per CNA that day on her side of the facility. CNA A stated that she always felt that she could ask for help, but she also feels that there should be 3 CNAs working at that time in those halls instead of just 2. CNA A stated that the amount of work on that side of the building was often overwhelming. She continued to state that it was the decision of the facility and company to terminate her. She stated that that last day she worked was the day on which the incident occurred. CNA A stated that when she was in the resident's room before she attempted the transfer, she was waiting for another staff member, and the resident said, "Let's just get it done." CNA A stated that that does not make what she did excusable. CNA A stated that after she and Resident #1 fell , she tried to keep the resident calm. CNA A stated that the nurse came into the room and they used the Hoyer lift to transfer the resident to her bed. CNA A stated that before the fall, Resident #1 had told CNA A that she was in pain, but the resident seemed unsure of where the pain was coming from. CNA A stated that at one point, Resident #1 had said that her leg was in pain, but then she later stated that her leg was not in pain. CNA A stated that she reported the resident's complaints of pain to the nurse. CNA A stated that the facility conducted in-services regarding transfers on the Sunday and Monday after the incident. During an interview on 09/26/13 at 4:10 pm, CNA D stated that on the day of the incident (09/05/13), he was in another resident's room nearby providing care. He stated that he heard a "banging" sound and went into Resident #1's room after he finished providing care to the other resident. CNA D stated that when he entered Resident #1's room, he saw Resident #1 and CNA A on the floor. CNA D stated that he went to go get the nurse and then he, the nurse, and CNA A used a Hoyer lift to transfer the resident to her bed. CNA D stated that Resident #1 is a two (2) person transfer and that he has never tried to transfer her without assistance. CNA D stated that the facility has had in-services and trainings for all the CNAs regarding Hoyer lift transfers and gait belt transfers. During an interview on 09/26/13 at 2:50 pm, LVN C stated that on the evening of the incident (09/05/13), she was sitting at the nurses' station when she heard some of Resident #1's "outbursts." LVN C stated that Resident #1 does have episodes of yelling at times, so she went to the resident's room to see what was going on . LVN C stated that she saw CNA A and CNA D in Resident #1's room. She saw Resident #1 on the floor, and she stated that the CNAs were trying to get her up off of the floor. LVN C stated that she explained to the CNAs that they need to notify a nurse immediately after a resident falls and that they should not try to get the resident off of the floor until a nurse is there and assesses the resident. CNA A told LVN C that during the transfer, the resident fell forward onto her (CNA A) and both she and the resident fell to the floor. LVN C stated that she assessed Resident #1 and her skin was intact. LVN C stated that they (she, CNA A, and CNA D) used the Hoyer lift to transfer Resident #1 to her bed. LVN C stated that she continued to assess Resident #1 and that Resident #1 did not complain of pain and could not explain what happened. LVN C stated that she checked the resident's range of motion and there were no significant findings. She continued to state that when she walked into the room, she assumed that CNA D and CNA A were performing the transfer together. LVN C stated that she later found out that CNA A tried to transfer the resident on her own. LVN C stated that Resident #1 was a two person transfer at the time of the incident and is now a Hoyer lift transfer. LVN C stated that signs regarding the transfer status of a resident are posted in cabinets in the residents' rooms. LVN C stated that she expects CNAs to always use a gait belt during manual transfers and to always use two people when a resident requires a two person transfer. LVN C stated that the CNAs have a heavy workload on the D hall, especially during the 2:00 pm to 10:00 pm shift. LVN C stated that she thinks the CNAs feel pressured to get all of their tasks done quickly. LVN C stated that the CNAs are receiving one-on-one training for gait belt transfers and Hoyer lift transfers. During an interview on 09/26/13 at 2:44 pm, CNA B stated that she worked with Resident #1 in the morning on the Sunday after the incident (09/08/13). He stated that as he was putting Resident #1's TED hose (thromboembolism-deterrent hose) on her right leg, she was complaining of pain. CNA B stated that that was not normal for her, so he called the nurse into the resident's room. CNA B stated that Resident #1's leg looked swollen and bigger than normal. CNA B stated that the nurse assessed Resident #1 and then an x-ray was ordered. He stated that the front of Resident #1's leg was a light purple, like a bruise just starting to form. He stated that the nurse looked at the back of Resident #1's knee and saw that the bruise was darker. CNA B stated that Resident #1 required the assistance of two (2) people for transfers. CNA B continued to state that he has never seen anyone attempt to transfer Resident #1 with just one person. During an interview on 09/26/13 at 4:31 pm, the Director of Nurses (DON) stated that after the fall (09/05/13), Resident #1 seemed to function normally until Sunday (09/08/13), when the fracture was discovered. The DON stated that on Sunday after the incident, the facility began conducting in-services and one-on-one training sessions for staff members regarding transfers and abuse and neglect. The DON stated that CNA A attended the in-service on Sunday and was then suspended. The DON stated that she did not work or provide care after the incident, she just attended the in-service. The DON stated that she talked to CNA A and CNA D to find out how the fall occurred, and CNA D told her that he did not assist with the transfer but came into the room later to help CNA A and Resident #1. The DON stated that the facility has conducted skills checks for Hoyer lift, one person, and two (2) person transfers for all of the CNAs. The DON stated that on a normal basis, the facility conducts skills checks for CNAs about once or twice a year and also on an as needed basis. She expects the staff members to always ask for another staff member's assistance when performing a transfer that requires two (2) people, and to check the transfer status of the resident before performing the transfer. The DON continued to state that Resident #1 was having a lot of behavioral issues before the incident and that most of her day-to-day activities have not changed. The DON stated that Resident #1 no longer goes to the dining room to eat meals because her leg extends and there is not a lot of room at the dining room tables. During an interview on 09/26/13 at 5:09 pm, Resident #1 stated that her leg is feeling better and the staff is helping her heal. She stated that the staff treat her fine and she feels safe. Resident #1 stated, "I am doing well, thank you." The resident responded with short answers and did not wish to elaborate further. During an interview on 09/26/13 at 3:52 pm, LVN C stated that before the fall, Resident #1 still required a lot of assistance including two (2) person assistance with transfers, bathing, and incontinent care. LVN C stated that before the fall, Resident #1 did not participate in many activities. LVN C stated that Resident #1's mental condition and status started declining a few months before the fall occurred. During an interview on 09/26/13 at 4:49 pm, the MDS Nurse stated that Resident #1 has been experiencing cognitive and behavioral changes for the past few months that started before the incident. During an interview on 09/26/13 at 4:58 pm, the Administrator stated that CNA A was terminated and the facility has conducted thorough in-services and one-on-one trainings regarding gait belt and Hoyer lift transfers. The Administrator stated that each employee has had previous in-services regarding transfers as well. During an interview on 09/26/13 at 9:02 am, the Assistant Director of Nurses (ADON) stated that CNA A no longer works at the facility. The ADON stated CNA A used to work on the 2:00 pm to 10:00 pm shift and that she had worked on all of the resident hallways because the CNAs at the facility rotate. Review of CNA A's individual in-service file dated 06/21/13-09/13/13 reflected that CNA A had attended an in-service on how to perform two (2) person transfers and signed an acknowledgement form that included a step-by-step transfer guide on 07/14/13. CNA A also signed a Gait Belt Use Policy and Procedure form on 07/14/13 that states, "Transfer status lists are posted in several areas to identify residents requiring one or two person transfers. Two person are also indicated with a picture hung on the resident's wall. If you do not know how to correctly transfer a resident using a gait belt, ask one of the nurse managers to assist you and/or demonstrate the correct technique....Failure to comply with use of gait belts for all transfers will result in termination if disciplinary warnings do not correct this job-related conduct." CNA A also signed an abuse and neglect "zero tolerance" form on 07/14/13. CNA A was also checked off during initial orientation on 06/21/13 for "lifiting/moving residents." On 06/21/13, CNA A signed the Employee Safety Rules which include "all resident lifting and transfers will be done correctly and safely. Each employee who has direct patient care must demonstrate the knowledge and ability of lifting techniques to the nursing supervisor." Review of the facility's Transfer Status report dated 09/06/13 reflected that 19 residents require the assistance of two (2) staff members during transfers.

Based on observation, interview, and record review the facility failed to ensure that a resident with pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new ulcer development for 1 of 3 residents (Resident #11) reviewed for pressure ulcers. Resident #11 was admitted with a Stage I pressure ulcer to his coccyx on 02/03/12. Resident #11 developed a Stage II pressure ulcer to his coccyx on 03/21/12, a Stage II pressure ulcer to his upper right buttock on 09/27/12, and developed 5 additional Stage II pressure ulcers to both feet and heels on 10/12/12, within 15 days. The deficient practice placed 3 residents at risk for not getting necessary medical treatment and services to promote healing, prevent infection, and prevent development of pressure ulcers. Findings included: Review of the physician orders [REDACTED]. Observation of Resident #11 on 10/18/12 at 4:00 PM. revealed: 1. The right heel and right lateral malleolus (outer ankle bone) with discolored purple/yellow areas without drainage. The heel wound was approximately 3.0 centimeters (cm) x 3.0 centimeter (cm) in size and the lateral malleolus (ankle) was approximately 1.0 cm x 1.0 cm in size. 2. The left heel left lateral ankle and left distal metatarsal (toe) revealed light purple/pink areas without drainage. 3. The right coccyx wound was open and red in color. It was approximately 4.0 cm long x 2.0 cm wide x 0.2 cm deep. The wound was moist. Review of Resident #11 ' s Admission Nursing assessment dated [DATE] reflected Resident #11 was admitted with pink scaring circulation on buttocks indicating a healing pressure ulcer. Review of Resident #11 ' s Admission Minimum Data Set ((MDS) dated [DATE] reflected Resident #11 was not at risk for developing pressure ulcers. Review of the facility ' s Pressure Sore Surveillance Forms dated 04/06/12, reflected Resident #11 developed a Stage II pressure ulcer to his coccyx on 03/21/12. It was described as a small open area on coccyx. Review of Resident #11 ' s physician telephone order dated 04/17/12 reflected an order for [REDACTED]. Review of Resident #11 ' s Quarterly MDS dated [DATE] reflected Resident #11 was at risk for developing pressure ulcers and had a treatment of [REDACTED]. . Review of Resident #11 ' s Care Plan dated 2/17/12 and revised on 5/23/12 reflected no risk of pressure ulcer development or any treatments to reduce risk of pressure ulcers. Review of the facility ' s Nurses Notes reflected: On 06/22/12 Resident #11 complained about right heel pain. Skin break down was noted. On 07/14/12 Resident #11 complained about severe heel pain to his heel. Resident #11 was given Tylenol 325 mg and his heels were floated. On 07/16/12 Resident #11 complained about right heel pain. A red area about a quarter in size on his heel was noted. Review of Resident #11 ' s Quarterly MDS dated [DATE] reflected Resident #11 was at risk for developing pressure ulcers and had a treatment of [REDACTED]. Review of Resident #11 ' s physician telephone order dated 09/04/12 reflected an order to discontinue the gel cushion to Resident #11 ' s bedroom chair. Review of Resident #11 ' s Care Plan dated 09/10/12 reflected no risk of pressure ulcer development or any treatments to reduce risk of pressure ulcers. Review of Nurses Notes reflected on 10/12/12 Resident #11 ' s parents were told about tight fitting shoes that could have contributed to the pressure sores on his legs and discussed purchasing larger shoes that day. Review of the facility ' s Pressure Sore Surveillance Form dated 09/28/12 and 10/05/12 reflected Resident #11 had a Stage II pressure ulcer to his right inner buttocks. Review of the facility ' s Pressure Sore Surveillance Form dated 10/12/12 reflected Resident #11 had 5 Stage II pressure ulcers to both feet and heels. Review of the facility ' s Resident Incident Report dated 10/12/12 reflected Resident #11 developed 5 Stage II pressure ulcers on his feet and heels as follows: one to his left foot lateral malleolus, left distal metatarsal, inner left heel, right inner heel, and right lateral malleolus. Further review of the Incident Report reflected the facility rented a high low bed from a medical supply company in an effort to prevent falls. The bed was a very hard plastic coated mattress that probably caused the development of several pressure areas. " Further review of the Incident Report reflected the Family stated this type of pressure areas occurred 18 months prior. " During an interview at 8:15 AM on 10/19/12 the Director of Nursing (DON) stated, Resident #11 was admitted with a reddened pink area on his coccyx. She felt it was not necessary to care plan Resident #11 for risk of pressure sores upon admission because there had been no history of pressure ulcers. He was care planned for risk of pressure ulcer development from the end of March 2012 to May 2012, when he developed a Stage II pressure ulcer on his coccyx. We were turning him, doing weekly skin assessments, and added a gel cushion to his chair. She further stated that they discontinued the care plan because they felt that Resident #11 was no longer at risk for further pressure ulcer development and that they had discontinued the gel cushion to his chair on 09/04/12, for lack of need. When asked how Resident #11 could have developed 5 pressure ulcers the DON stated, we ordered a bed from a medical supply company on 09/27/12, that would help with Resident #11 ' s risk of falling. It ended up being a very hard mattress and we should have checked it when it arrived. He had a small pressure area on his coccyx the day the mattress arrived the mattress probably made it worse and caused the new ulcers on his feet. Once I saw the pressure ulcers on his feet, I realized that the mattress was not a regular soft mattress and I called the medical supply company to replace the mattress with a more appropriate one. Review of the 'Pressure Ulcer Prevention & Treatment' QUICK REFERENCE GUIDE International NPUAP-EPUAP Pressure Ulcer Classification System reflects: Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough. May also present as an intact or open/rupturedserum-filled or serosanginous-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. *Bruising indicates deep tissue injury. Review of the facility ' s CMS 672 reflected three residents with pressure ulcers.