Every finding on record at Mirador

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 in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. The facility failed to ensure the hot chocolate and latte dispenser nozzle was clean and free from corrosion. The facility failed to ensure all expired foods were discarded. The facility failed to ensure all foods were securely closed, labeled, and dated. The facility failed to ensure staff did not enter the kitchen without a hairnet. The facility failed to ensure the ice machine was clean. The facility failed to ensure all chemicals in the cleaning and chemical storage area in the kitchen were appropriately labeled. These failures placed residents at risk for cross contamination and food-borne illness. The findings included: During the initial observation and initial tour of the kitchen on 06/29/2026 at 8:40 AM, the DM was noted to enter the kitchen without a hair net on. The juice dispenser nozzles and backsplash were dirty and covered in sticky spots, runs, and drips. The hot chocolate and latte dispenser had build-up and corrosion on the dispenser nozzle, and the backsplash and drip tray were dirty and sticky. Inside the kitchen fridge there was an unlabeled and undated pan of a thick creamy substance, and a jar of sliced jalapenos which had expired 09/06/2025. The ice machine had corrosion along the outside of it, and on the inside of the lid there was a black-brown substance all the way across the inside of the lid. In the chemical / cleaning storage room in the kitchen was an unlabeled spray bottle with a small amount of clear liquid in the bottom of it. In the area where the clean dishes were stored there were multiple pitchers which were both corroded and appeared to be melted, as well as multiple pans with dings in them, and the Teflon scraped off of them. On the inside of the kitchen refrigerator there was a black - brown substance observed all along the rubber seal of the refrigerator. Inside the kitchen refrigerator there was an unlabeled and undated tray with 28 individual cups of shredded cheese, sour cream, and bacon bits. Inside the walk-in cooler there was expired dessert topping sauce (06/27/2026), expired simple syrup (06/22/2026), expired homemade croutons (06/28/2026), expired cut carrots (06/21/2026), expired cornbread muffin mix (04/07/2026), an opened, unlabeled, and undated bag of French fries, an opened, unlabeled and undated bag of breaded meat, and an unsealed bag of granola. Inside the kitchen ice cream cooler there were multiple containers of ice cream with the lids off, or not completely on, the ice cream containers. On the bread shelf there were multiple open, unlabeled and undated packages of bread, as well as an expired (04/28/2026) package of croissants. In an interview on 06/30/2026 at 3:30 PM, the CNM stated hair nets should be worn anytime staff were entering the kitchen to prevent hair from falling into the food or dishes. The CNM stated all foods should be labeled, dated, and sealed appropriately to prevent cross-contamination, and prevent residents from getting sick. In an interview on 06/30/26 at 4:25 PM, the DM said staff cleaned the kitchen and wiped things down daily and deep cleaned the kitchen and equipment weekly. He stated he did not know what the slimy, black-brown substances on the inside of the ice machine and fridge were. He stated hair nets were supposed to be worn in the kitchen, expired food was supposed to be discarded, and all other foods should have been closed, sealed, labeled and dated to avoid cross-contamination and prevent the residents from becoming sick. A kitchen or food policy which addressed sanitary conditions (to include expired foods and hairnets) was requested from the Administrator on 06/30/2026 at 1:45 PM. Record review of the facility's Food Handling Guidelines policy, issued 05/1995 and revised 01/2026, revealed Policies: Food is handled. in accordance with regulatory guidelines. Proper handling procedures and techniques are visually monitored on an ongoing basis. Prevention of Food Allergy Reactions: Prepare food with clean, sanitized equipment and serve on clean, sanitized dishes. Procedures: Use clean sanitized equipment. Cold Holding Temperatures: Protect food from contamination with covers or shield. References: FDA Food Code 2022: Chapter 2. Management and Personnel: 2-402 Hair Restraints: 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. References: FDA Food Code 2022: Chapter 2-102.20 Food Protection Manager Certification 2-103 Duties 2-103.11 Person in Charge. The person in charge shall ensure that: 2-4 Hygienic Practices 2; Ch. 3-305 Preventing contamination from the premises 3-305.11 Food Storage (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination (2) Where it is not exposed to splash, dust, or other contamination.

Based on interview and record review the facility failed to ensure the comprehensive careplan was developed and implemented for each resident consistentwith resident rights; to include measurable objectives and timeframes to meet residentsmedical, nursing, mental, and psychosocial needs identified in the comprehensiveassessment for 1 of 5 residents (Resident #16) reviewed for care plans.The facility failed to implement Resident #16's care plan for fallinterventions.The failure could place the residents at risk of not receiving adequate or required careThe findings included:Record review of Resident #16's admission record dated 06/30/26 revealed Resident #16was a [AGE] year-old female with an original admission date of 03/01/24, and a currentadmission date of 06/15/26. Pertinent diagnoses included: Acute Kidney failure, (sudden andrapid loss of your kidneys' ability to filter waste from your blood); Chronic ObstructivePulmonary Disease (COPD), (a progressive, irreversible lung disease that restricts airflow,causing severe breathing difficulties); Muscle Weakness, (a reduced ability to exert forcewith your muscles, often caused by nerve damage, muscle cell issues, or inactivity).Record review of Resident #16's Annual MDS assessment dated [DATE] indicated aBIMs score of 08, which indicated moderate cognitive impairment.Record review of Resident #16's care plan dated 01/29/26 revealed Resident #16 had a fallintervention in place for fall mats x 2 while resident was in bed.Record Review of Resident #16's Physician Order Summary Report dated06/30/26 indicated fall mats x2 while resident was in bed ordered 05/19/26.In an observation on 06/29/26 at 11:00 AM, resident #16 was observed lying in bed with thebed at its lowest position. There was no fall mats noted on the floor next to her bed oranywhere else in her room.In an interview on 07/01/26 at 11:00 AM, the ADON stated floor mats were to preventinjury should a resident fall on the floor; they act like a cushion. The ADON stated if theresident falls and the floor mats were not in place, it could lead to injury, possibly a headinjury. She stated sometimes the mats were moved if the patient was out of bed and it was thestaff's responsibility to ensure the mats were put back once the resident returns to bed.In an interview on 07/01/26 at 3:35 PM, the DON stated that fall mats were ordered as afall risk precaution. She stated the resident could fall and injure themselves. She stated thefall mats would help prevent injury. The DON stated the fall mats were probably taken outand cleaned when the resident #16 went to the hospital and were not put back upon her return.She stated the mats should be on the floor next to the resident's bed whenever the residentwas in bed. The DON stated staff were in serviced on fall prevention during the Annual SkillsCheck Off Clinic in February 2026.Record review of the Care Plan, Comprehensive Person-Centered Policy datedFebruary 2026 revealed:7. The comprehensive, person-centered care plan: B. describes the services that are to be furnished to attain or maintain theresident's highest practicable physical, mental and psychosocial well-being. 9. Care plan interventions are chosen only after data gathering, propersequencing of events, careful consideration of the relationship between theresident problem areas and their cause and relevant clinical decisionmakingdecisions.

Based on observations, interviews, and record review the facility failed to ensure thatresidents who needed respiratory care were provided with such care consistent withprofessional standards of practice, the comprehensive person-centered care plan, and theresidents' goals and preferences to include Oxygen in Use sign posted at the door to resident's room for 1 (Resident #16) of 5 residents reviewed for respiratorycare.1. The facility failed to ensure Resident #16's Nasal Cannula, (a small, flexibleplastic tube worn under the nose that delivers supplemental oxygen therapy), wasfree of kinks. (A kink in the Nasal Cannula restricts the flow of prescribed oxygen tothe patient).2. The facility failed to ensure Resident #16's oxygen concentrator, (a medicaldevice that.delivers concentrated oxygen.to patients with respiratory conditions),was set at the oxygen liters ordered by the physician. These failures can place residents at risk of a discrepancy in oxygen delivery and cause the resident's oxygen level to decrease and possible have trouble breathing.The findings included:Record review of Resident #16's admission record dated 06/30/26 revealed Resident #16was a [AGE] year-old female with an original admission date of 03/01/24, and a currentadmission date of 06/15/26. Pertinent diagnoses included: Acute Kidney failure, (suddenand rapid loss of your kidneys' ability to filter waste from your blood); Chronic ObstructivePulmonary Disease (COPD), (a progressive, irreversible lung disease that restricts airflow,causing severe breathing difficulties); Muscle Weakness, (a reduced ability to exert forcewith your muscles, often caused by nerve damage, muscle cell issues, or inactivity).Record review of Resident #16's Annual MDS assessment dated [DATE], indicated aBIMs score of 08, which indicated moderate cognitive impairment. Record review of Resident #16's care plan dated 01/29/26 revealed Resident #16 had aCare Plan Focus for Impaired Airway Clearance Intervention in place for Continuous/PRNOxygen at 2L/Min via Nasal Cannula dated 05.19.26. In an observation on 06/29/26 at 11:00 AM, resident #16 was observed lying in bed withher Nasal Cannula, a lightweight, flexible medical device used to deliver supplementaloxygen directly into the nostrils) in her nostrils. Her Nasal Cannula tube was observed to becaught between the door frame and the door leading to the bathroom. The door waspartially closed on the tube causing it to kink. During further observations, the OxygenConcentrator was noted to be set at 3.5L/min and there was no Oxygen in Use sign postedat the door to her room.Record review of Record Review of Resident #16's Physician Order Summary Report dated06/30/26 indicated an order for Continuous/PRN Oxygen at 2L/Min via Nasal Cannula dated05.19.26.In an interview on 07/01/26 at 11:00 AM, the ADON stated oxygen was usedto maintain minimal parameters based on the resident's baseline oxygen levels.She stated incorrect settings on the oxygen concentrator or kinks in the nasal cannula tubewould not deliver the oxygen concentration levels set by the physician's order and liters perminute set on the oxygen concentrator. The ADON stated this would lead to hypoxia, adangerous condition where your body's tissues and organs do not receive enough oxygento function properly) or other medical complications. The ADON was asked toprovide an policy in regard to posting Oxygen in Use Policy signage; she stated the facilitydid not have one. She stated the Oxygen in Use Signs were posted in the community andsince the facility was a non-smoking facility, she presumed the signed posted in thecommunity would suffice.In an interview on 07/01/26 at 3:35 PM, the DON stated the importance of the residentgetting the correct amount of oxygen was so the resident will not struggle for air andbecome hypoxic. She stated an incorrect setting on the oxygen concentrator, or a kinkoxygen tube would not deliver the oxygen liters per minute set by the physician's order.The DON stated getting higher liters per minute of oxygen than ordered by the physiciancould lead to medical complications.

Based observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #18) reviewed for infection control practices. The facility failed to ensure the ADON knew the proper techniques and practices to keep the wound from becoming contaminated by a dirty brief during wound care on 07/01/2026.The facility failed to ensure the ADON performed proper or adequate hand hygiene while performing wound care on 07/01/2026.The facility failed to ensure the ADON donned (to put on) proper PPE during wound care on 07/01/2026.The facility failed to ensure CNA-C donned proper PPE during wound care on 07/01/2026.These failures could place residents at risk for cross-contamination and infection. The findings included:Record review of Resident #18's face sheet, dated 07/01/2026, revealed an [AGE] year-old male with an admission date of 03/26/2026.Record review of Resident #18's physician order summary, reviewed 07/01/2026, revealed a current order dated 06/10/2026 to cleanse stage 3 pressure injury to sacrum with DWS or Vashe (solutions used to irrigate or cleans wounds), pat dry, apply Medi-honey (a topical medication use to promote wound healing, skin protection, and infection control), cover with Calcium Alginate (a type of wound dressing used to absorb exudate [wound drainage], apply skin prep to surrounding wound edges, secure with a foam dressing every day shift Tuesday, Thursday, and Saturday . The physician order summary also revealed a current order dated 04/01/2026 for Enhanced Barrier Precautions every shift for wounds. In an observation of wound care on 07/01/2026 at 8:10 AM, there was an EBP sign located next to Resident #18's door. CNA-C was observed already standing in Resident 18's room against his bed with gloves on her hands, but she did not have a gown on. She was observed to roll Resident #18 toward her and hold him in place while the ADON performed wound care. The ADON was observed to have gone into Resident #18's room and got his bedside table. Without performing hand hygiene, but utilizing gloves, the ADON proceeded to clean the table, looked up Resident #18's wound care order, and set up her clean field with the wound care supplies. The ADON proceeded to wash her hands, push her hair back, apply gloves and start wound care. The ADON never donned a gown. The ADON pulled Resident #18's brief aside and proceeded to cleanse the wound. The dirty brief kept sliding up, and the ADON continued to grab it and push it down without performing hand hygiene and re-gloving in between. After cleansing the wound, the ADON performed hand hygiene with ABHS for approximately 3-4 seconds, then attempted to put gloves on while hands were still visibly wet. The ADON could not get one of the gloves on, so she threw it away and started over. The ADON touched the dirty brief again to push it out of the way, then continued wound care. After finishing wound care, with the same gloves on, the ADON put Resident #18's brief back on and pulled up his blankets without performing hand hygiene and replacing gloves in between. In an interview on 07/01/2026 at 10:34 AM, CNA-C stated EBP was used when residents had open wounds, but she did not know what the EBP sign said, or what high contact activities it was used for other than showering and peri-care. CNA-C stated she performed hand hygiene and put gloves on prior to going into the Resident #18's room but forgot to put on a gown. CNA-C stated she had training or in-services regarding EBP previously, but she did not remember when they were. After reviewing the EBP sign, she stated she should have been wearing a gown while she assisted with wound care to prevent cross contamination and infections. In an interview on 07/01/2026 at 10:56 AM, the ADON stated she was also the Infection Control Nurse and oversaw wound care. She stated the charge nurses on the floor typically did their own wound care, but since she had already discussed wound care with the surveyor the prior day, she was the one who performed it today. The ADON stated EBP was to protect residents with open wounds and/or indwelling medical devices during high contact care such as wound care and bathing. She stated she should have placed a barrier between the brief and wound or pulled the brief all the way down, so it did not keep touching the wound during wound care. She stated if she had realized she touched the dirty brief during wound care, she would have performed hand hygiene again and changed gloves. She also stated she should have performed hand hygiene after wound care and before pulling Resident #18's sheets and blankets up. The ADON stated hand hygiene with the ABHS should be performed until hands were dry, around 15 seconds, and if hand hygiene and wound care were not performed appropriately, it could have caused cross-contamination and infection.Record review of the facility's Hand Hygiene Policy, revised October 2023, revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections. Indications for Hand Hygiene: 1. Hand hygiene is indicated: A. Immediately before touching a resident; C. After contact with blood, body fluids, or contaminated surfaces; D. After touching a resident; E. After touching the resident's environment; F. Before moving from work on a soiled body site to a clean body site on the same resident; and G. Immediately after glove removal. Applying Alcohol-Based Hand Rubs: 1. Apply generous amount of product to palm of hand and rub hands together. 2. Cover all surfaces of hands and fingers until hands are dry. 3. Rub hands together for a minimum of 15 seconds.Record review of the facility's Enhanced Barrier Precautions Policy, revised June 2026, revealed Policy Interpretation and Implementation: 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. 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: C. Providing hygiene. D. Changing briefs. F. Providing bed mobility; H. Prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin. J. Wound care (any skin opening requiring a dressing).Record review of CDC Clean Hands: About Hand Hygiene for Patients in Healthcare Settings, dated 02/27/2022, revealed How to clean hands with an alcohol-based hand sanitizer:1. Put product on hands and rub hands together.2. Cover all surfaces until hands feel dry.3. This should take around 20 seconds. https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles for medications stored in 1 of 4 medication carts (Side 2 Medication Aide Cart) reviewed for storage. The facility failed to ensure the timolol eye drops (lowers pressure in the eye) for Resident #5 in the Side 2 Medication Aide Cart were labeled with the date they were opened. This failure could place residents in the facility at risk of receiving expired medications from staff.The findings include: Record review of Resident #5's face sheet dated 06/30/26 revealed an [AGE] year-old female with an original admission date of 10/04/21 and a current admission date of 04/06/23. Resident #5's pertinent diagnosis included Age-Related Nuclear Cataract (a condition where the central zone (nucleus) of the eye's natural lens hardens, clouds, and yellows with age). Record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed a BIMS score could not be obtained because Resident #5 was rarely understood. Record review of Resident #5's Comprehensive Care Plan dated 06/30/26 revealed the focus [Resident #5] has impaired visual function r/t Cataracts (cloudy or opaque area in the natural lens of the eye that prevents light from passing clearly to the retina, leading to blurred vision, faded colors, or glare) initiated on 04/24/23 and revised on 05/01/25. Record review of Resident #5's order summary revealed an active order for timolol 0.5% solution eye drops instill 1 drop in left eye two times a day related to AGE-RELATED NUCLEAR CATARACT, BILATERAL initiated on 02/13/25. During an observation of the Side 2 Medication Aide Cart at 2:30 PM on 06/30/26, a used bottle of timolol eye drops was found. The label on the bottle stated it was for Resident #5. A sticker was on the bottle with the words Date Opened: _______ written on it but no date was filled in. During an interview with MA A at 11:35 AM on 07/01/26, MA A stated she had administered the timolol eye drops to Resident #5 using the bottle in the Side 2 Medication Aide Cart several times. MA stated she was supposed to ensure the right drug was given to the right resident at the right dose and with the right route for each administration. MA A stated she was also supposed to ensure the medication was not expired. MA A stated she did not know when the timolol eye drops were first used. MA A stated she was unable to tell if the bottle in the medication cart had expired or not. MA A stated the date of the first time it was used should have been written on the sticker. MA A stated it was possible Resident #5 was administered expired eye drops. MA A stated expired medications could lose their potency leaving the residents to receive ineffective treatment for their conditions. During an interview with the DON at 2:40 PM on 07/01/26, the DON stated when a new bottle of the timolol eye drops was opened it should have had the date written on the label. The DON stated they could not determine if the bottle in the medication cart had expired or not. The DON stated Resident #5's timolol eye drops expired approximately 28-30 days after it was opened. The DON stated there was a possibility Resident #5 was administered expired medication. The DON stated administering expired medications could lead to adverse effects. Record review of the facility policy Administering Medications dated June 2026 revealed the following policy: .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.

Based on interview and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 5 residents (Resident #25) reviewed for medication errors. The facility failed to hold Resident #25's carvedilol (medication that lowers blood pressure and heart rate) when Resident #25's heart rate was outside of physician's parameters twice on 06/27/26 and once on 06/28/26. These failures could place residents at risk for complications such as decreased blood pressure, decreased heart rate, exacerbation of symptoms, and potential hospitalization.The findings include: Record review of Resident #25's face sheet dated 07/01/26 revealed a [AGE] year-old female with an initial admission date of 02/02/23 and current admission date of 06/10/23. Resident #25's pertinent diagnoses included Essential Hypertension (high blood pressure that is not caused by an underlying medical condition) and Transient Cerebral Ischemic Attack (a temporary blockage of blood flow to the brain). Record review of Resident #25's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 indicating severe impairment. Record review of Resident #25's Comprehensive Care Plan dated 07/01/26 revealed the focus [Resident #25] has an alteration in hematological status (the physiological condition of your blood and its components) r/t unruptured Cerebral Aneurysm (a weak, bulging area in an artery wall that can fill with blood) initiated on 02/13/23 and revised on 05/25/23. An intervention listed for the focus included Give medications (Coreg (Brand name for carvedilol), Lisinopril (Medication that lowers blood pressure)) as ordered. initiated on 02/13/23 and revised on 03/29/25. Record review of Resident #25's order summary dated 07/01/26 revealed an active order for carvedilol 12.5 MG Give 1 tablet by mouth two times a day for cerebral aneurysm HOLD IF HR LESS THAN 60. give with food in stomach initiated on 12/26/23. Record review of Resident #25's MAR for June 2026 revealed carvedilol was administered at the following dates and times with associated heart rates:06/27/26 in the morning; HR 55 - administered by MA B06/27/26 in the evening; HR 56 - administered by MA B06/28/26 in the evening; HR 55 - administered by MA B During an interview with the DON at 2:40 PM on 07/01/26, the DON stated the June MAR for Resident #25 showed her carvedilol was administered outside of physician's parameters twice on 06/27/26 and once on 06/28/26. The DON stated the carvedilol should have been held by MA B on all three of those occasions. The DON stated administering carvedilol outside of physician's parameters may cause the resident's heart rate to drop too low leading to dizziness or causing the resident to faint. During an interview with MA B at 3:10 PM, MA B stated carvedilol was used to lower a resident's blood pressure or heart rate. MA B stated she measured a resident's blood pressure and heart rate when necessary before administering a medication. MA B stated she was supposed to hold a medication if it was outside of the physician's parameters on the order. MA B stated administering carvedilol outside of physician parameters could lead to a depressed heart rate or blood pressure causing dizziness or light-headedness. Record review of the facility's policy Administering Medications last revised June 2026 revealed the following policy: Medications are administered in a safe and timely manner, and as prescribed.11. The following information is checked/verified for each resident prior to administering medications:a. Allergies to medications; andb. Vitals signs, if necessary.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions for 1 of 1 kitchen reviewed for food served under sanitary conditions. The handwashing sink's water drainage box was dirty with a black substance and the drainage plug was loose. A large frying pan was on the kitchen floor beneath a cooking table and near the cooking stoves. These failures could place residents at risk for food contamination, food borne illness and a diminished quality of life. The findings included: Observation on 5/27/25 at 1:05 PM of the kitchen reflected a dirty drainage box at the location of the wash sink. The drainage box was dirty, had a dark substance on the surface, and the drain plus was not secured. During an interview on 5/27/25 at 1:05 PM, the Dietician stated the drainage box needed to be cleaned and sanitized. The Dietician stated the dirt on the drainage box which captured the staff washing their hands in the sick had the potential to lead to an unsanitary condition in the kitchen. The Dietician added the unsanitary condition of the drainage box could lead to food borne illnesses. During an interview on 5/27/25 at 1:07 PM, the FSS stated the drainage box was dirty and the plug was loose. The FSS stated the loose drainage plug could create a spillage of water containing substances from hand washing by staff. The FFS stated the drainage plug had to be secured and the drainage box cleaned of the dirt and the dark substance. The FSS had no explanation for the drainage box being dirty and the water plug loose. Observation of the kitchen on 5/27/25 at 1:10 PM revealed a large frying pan was on the floor under a steel cabinet near the cooking stoves. During an interview of 5/27/25 at 1:11 PM, [NAME] B stated he had not seen the large frying pan on the floor under the steel cabinet. [NAME] A stated the large frying pan on the floor created unsanitary conditions and needed to be washed and sanitized. [NAME] A stated the frying pan on the floor had the potential to lead to food contamination. During an interview on 5/27/25 at 1:12 PM, the Dietician stated the frying pan should not have been on the floor under a cabinet. The frying pan on the floor was unsanitary. The Dietician stated the large frying pan was also needed for the cooking of meals. The Dietician stated the frying pan on the floor had the potential to lead to food contamination and food borne illnesses. During an interview on 5/27/25 at 1:13 PM, the FSS stated it was not okay for a large frying pan to be on the floor and un-noticed by kitchen staff. The FSS stated the frying pan needed to be cleaned and sanitized before any use to prevent food borne illnesses. The FSS had no explanation for the frying pan being on the floor. Record review of facility's Sanitation and Infection Prevention/Control policy dated 1/2025 read, .To prevent cross contamination, kitchenware and food-contact surfaces of equipment shall be washed, rinsed, and sanitized .Nonfood contact surfaces of equipment .shall be cleaned . Record review of facility's Preventing Foodborne Illness-Food Handling, dated revised July 2024 read .The facility recognizes that the critical factors implicated in foodborne illnesses are .Contaminated equipment . Record review of facility's census list dated 5/29/25 reflected 35 out of 36 residents eat from the kitchen.

Based on the interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, that medical records were accurately maintained for each resident, as documented for 1 of 4 residents (Resident #132) reviewed for the accuracy of their medical records. The facility failed to ensure that documentation on Resident #132's chart accurately reflected an allergy to Azithromycin (an Antibiotic). This failure could place residents at risk of receiving improper care. Findings included: Record review of Resident #132's face sheet, dated 5/27/25, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: hypertension (medical term used when the force of your blood against arterial walls is consistently too high), asthma (condition in which a person's air ways becomes inflamed, which makes it difficult to breath), and anxiety disorder (mental condition characterized by excessive and persistent feelings of fear, that significantly interferes with daily life function). Record review of face sheet for Resident #132, dated 5/27/25, revealed no allergies. Record review of Resident #132's BIM's assessment, completed 5/27/25, revealed a BIM's score of 15, which indicated cognition was intact. Record review of Resident #132's hospital discharge paperwork, dated 5/22/25, revealed an allergy to azithromycin (an antibiotic). Record review of Resident #132's monthly physician order summary for May 2025 reflected no orders for azithromycin. Interview with Resident #132 on 5/27/25 at 10:55 AM revealed she had an allergy to azithromycin (an antibiotic), which causes severe skin itching if consumed. Interview with LVN A on 5/29/25 at 9:15 AM revealed that she was the admission nurse on 5/24/25 and was not informed in a hospital nurse report that Resident #132 had any allergies; she only reviewed the medication list from the hospital to enter orders. LVN A noted that she must have missed the allergy to azithromycin when transcribing orders, and that Resident #132 risked having an allergic reaction if she was prescribed azithromycin since it was not accurately documented on the face sheet. Interview with the Nursing Supervisor on May 29, 2025, at 10:20 a.m. revealed she was responsible for auditing new admissions for accuracy. Because Resident #132 was admitted on Saturday, 5/24/25, and Monday, 5/26/25, was a holiday, she was unable to verify the orders for accuracy. The Nursing Supervisor added that the allergies not reflected on the Resident #132's face sheet could lead a physician to possibly prescribe azithromycin, which could result in an allergic reaction. Record review of the facility's policy charting and documentation, dated 2001, revealed Documentation of procedures and treatments will be care specific.

Based on the interview and record review, the facility failed to ensure that residents are free from chemical restraints related to PRN orders for psychotropic drugs are limited to 14 days. Except as provided in S483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order, for 1 of 3 residents (Resident #132) reviewed for chemical restraint, in that: The facility failed to ensure Resident #132 was prescribed a psychotropic drug for anxiety, no longer than 14 days PRN (as needed). This failure could place residents at risk of receiving unnecessary psychotropic medications. The findings were: Record review of Resident #132's face sheet, dated 5/27/25, revealed the resident was admitted to the facility on [DATE] with the diagnoses that included: hypertension (medical term used when the force of your blood against arterial walls is consistently too high), asthma (condition in which a person's air ways becomes inflamed, which makes it difficult to breath), and anxiety disorder (mental condition characterized by excessive and persistent feelings of fear, that significantly interferes with daily life function). Record review of Resident #132's BIM's assessment, completed 5/27/25, revealed a BIM's score of 15, which indicated cognition was intact. Record review of Resident #132's care plan, dated 5/26/25, revealed the resident uses antianxiety medication Xanax with interventions to administer medicines as ordered by a physician. Record review of Resident #132 order summary, dated May 2025, revealed an order for Xanax oral tablet 0.5 mg, give one tablet by mouth every 8 hours as needed for anxiety indefinite. Record review of the medication administration record for Resident #132, dated 05/27/25, revealed Resident #132 had received Xanax 0.5 mg on 5/24/25 @ 2300 and on 5/26/25 @ 1343. Interview with Resident #132 on 5/26/25 at 12:03 PM, revealed the resident took this anxiety medication at home but could not recall the name at this time, but knew the facility staff give it to her at this facility. During an Interview with the Nursing Supervisor on 5/27/25 at 8:25 AM, it was confirmed Resident #132 had an order for Xanax 0.5 mg every 8 hours PRN indefinite, and the order should have only been for 14 days. The Nursing Supervisor stated she did not know why the order was written over 14 days, as overuse could place Resident # 132 at risk for respiratory depression. The Nursing Supervisor confirmed she was responsible for overseeing this task daily and currently monitored it at random, which was why the deficient practice was an oversight. Record review of the facility's policy titled, Psychotropic Medication Use Policy, dated 2001, revised July 2022, revealed, .PRN orders for psychotropic medication are limited to 14 days.

Based on observation, interview, and record review the facility failed to develop and implement a person-centered comprehensive care plan to include measurable objectives and timeframes to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being for 2 of 5 (Resident #1 and #2) residents reviewed for comprehensive care plans in that: The facility failed to revise or update Resident #1's care plan to reflect the need and order for Enhanced Barrier Precautions (EBP). The facility failed to revise or update Resident #2's care plan to reflect the need and order for Contact Precautions. This failure could affect the residents by placing them at risk for not receiving appropriate interventions or care to meet their current needs. The findings included: Record review of Resident #1' s face sheet dated 04/29/25 revealed an [AGE] year-old male with an admitted [DATE]. Record review of Resident #1' s care plan initiated 03/27/25 revealed a care plan for an indwelling foley catheter, but no care plan or interventions for EBP. Record review of Resident #1's physician orders dated 04/28/25 revealed an order for EBP. In an observation on 04/29/25 at 9:35 AM it was revealed Resident #1's room had an EBP sign outside of the door. Record review of Resident #2' s face sheet dated 04/29/25 revealed a [AGE] year-old female with an original admitted [DATE], and a current admitted [DATE]. Record review of Resident #2' s care plan initiated 02/03/23 revealed no care plan for C. Diff (Clostridium Difficile is an infection in the colon caused by bacteria), and no care plan or interventions for Contact Precautions. Record review of Resident #2's physician orders dated 04/21/25 revealed an order for Contact Precautions for C. Diff. In an observation on 04/29/25 at 9:42 AM it was revealed Resident #2's room had a Contact Isolation sign outside of the door. In an interview with CNA-A, on 04/29/25 at 9:35 AM, she stated residents were on EBP or contact precautions to help prevent cross contamination and infections, and the signs helped them know what to wear when providing care to the residents. She also stated the CNAs did not use the care plans, and care plans were something the nurses used to keep updated information about the residents. In an interview with RN-B, on 04/29/25 at 9:44 AM, she stated residents were on EBP or contact precautions so the staff knew the proper PPE to wear and to prevent cross contamination and possible infection. She also stated she had not known how to access the care plan to check for precautions because the floor nurses did not really use the care plan. She agreed that the nurses working on the floor should have known how to access and use the care plan. After searching, she stated she could not find Resident #1's EBP care plan or Resident #2's Contact Precautions care plan, but it was definitely something that should have been care planned so the nurses and staff were aware of any precautions, changes, or updates with these residents. In an interview with the DON on 04/29/25 at 10:00 AM, she stated the types of residents that were placed on EBP included residents with C. Diff, foley catheters, Gastrostomy tubes, and/or open wounds. The DON stated if a resident had a foley catheter or C. Diff, it should have been care planned. After searching, the DON was unable to find an EBP care plan for Resident #1 or a Contact Isolation care plan for Resident #2. She stated care plans were supposed to be used as a communication tool for the staff and nurses, as well as to ensure residents received the best possible care. She stated the nurses did not use the care plans though because this was real life, and the nurses were too busy and did not have time to read resident care plans. The DON also stated that was why they had other tools such as the Kardex and other forms to keep the nurses updated on each resident. She also stated that even though they did not really use the care plans, they should have known how to access them and how to use them, and if the nurses were not properly aware of a resident's isolation status, cross-contamination and infection could occur. The DON stated the MDS nurse was the one who updated the clinical care plans. In an interview with the MDS nurse on 04/29/25 at 11:15 AM, she stated she was aware that some of the care plans were missing, and she had been doing an audit today with her supervisor that double checked any residents that had an issue that qualified for EBP or Contact Precautions was care planned. She stated the IDT team met once per week, usually on Wednesdays, and went over any updates or changes that needed to be made to the care plans, as well as any updates and changes regarding infection control between meetings got relayed to her by the infection control nurse. Infection control relayed the information when she placed a resident on precautions, and then the MDS nurse updated the care plans. She stated she was aware of the precautions, but she forgot to update the care plans. The MDS nurse stated the nurses on the floor should have known how to use the care plans, but they were too busy on the floor most of the time, so anytime there was something new added to the care plan, she actually went to the nurses and updated them. She also stated these care plans just got overlooked on Resident #1 and Resident #2 because there had been a GI outbreak, and a lot going on, and that was the reason these two care plans got overlooked. The MDS nurse stated if the care plan was not updated appropriately, nurses or other staff could have provided care to a resident without having known the proper precautions to take or proper PPE to wear, and cross-contamination could have occurred. Record review of the Care Plan Goals and Objectives policy, revised April 2009, revealed Policy Statement: Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Policy Interpretation and Implementation 4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. Record review of the Care Planning - Interdisciplinary Team policy, revised March 2022, revealed Policy Statement The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accident hazards and supervision on 09/07/24. The facility failed to identify and eliminate a foreseeable fall. CNA A left Resident #1 unattended and did not ensure her body was positioned in a safe manner when providing incontinent care resulting in Resident #1 falling off her bed, sustaining a femur fracture, and her feeding tube to be dislodged. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/25/25. The non-compliance began on 09/07/24 and ended on 09/07/24. The facility had corrected the non-compliance before the investigation began on 04/11/25. This failure could affect residents by placing them at risk for falls, injury, major injury, or death. Findings included: Record review of Resident #1's face sheet revealed an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. Diagnoses included cerebrovascular disease, metabolic encephalopathy (a brain disorder caused by problems with the body's chemistry or metabolism such as liver or kidney disease, nutritional deficiencies .), gastrostomy status (feeding tube), dominant right sided weakness, dysphagia (difficulty swallowing), esophageal stricture (narrowing), malnutrition, abnormal posture, rheumatoid arthritis, seizures, and history of traumatic brain injury. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS Score of 12 indicating moderate cognitive impairment and required substantial assistance with oral and personal hygiene, rolling left or right, sitting up or down, lying to sitting on side of bed, and was dependent or required extensive assistance with toileting, showering, upper and lower body dressing, footwear, and all transfers. She was always incontinent of bladder and bowel. Record review of Resident #1's care plan dated 08/29/24 revealed Resident #1 was dependent on staff assistance for transfers and all ADL's (Activities of Daily Living). o Resident #1 has become more active with activities Date Initiated: 07/15/2021 Revision on: 08/24/2022. o Resident #1 needs assistance/escort to activity functions. Date Initiated: 07/15/2021. Resident #1 has an ADL self-care performance deficit Date Initiated: 01/04/2021 Revision on: 06/20/2023. Resident #1 will maintain current level of function in (ADLs) through the review date. Date Initiated: 01/04/2021. Resident #1 has impaired cognitive function or impaired thought processes r/t short term memory loss Date Initiated: 02/21/2024. Resident #1 has an alteration in musculoskeletal status related to weakness. Date Initiated: 07/10/2024. Record review of PIR (Provider Investigation Report) interview questions dated 09/07/24 asked to CNA A by the previous ADM revealed: Did you witness the fall? answer: Yes, I did. She just shifted her weight and fell forward; she has never done that before. Did you leave the room completely and return to find her on the floor? answer: No, I was in the room, just went to the closet. Why did you pick her up? answer: I didn't know what to do. My first thought was to just help her right away. Why didn't you cover her up? answer: I was just grabbing the sheets from the closet, so I didn't plan on leaving her in that position, I was going to change her sheets right at that moment and continue care. Record review of local hospital emergency room records dated 10-Sep-2024 revealed Right distal femur nondisplaced fracture. Nonsurgical management of nondisplaced femoral fracture.Orthopedic surgery evaluated your fracture and recommended non-operative management. You will need to keep your brace on at all times. Frequently check the skin under your brace for skin breakdown. You will need a Hoyer lift to get into your wheelchair, which should have an elevated rest for your right leg. Primary Impression: Right femoral fracture Secondary Impressions: Fall, Malfunction of percutaneous endoscopic gastrostomy (PEG) tube. Disposition. Reason For Visit: RT FEMORAL FX Problems: Malfunction of gastrostomy tube. Onset: 7-Sep-2024. Impression By: Procedures PEG Tube Replacement. Observation of the personal in-room surveillance video dated 09/07/24 revealed the clock on the wall, located directly in front of Resident #1, showed a time of approximately 8:22 (am or pm not identified), when CNA A was observed to be providing Resident #1 perineal/incontinent care while on her left side. Resident #1 was awake, was seen to move her arms and independently held the grab bars of the bed. Resident #1 had a sleeveless shirt on, but no pants or brief were on. CNA A instructed Resident #1 to roll this way indicating to her right side. Resident #1 was seen to initiate the task slowly and independently, and as Resident #1 was in a face up position, CNA A assisted in turning her to her right side. After providing personal hygiene, CNA A asked Resident #1 to turn (to her left side) and again Resident #1 initiated the task and held on to the left side of bed grab bar with both hands. Resident #1's pelvic area was observed to be at the center of the bed however, her legs were slightly bent forward, not in alignment with her pelvis. While on her left side, Resident #1's thighs were on top of each other while her right foot was behind her left foot. The video showed Resident #1 slowly repositioned her right foot over and in front of her left foot, closer to the edge of the bed. After CNA A removed the fitted bed sheet from the right upper corner of the bed, Resident #1's right leg/foot was seen slipping forward. When CNA A loosened the rest of the right side fitted bed sheet and removed the fitted sheet off the right foot of the bed, Resident #1's right leg was no longer seen on the bed. While Resident #1's right leg dangled off the bed, CNA A was seen rolling and tucking Resident #1's right side sheets toward and behind Resident #1's body. A couple of seconds later, CNA A turned around with his back to Resident #1 and then moved out of video footage, at the same time, Resident #1's right leg dangled off the bed and her left leg was seen slipping off the bed. Once Resident #1's both legs dangled down off the bed, her entire body fell off the bed. Resident #1 was seen to hit her head on the left grab bar of the bed and the left side table. CNA A immediately walked toward Resident #1, carried her off the floor and sat her on the edge of the bed then reached his right hand into his right pocket and pulled out his phone while he held on to Resident #1 with his left hand. In an interview with the ADM on 04/22/2025 at 1:15 pm, she said the FRI (Facility Reported Incident) was cited for falls because CNA A picked Resident #1 up off the floor. Incidentally, he was immediately suspended then terminated because of this incident and for not following policies for peri care/positioning. The ADM said she was not here at the time of the incident on 09/07/24-she started on 12/30/24. She said there was an active lawsuit against the facility at this time. She said they have not yet gone to litigation. She believed they were going to mitigation this summer. In an interview with the ICP/ADON on 04/22/2025 at 1:45 pm, said she had worked here for more than [AGE] years and almost 4 years as ICP. She said annual competencies included infection control, fall prevention, hand washing, peri care, transfers, etc. She said she had corrected, documented, and educated CNA A 1:1 on several occasions regarding infection control and peri care, but this incident was the last straw. She said he would pass his annual competencies without any problems, but when no one was there to watch him, implying he would not properly use PPE. In an interview with the DON on 04/23/2025 at 1:33 pm, she said she had worked at the facility for 6 years. She said she viewed footage from Resident #1's personal in-room camera the previous ADM showed her. She said the footage she saw cut off just before Resident #1 fell off the bed. She said Resident #1 was in her bed and CNA A was repositioning and performing peri care and he stepped away to grab supplies and it was at that time Resident #1 fell off the bed and suffered a fracture. She said Resident #1 was sent to the hospital and did not return to the facility. She said Resident #1 passed away about a month later. She said one of Resident #1's family members told them about her passing. She said CNA A had at least competency training once a year. She said CNA A was qualified for the job of repositioning and performing peri care. She said the previous ADM had a questionnaire that he asked, and it was in the investigation file. She said the facility conducted various in-services and computer-based training throughout the year in addition to yearly competencies. She said she and the ADON nurse spot checked hand washing, donning and doffing PPE, and dressing changes, but not repositioning. She said there was no specific policy or guideline for 1 or 2 person assists. She said staff utilized a census sheet with specifics for each resident and said if someone was a 1 or 2 person assist, it would be on the census sheet. She said the census sheets were saved on the nurse's computers as live documents and could be accessed by any staff member to modify or add to it. She said there was no way to retrieve past census sheets because the information in them was deleted with every discharge. She said the census sheet was not generated by the electronic charting system, it was an internal document that populated from resident's care plans. She said CNA A was not referred to the NAR (Nurse Aide Registry) that she knew of. In an interview with the ADM on 04/23/25 at 3:05 pm, she said the nursing team led all staff in-services and training, including monitoring after the incident. She said CNA A was fired. In a phone interview with MD on 04/24/2025 at 9:02 am, he said he remembered Resident #1 had a fall and he was notified. He said he did not know Resident #1's outcome because she did not return to the facility. He said Resident #1 was a lovely lady. He said since she hit her head, and broke her femur, an embolism from the long bone fracture could have caused the code at the local post-acute hospital. He said this incident may have exacerbated or caused the outcome or influenced Resident #1's death. He said Resident #1 was quite frail. He said when older people break their femur and cannot get it fixed, they generally do not do well. In an interview with LVN A on 04/24/2025 at 2:52 pm, he said he recalled seeing CNA A in Resident #1's room without PPE. He said he was the charge nurse that day and he was in the hall. He said CNA A called his phone to tell him that the Resident #1 had fallen off or rolled off the bed and assumed he meant she was on the floor. He said when he entered Resident #1's room, she was in the bed, not on the floor. He asked CNA A why he moved Resident #1. He said CNA A told him he did not want to leave her on the floor. LVN A said he did not know what CNA A was thinking. LVN A said he assumed CNA A was trained on not moving residents who had fallen or were on the floor because they could have a cervical (neck) injury, or some other injury. He said his findings during his assessment of Resident #1 were no peg tube (feeding tube), and pain to her right upper leg, and she was groggy. He said Resident #1 was normally pretty with it and alert. He said Resident #1 was groggy on his 1st encounter of seeing her on the bedside and could not tell him what happened. He said he noticed CNA A should not have picked Resident #1 up. He said Resident #1 was on contact isolation at the time for c-diff. He said signage & PPE was outside the door of her room. He said CNA A did not have PPE on. He said we (staff) got trained on infection control and PPE-we just had one (in-service/training) within the last few weeks and last month. He said CNA A had gloves on. He said he knew about the in-room camera. He said he would not be surprised that CNA A did not change his gloves if he forgot the PPE for a contact isolation room for C-Diff and was performing incontinent care. He said CNA A was reluctant to follow directions. He said CNA A would [NAME] about being a CNA A for 20-[AGE] years. LVN A said if he saw staff not wearing proper PPE, he re-educated them on the spot and informed the ICP. The following staff from the morning and evening shifts were interviewed throughout the investigation from 04/22/25-04/25/25 on the below policies and procedures and in-services: 3 RN's, 4 CNA's, 2 MA's, 3 HSK, and 2 LVN's . All staff were able to verbalize the identification of abuse, neglect, and exploitation as well as the policies and procedures as per the trainings listed below. Record review of facility documents revealed the following in-services: 06/23/24, 08/13/24, 08/23/24, 09/07/24 Abuse & Neglect; Identifying abuse as defined as willful, Types of abuse included physical, mental/verbal, Sexual/unwanted touching. 07/19/24, 09/07/24, 03/04/25, 04/21/25 Infection Control and Handwashing; To keep staff and resident's safe, not spread germs or infect someone who is not able to fight it off, Different types of isolation-contact isolation for c-diff is impoortant because it can live outside the body for a very long time-that's why you have to use soap and water to clean your hands not just sanitizer. 08/13/24, 09/07/24 Injuries of Unknown Origin; reporting bruises, new pain, skin tears, redness, scratches, etc. right away to the nurse and/or administrator. Document. 09/07/24 Dignity; Respect at all times, permission to enter rooms and knocking first, not talking about residents to each other in the hall or elsewhere, keeping computers private, privacy especially when providing personal care-bathing, changing clothes or briefs or wound care, privacy bags on catheter bags. 09/07/24, 01/29/25, 03/04/25 Hand Hygiene; Done before providing care. The number one thing to help prevent spreading germs, everyone has to do it-no exeptions, you can use hand sanitizer unless you know your hands are dirty or if it's c-diff, then you have to use soap and water. Sanitize before and after going in and coming out of the room, if you touch anything in the room and are going to touch the resident or their belonging's. You have to lather for at least 20 seconds and use the towel you dry your hands with to turn off the faucet. 09/07/24, 03/04/25 PPE; gowns, gloves, eye protection and face mask. Use it when you do pericare, catheter care, if there's a feeding tube, an IV line, any dressing changes, and isolation. First, you wash your hands, then put on the gown, then the mask, then the eye protection then the gloves last. To take it off, reverse the order. 09/07/24 Peri Care; PPE, wash your hands before you start, have all your supplies ready so you don't have to step away from the bedside, keep the resident covered so they don't get cold or if somone walks in, change gloves before you go from clean to dirty, on ladies, wipe from top to bottom and inside to outside, document and let the charge nurse know if you find anything new. 09/07/24 C-Diff; highly contagious. Can cause nausea, vomiting, diarrhea and/or fever. Hand washing with soap and water is essential. 09/07/24, 04/12/25 Falls and Falls with Injury; Fall risk factors such as wet floors, not having non-slip shoes or socks, when they need to go to the bathroom, UTI's (urinary tract infections), some medications, weakness, thinking they can when they can't get up on their own, using 2 person assistance when indicated CNA A's signature was noted on all in-services dated from 06/23/24 to 09/07/24 . Record review of CNA A's yearly competency skills dated 02/24/24 revealed he was competent to perform Infection Control/PPE, Fall Prevention, Handwashing, Peri Care, Foley Catheter care, Diet Textures, Transfers and Gait Belt, and N95 Fit testing. Record review of CNA A's personnel file revealed a document titled, Understanding Job Expectations dated 09/02/24 revealed CNA A had been reported not using correct hand hygiene when providing resident care. Also noted at times not wearing proper PPE while providing resident care. CNA A was to ensure to wear gloves while providing resident care and ensure to use proper hand hygiene. The document was signed and dated by CNA A on 09/02/24. There was no other disciplinary actions documented in CNA A's personnel file. There was no documentation of CNA A's termination date. An email received from the present ADM stated, CNA A's termination was a progressive process. Our Administrator at the time spoke with him one on one following the incident. After this, we increased supervision of the care provided by providing spot checks. Then, we began to notice gaps in CNA A's performance so we followed our companies progressive process and moved to term with his last day worked being 12/30/2024. Record review of nurse's note evaluations dated 08/15/24 at 12:01 am revealed Resident #1 had no decrease in food intake or weight loss in the last 3 months. Resident #1 was bed or chair bound, had not suffered psychological stress or acute disease in the past 3 months. Resident #1 had severe dementia or depression. Resident #1 was cooperative with transfers but not cooperative with repositioning. Resident #1did not have upper extremity strength, was not able or partially able to assist with transfers from bed to bed. Resident #1 was partially able to assist with repositioning in bed, but not able to assist with repositioning in chair. Resident #1 had parts of her body that lacked sensation. Record review of lab results dated 08/30/24 revealed Resident #1 was positive for c-diff. Record review of nurse's notes dated 09/07/24 at 8:30 am revealed Resident #1 had a witnessed fall at 8:20 am. CNA A called nurse that resident was on the floor. Nurse gowned and entered room with resident. CNA A in front of resident with resident sitting on the side of the bed. PEG tube (feeding tube) was not in place. Resident noted in a daze and was not responding while being conscious. Resident #1 was then repositioned by CNA A. Resident #1 states she rolled out of bed. Did not hit head, complained of pain to right leg. Nurse upon entering room Resident #1 noted in bed after fall. Assessed vital signs, Checked Range of motion, Assessed pain to upper extremities and lower extremities. Pain noted to right hip. 8/10. Blood Pressure:154/64 Pulse:73 Oxygen saturation: 93% Respiratory rate; 18. Peg tube site noted blood. PEG tube was removed during fall. Resident #1 did speak to notify of pain to leg. Notified MD at 8:38 am, Daughter at 8:40 am to 8:43 am till answered. Notified DON, ADON. Called 911 and sent to local ER per family request. Resident #1 picked up 9:03 am. Report called to at 9:06 am. Record review of the facility policy revised August 2021, titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program . 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. Record review of the facility policy revised March 2018, titled, Falls and Fall Risk, Managing under Fall risk Factors 2. Resident conditions that may contribute to the risk of falls include b. infection, c. delirium and other cognitive impairment, e. lower extremity weakness, k. incontinence. 3. Medical factors that contribute to the risk of falls included d. neurological disorders e. balance and gait disorders. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/25/25. The non-compliance began on 09/07/24 and ended on 09/07/24. The facility had corrected the non-compliance before the investigation began on 04/11/25.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for one (Resident #1) of three residents reviewed for injuries. The facility failed when CNA A did not ensure Resident #1 was medically assessed before picking up Resident #1 off the floor after she fell off the bed and CNA A left her unattended and misaligned in bed on 09/07/2024. Resident #1 sustained a femur fracture and her feeding tube was dislodged as a result of the fall. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/25/25. The non-compliance began on 09/07/24 and ended on 09/07/24. The facility had corrected the non-compliance before the investigation began on 04/11/25. This failure could place residents with any acquired injury at risk for complications. Findings included: Record review of Resident #1's admission record dated 04/12/2025 revealed Resident #1 was an [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE]. Resident #1 was admitted with diagnoses of cerebrovascular disease (stroke), and hemiplegia (paralysis) of right dominant side. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 12 which meant moderate cognitive impairment and was dependent on staff for ADLs. Record review of Resident #1's care plan initiated 01/04/2021 and revised on: 06/20/2023 revealed Resident #1 has an ADL self-care performance deficit. Goal: Resident #1 will maintain current level of function in (ADLs) through the review date. Bed mobility: Elder requires substantial max assist by staff to turn and reposition in bed (every 2 hours) and as necessary. Elder requires total dependence on staff with dressing. Personal hygiene: Elder requires substantial max assistance with personal hygiene. Elder requires dependent by staff for toileting. Transfer: Elder is dependent with transfers with staff assistance for transfers. Record review of local hospital emergency room records dated 10-Sep-2024 revealed Right distal femur nondisplaced fracture. Nonsurgical management of nondisplaced femoral fracture. Orthopedic surgery evaluated your fracture and recommended non-operative management. You will need to keep your brace on at all times. Frequently check the skin under your brace for skin breakdown. You will need a Hoyer lift to get into your wheelchair, which should have an elevated rest for your right leg. Primary Impression: Right femoral fracture Secondary Impressions: Fall, Malfunction of percutaneous endoscopic gastrostomy (PEG) tube. Disposition. Reason For Visit: Right Femoral Fracture Problems: Malfunction of gastrostomy tube. Onset: 7-Sep-2024. Impression By: Procedures PEG Tube Replacement. Observation of the in-room surveillance video dated 09/07/24 revealed the clock on the wall, located directly in front of Resident #1, showed a time of approximately 8:22, when CNA A was observed to be providing Resident #1 perineal/incontinent care while on her left side. Resident #1 was awake, was seen to move her arms and independently held the grab bars of the bed. Resident #1 had a sleeveless shirt on, but no pants or brief were on. CNA A instructed Resident #1 to roll this way indicating to her right side. Resident #1 was seen to initiate the task slowly and independently, and as Resident #1 was in a face up position, CNA A assisted in turning her to her right side. After providing personal hygiene, CNA A asked Resident #1 to turn (to her left side) and again Resident #1 initiated the task and held on to the left side of bed grab bar with both hands. Resident #1's pelvic area was observed to be at the center of the bed however, her legs were slightly bent forward, not in alignment with her pelvis. While on her left side, Resident #1's thighs were on top of each other while her right foot was behind her left foot. The video showed Resident #1 slowly repositioned her right foot over and in front of her left foot, closer to the edge of the bed. After CNA A removed the fitted bed sheet from the right upper corner of the bed, Resident #1's right leg/foot was seen slipping forward. When CNA A loosened the rest of the right side fitted bed sheet and removed the fitted sheet off the right foot of the bed, Resident #1's right leg was no longer seen on the bed. While Resident #1's right leg dangled off the bed, CNA A was seen rolling and tucking Resident #1's right side sheets toward and behind Resident #1's body. A couple of seconds later, CNA A turned around with his back to Resident #1 and then moved out of video footage, at the same time, Resident #1's right leg dangled off the bed and her left leg was seen slipping off the bed. Once Resident #1's both legs dangled down off the bed, her entire body fell off the bed. Resident #1 was seen to hit her head on the left grab bar of the bed and the left side table. CNA A immediately walked toward Resident #1, carried her off the floor and sat her on the edge of the bed then reached his right hand into his right pocket and pulled out his phone while he held on to Resident #1 with his left hand. Attempted phone interview with CNA A on 04/12/2025 at 4:22 PM, 04/13/2025 at 9:41AM, and 1:07PM. CNA A did not return call prior to exit conference. During a phone interview on 04/12/2025 at 6:39 PM, LVN A stated CNA A notified him that Resident #1 had fallen out of bed and was found on the floor. LVN A stated when he arrived in Resident #1's room, she was not on the floor, but on her bed. LVN A stated he asked CNA A why Resident #1 was on the bed, given that CNA A had just notified him that Resident #1 was found on the floor. LVN A stated CNA A stated, I couldn't just leave her like that. LVN A stated he notified CNA A that Resident #1 should not have been moved prior to LVN A's physical head-to-toe evaluation, as an attempt to ensure that if Resident #1 had sustained an injury, the injury would not be exacerbated by additional movement. LVN A stated CNA A should have engaged the emergency light system that was connected to the call light system and should have waited for LVN A to arrive to conduct a physical assessment on Resident #1. LVN A stated CNA A could have compromised Resident #1's wellbeing by picking her up prior to LVN A's head-to-toe evaluation. LVN A stated he was not given access to the video regarding Resident #1's incident. LVN A stated he did not observe any skin irregularities but given that Resident #1 sustained an unwitnessed fall he sent her for evaluation and treatment to an emergency room . LVN A stated CNA A no longer was employed with the facility. During an interview on 04/12/2025 at 5:02 PM, the DON stated she was made aware of the incident by not only LVN A, but the previous administrator. The DON stated the previous administrator allowed her to watch the evidentiary video regarding Resident #1 from his phone that was not facility owned footage. The DON stated she observed CNA A enter Resident #1's room, followed by CNA A lifting Resident #1 to her bed from the floor. The DON stated the expectation was for all clinical staff to follow facility protocols regarding fall management. The DON stated CNA A should have left Resident #1 on the floor, notified LVN A of the situation, waited for LVN A to arrive to conduct a head-to-toe evaluation, then follow LVN A's directive. The DON did not give a definitive answer as to what potentially could have occurred given that CNA A did not follow fall management protocol. The DON stated in her professional opinion, the reason residents are not moved prior to physical evaluation by the nurses, is to minimize any exacerbation of initial injury. The DON stated LVN A conducted the physical head-to-toe assessment on Resident #1 and did not note any skin irregularities, but due to her unwitnessed fall, she was sent to the emergency room for evaluation and possible treatment. The DON stated CNA A was no longer employed by the facility . In a subsequent interview with the DON on 04/23/2025 at 1:33 pm, who said she viewed footage from Resident #1's in-room camera the previous ADM showed her. She said the footage she saw cut off just before Resident #1 fell off the bed. She said Resident #1 was in her bed and CNA A was repositioning and performing peri care and he stepped away to grab supplies and it was at that time Resident #1 fell off the bed and suffered a fracture. She said Resident #1 was sent to the hospital and did not return to the facility. She said Resident #1 passed away about a month later. She said one of Resident #1's family members told them about her passing. She said CNA A had at least competency training once a year. She said CNA A was qualified for the job of repositioning and performing peri care. She said the previous ADM had a 5-point questionnaire that he asked, and it was in the investigation file. She said the facility conducted various in-services and computer-based training throughout the year in addition to yearly competencies. She said she and the ICP nurse spot checked hand washing, donning and doffing PPE, and dressing changes, but not repositioning. She said there was no specific policy or guideline for 1 or 2 person assists. She said staff utilized a census sheet with specifics for each resident and said if someone was a 1 or 2 person assist, it would be on the census sheet. She said the census sheets were saved on the nurse's computers as live documents and could be accessed by any staff member to modify or add to it. She said there was no way to retrieve past census sheets because the information in them was deleted with every discharge. She said the census sheet was not generated by the electronic charting system, it was an internal document that populated from resident's care plans. She said CNA A was not referred to the NAR (Nurse Aide Registry) that she knew of. In an interview with the ADM on 04/23/25 at 3:05 pm, she said the nursing team led all staff in-services and training, including monitoring after the incident. She said CNA A was fired. In a phone interview with MD on 04/24/2025 at 9:02 am, he said he remembered Resident #1 had a fall and he was notified. He said he did not know Resident #1's outcome because she did not return to the facility. He said Resident #1 was a lovely lady. He said since she hit her head, and broke her femur, an embolism from the long bone fracture could have caused the code at the local post-acute hospital. He said this incident may have exacerbated or caused the outcome or influenced Resident #1's death. He said Resident #1 was quite frail. He said when older people break their femur and cannot get it fixed, they generally do not do well. In a subsequent interview with LVN A on 04/24/2025 at 2:52 pm, he said he was the charge nurse on 09/07/2024 and was in the hall. He said CNA A called his phone to tell him that the Resident #1 had fallen off or rolled off the bed and assumed he meant she was on the floor. He said when he entered Resident #1's room, she was in the bed, not on the floor. He asked CNA A why he moved Resident #1. He said CNA A told him he did not want to leave her on the floor. LVN A said he did not know what CNA A was thinking. LVN A said he assumed CNA A was trained on not moving residents who had fallen or were on the floor because they could have a cervical (neck) injury, or some other injury. He said Resident #1 was normally pretty with it and alert. He said Resident #1 was groggy on his 1st encounter of seeing her on the bedside and could not tell him what happened. He said he noticed CNA A should not have picked Resident #1 up. He said CNA A was reluctant to follow directions. He said CNA A would [NAME] about being a CNA A for 20-[AGE] years. Record review of the facility's 09/07/2024 in-service regarding topics Abuse and Neglect, Reporting injuries of unknown origin, and fall prevention was facilitated ensue of the 09/07/2024 event and revealed CNA A was in attendance. The following staff from the morning and evening shifts were interviewed on the below policies and procedures and in-services: 3 RN's, 4 CNA's, 2 CMA's, 3 HSK, and 2 LVN's . All staff were able to verbalize the identification of abuse, neglect, and exploitation as well as the policies and procedures as per the trainings listed below. Record review of facility documents revealed the following in-services: 06/23/24, 08/13/24, 08/23/24, 09/07/24 Abuse & Neglect; Identifying abuse as defined as willful, Types of abuse included physical, mental/verbal, Sexual/unwanted touching. 07/19/24, 09/07/24, 03/04/25, 04/21/25 Infection Control and Handwashing; To keep staff and resident's safe, not spread germs or infect someone who is not able to fight it off, Different types of isolation-contact isolation for c-diff is important because it can live outside the body for a very long time-that's why you have to use soap and water to clean your hands not just sanitizer. 07/31/24 Never Turn a Hip fracture to the affected side without specific orders; use the log roll method and make sure the resident is in a neutral position (aligned straight) on their back. Have sufficient pillows-minimum of two: between the thighs/knees to avoid misalignment which could cause pain, spasms, or dislocation. 08/13/24, 09/07/24 Injuries of Unknown Origin; reporting bruises, new pain, skin tears, redness, scratches, etc. right away to the nurse and/or administrator. Document. 09/07/24 Dignity; Respect at all times, permission to enter rooms and knocking first, not talking about residents to each other in the hall or elsewhere, keeping computers private, privacy especially when providing personal care-bathing, changing clothes or briefs or wound care, privacy bags on catheter bags. 12/20/24 Transfer Training; Proper use of mechanical lift-2 person at all times, sling straps must be double checked, how to maneuver the lift, resident safety is high priority-all instructions and education must be followed by each staff member. 12/26/24, 01/13/25, 03/05/25 Identifying and Reporting Types of Abuse; Identifying abuse as defined as willful, Types of abuse included physical, mental/verbal, Sexual/unwanted touching. 09/07/24, 01/29/25, 03/04/25 Hand Hygiene; Done before providing care. The number one thing to help prevent spreading germs, everyone has to do it-no exceptions, you can use hand sanitizer unless you know your hands are dirty or if it's c-diff, then you have to use soap and water. Sanitize before and after going in and coming out of the room, if you touch anything in the room and are going to touch the resident or their belongings. You have to lather for at least 20 seconds and use the towel you dry your hands with to turn off the faucet. 02/27/25 Gait Belts; Labeled with each room number for the resident in that room only. They will be sanitized as needed. 09/07/24, 03/04/25 PPE; gowns, gloves, eye protection and face mask. Use it when you do peri care, catheter care, if there's a feeding tube, an IV line, any dressing changes, and isolation. First, you wash your hands, then put on the gown, then the mask, then the eye protection then the gloves last. To take it off, reverse the order. 03/31/25 Foley Catheter care; Clean the catheter and surrounding area skin each shift to prevent bacteria build-up. Drainage bag must always be below the level of the bladder to avoid back flow and always have a privacy bag on the reservoir. Bags should never be touching the floor or placed on the bed. Check for kinks in the tubing. Clean the catheter with every incontinent episode or after toileting. Notify the charge nurse if there are any concerns. 09/07/24 Peri Care; PPE, wash your hands before you start, have all your supplies ready so you don't have to step away from the bedside, keep the resident covered so they don't get cold or if someone walks in, change gloves before you go from clean to dirty, on ladies, wipe from top to bottom and inside to outside, document and let the charge nurse know if you find anything new. 09/07/24 C-Diff; highly contagious. Can cause nausea, vomiting, diarrhea and/or fever. Hand washing with soap and water is essential. 09/07/24, 04/12/25 Falls and Falls with Injury; Fall risk factors such as wet floors, not having non-slip shoes or socks, when they need to go to the bathroom, UTI's (urinary tract infections), some medications, weakness, thinking they can when they can't get up on their own, using 2-person assistance when indicated 04/22/25 Norovirus; highly contagious. Can cause nausea, vomiting, diarrhea and/or fever. Hand washing with soap and water is essential. CNA A's signature was noted on all in-services dated from 06/23/24 to 09/07/24 . Record review of CNA A's yearly competency skills dated 02/24/24 revealed he met competency for Fall Prevention, Peri Care. Record review of CNA A's personnel file revealed a document titled, Understanding Job Expectations dated 09/02/24 revealed CNA A had been reported not using correct hand hygiene when providing resident care. Also noted at times not wearing proper PPE while providing resident care. CNA A was to ensure to wear gloves while providing resident care and ensure to use proper hand hygiene. The document was signed and dated by CNA A on 09/02/24. There were no other disciplinary actions documented in CNA A's personnel file. There was no documentation of CNA A's termination date. An email received from the present ADM stated, CNA A's termination was a progressive process. Our Administrator at the time spoke with him one on one following the incident. After this, we increased supervision of the care provided by providing spot checks. Then, we began to notice gaps in CNA A's performance, so we followed our companies progressive process and moved to term with his last day worked being 12/30/2024. Record review of the facility's Assessing Falls and Their Causes revision dated March 2018 documented, Steps in the Procedure After a Fall: 1. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. Obtain and record vital signs as soon as it is safe to do so. 3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying or standing position, and then document relevant details. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/25/25. The non-compliance began on 09/07/24 and ended on 09/07/24. The facility had corrected the non-compliance before the investigation began on 04/11/25.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of 4 residents reviewed for infection control practices. The facility failed to ensure CNA A wore a gown before entering a contact isolation room to perform incontinent care on 09/07/24. The facility failed to ensure CNA A wore his face mask properly while in a contact isolation room for a communicable disease on 09/07/24. The facility failed to ensure CNA A performed hand hygiene before putting on gloves to perform incontinent care on 09/07/24. The facility failed to ensure CNA A changed his gloves or sanitized his hands during incontinent care, applying a clean brief, touching everything, and helping Resident #1 remove her shirt, assisting with turning her, and changing her linen on 09/07/24. A Past Non-Compliance (PNC) at a second level was identified on 04/25/25. The non-compliance began on 09/07/24 and ended on 09/07/24. The facility had corrected the non-compliance before the investigation began on 04/11/25. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: Record review of Resident #1's face sheet revealed an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. Diagnoses included cerebrovascular disease, gastrostomy status (feeding tube), dysphagia (difficulty swallowing), right dominate paralysis, esophageal stricture (narrowing), malnutrition, rheumatoid arthritis, seizures, and history of traumatic brain injury. Record review of Resident #1's quarterly MDS dated [DATE] revealed Resident #1 had a BIMS Score of 12 indicating moderate cognitive impairment and required substantial assistance with oral and personal hygiene, rolling left or right, sitting up or down, lying to sitting on side of bed, and was dependent or required extensive assistance with toileting, showering, upper and lower body dressing, footwear, and all transfers. She was always incontinent of bladder and bowel. Record review of Resident #1's care plan dated 08/29/24 revealed Resident #1 was totally dependent on staff to provide (bath/shower)(3x/week) and as necessary. Date Initiated: 01/04/2021 Revision on: 06/20/2023. o Resident #1 requires substantial max assist by staff to turn and reposition in bed (every 2 hours) and as necessary. Date Initiated: 01/04/2021 Revision on: 06/05/2024. Resident #1 requires total dependence on staff with dressing. Date Initiated: 01/04/2021 Revision on: 06/19/2024. Resident #1 required substantial max assistance with personal hygiene. Date Initiated: 01/04/2021 Revision on: 06/19/2024 Resident #1 was dependent on staff for toileting. Date Initiated: 01/04/2021 Revision on: 06/19/2024. Resident #1 was dependent on staff assistance for transfers and all ADL's. Resident #1 has become more active with activities Date Initiated: 07/15/2021 Revision on: 08/24/2022. Resident #1 needs assistance/escort to activity functions. Date Initiated: 07/15/2021. Resident #1 has an ADL self-care performance deficit Date Initiated: 01/04/2021 Revision on: 06/20/2023. Resident #1 will maintain current level of function in (ADLs) through the review date. Date Initiated: 01/04/2021. Resident #1 has impaired cognitive function or impaired thought processes r/t short term memory loss Date Initiated: 02/21/2024. Resident #1 had an alteration in musculoskeletal status related to weakness. Date Initiated: 07/10/2024. Resident #1 is on antibiotic therapy, Vancomycin for diagnosis: C diff. (a bacterial infection that can cause diarrhea and produce toxins that can damage the colon lining. It is often transmitted through contaminated surfaces or hands that have been in contact with feces from an infected person. The germ can live outside the body for months or years on surfaces and in the soil.) Resident is on contact isolation. Date Initiated: 06/17/2024 Revision on: 06/19/24. Record review of nurse's notes dated 08/31/24 at 1:39 am revealed: Received results of Stool sample and was positive for Clostridium Difficile. Sent MD copy of lab and he gave new orders: Flagyl 500mg per tube 4x/day for 14 days, Questran 1pkg BID (twice a day) x 7 days and Acidophilus 3x/day for 14 days. Did put sign on door, wrote orders for contact isolation and set up isolation outside room. Notified Administration. Observation of the personsl in-room surveillance video dated 09/07/24 revealed the clock on the wall, located directly in front of Resident #1, showed a time of approximately 8:15 (am or pm was not identified) when CNA A approached the bedside of Resident #1 to perform incontinent care, brief, clothing, and linen changes. He was wearing gloves but did not change them when moving from dirty to clean; after wiping, then touching the resident to assist turning, and while removing her clothing. He removed clean wipes from their container with the same gloves on. He was not wearing a gown and his face mask was under his chin. Resident #1 was on contact isolation (for C-Diff - a bacterial infection that can cause diarrhea and produce toxins that can damage the colon lining. It is often transmitted through contaminated surfaces or hands that have been in contact with feces from an infected person. The germ can live outside the body for months or years on surfaces and in the soil.) CNA A was seen rolling and tucking Resident #1's sheets toward and behind Resident #1's body. In an interview with the ADM on 04/22/2025 at 1:15 pm, she said CNA A was immediately suspended then terminated because of this incident and for not following policies for peri care/positioning and infection control. The ADM said she was not here at the time of the incident on 09/07/24-she started on 12/30/24. She said there was an active lawsuit against the facility at this time. She said they have not yet gone to litigation. She believed they were going to mitigation this summer. In an interview with the ICP/ADON on 04/22/2025 at 1:45 pm, she said she had worked at the facility for more than [AGE] years and almost 4 years as ICP. She said annual competencies included infection control, fall prevention, hand washing, peri care, transfers, etc. She said she had corrected & educated CNA A 1:1 on several occasions regarding infection control and peri care, but this incident was the last straw. She said he would pass his annual competencies without any problems, but when no one was there to watch him, implying he may not use PPE properly. In an interview with the DON on 04/23/2025 at 1:33 pm, she said she had worked at the facility for 6 years. She said she was shown a video from Resident #1's in-room camera by the previous ADM. She said CNA A was not wearing PPE and at that time, Resident #1 was positive for C-Diff. She said there was signage and PPE equipment outside of the room. She said cross contamination was also part of their yearly competencies. She said the previous ADM had asked CNA A, and it was in the investigation file. She said she did not know if CNA [NAME] been counseled for not wearing PPE, she would have to look at his file. She said the facility conducted various in-services and computer-based training throughout the year that included infection control, PPE, and handwashing. She said she and the ICP nurse spot checked staff for hand washing, PPE, and dressing changes. She said the ICP had the documentation in a folder. She said the CNA was not referred to the NAR that she knew of. She said CNA A had at least competency training once a year. She said the CNA was qualified for the job of repositioning and incontinent care including proper PPE. In an interview with the ADM on 04/23/2025 at 3:05 pm, she said the nursing team led all staff in-services and training, including monitoring. She said CNA A was immediately suspended to protect other residents and staff, then terminated. In an interview with LVN A on 04/24/2025 at 2:52 pm, he said he recalled seeing CNA A in Resident #1's room without PPE. He said he was the charge nurse that day and he was in the hall. He said CNA A called his phone for assistance with Resident #1. LVN A said he assumed CNA A was trained on infection control and PPE. He said Resident #1 was on contact isolation on 09/07/24 for C-Diff. He said signage & PPE was outside the door of Resident #1's room. He said CNA A did not have PPE on throughout the encounter. He said we (staff) got trained on infection control and PPE-we just had one (in-service/training) within the last few weeks and last month. He said CNA A had gloves on. He said he knew about the in-room camera. He said he would not be surprised that CNA A did not change his gloves if he forgot the PPE for a contact isolation room for C-Diff and was performing incontinent care. He said CNA A was reluctant to follow directions. He said CNA A would [NAME] about being a CNA A for 20-[AGE] years. LVN A said if he saw staff not wearing proper PPE, he verbally re-educated them on the spot and informed the ICP. The following staff from the morning and evening shifts were interviewed throughout the investigation from 04/22/25-04/25/25 on the below policies and procedures and in-services: 3 RN's, 4 CNA's, 2 MA's, 3 HSK, and 2 LVN's . All staff were able to verbalize the identification of abuse, neglect, and exploitation as well as the policies and procedures as per the trainings listed below. Record review of facility documents revealed the following in-services: 07/19/24, 09/07/24, 03/04/25, 04/21/25 Infection Control and Handwashing; To keep staff and resident's safe, not spread germs or infect someone who is not able to fight it off, Different types of isolation-contact isolation for c-diff is important because it can live outside the body for a very long time-that's why you have to use soap and water to clean your hands not just sanitizer. 09/07/24 Dignity; Respect at all times, permission to enter rooms and knocking first, not talking about residents to each other in the hall or elsewhere, keeping computers private, privacy especially when providing personal care-bathing, changing clothes or briefs or wound care, privacy bags on catheter bags. 12/20/24 Transfer Training; Proper use of mechanical lift-2 person at all times, sling straps must be double checked, how to maneuver the lift, resident safety is high priority-all instructions and education must be followed by each staff member. 09/07/24, 01/29/25, 03/04/25 Hand Hygiene; Done before providing care. The number one thing to help prevent spreading germs, everyone has to do it-no exceptions, you can use hand sanitizer unless you know your hands are dirty or if it's c-diff, then you have to use soap and water. Sanitize before and after going in and coming out of the room, if you touch anything in the room and are going to touch the resident or their belongings. You have to lather for at least 20 seconds and use the towel you dry your hands with to turn off the faucet. 02/27/25 Gait Belts; Labeled with each room number for the resident in that room only. They will be sanitized as needed. 09/07/24, 03/04/25 PPE; gowns, gloves, eye protection and face mask. Use it when you do peri care, catheter care, if there's a feeding tube, an IV line, any dressing changes, and isolation. First, you wash your hands, then put on the gown, then the mask, then the eye protection then the gloves last. To take it off, reverse the order. 03/31/25 Foley Catheter care; Clean the catheter and surrounding area skin each shift to prevent bacteria build-up. Drainage bag must always be below the level of the bladder to avoid back flow and always have a privacy bag on the reservoir. Bags should never be touching the floor or placed on the bed. Check for kinks in the tubing. Clean the catheter with every incontinent episode or after toileting. Notify the charge nurse if there are any concerns. 09/07/24 Peri Care; PPE, wash your hands before you start, have all your supplies ready so you don't have to step away from the bedside, keep the resident covered so they don't get cold or if someone walks in, change gloves before you go from clean to dirty, on ladies, wipe from top to bottom and inside to outside, document and let the charge nurse know if you find anything new. 09/07/24 C-Diff; highly contagious. Can cause nausea, vomiting, diarrhea and/or fever. Hand washing with soap and water is essential. 09/07/24, 04/12/25 Falls and Falls with Injury; Fall risk factors such as wet floors, not having non-slip shoes or socks, when they need to go to the bathroom, UTI's (urinary tract infections), some medications, weakness, thinking they can when they can't get up on their own, using 2-person assistance when indicated 04/22/25 Norovirus; highly contagious. Can cause nausea, vomiting, diarrhea and/or fever. Hand washing with soap and water is essential. CNA A's signature was noted on all in-services dated from 06/23/24 to 09/07/24 . Record review of CNA A's yearly competency skills dated 02/24/24 revealed he was competent to perform Infection Control/PPE, Fall Prevention, Handwashing, Peri Care, Foley Catheter care, Diet Textures, Transfers and Gait Belt, and N95 Fit testing. Record review of the facility counseling document dated 06/02/22, titled Understanding Job Expectations under Infection Control revealed CNA A was reported for not wearing PPE correctly or adequately during incontinent care with a resident. CNA A was reminded of Infection Control policies and handwashing procedures. Employee recently completed skills check off for handwashing and equipment sanitizing. CNA A will ensure to wear gloves and PPE properly with good handwashing skills when providing resident care. Random check offs will be completed to ensure this is being done correctly. Record review of the facility counseling documentation form dated 12/20/23, written warning for performance revealed CNA A on 12/19/23 and 12/20/23 left two different residents with foley catheters up in their chairs and left the premises at the end of his shift without emptying the 2 residents' foley catheters, even though he was told to do so. It was documented one of the resident's foley bag had 1,000 ml the first day and 800 ml the next day and she was crying with pain. CNA A was advised to do a final round on patients. Leaving patients up can cause breakdown and pain. Not emptying patient's foley bag is dangerous, can cause pain and also infection. Record review of the facility counseling document dated 08/14/24, titled Understanding Job Expectations revealed CNA A was reported for leaving his assignment without having resident's ready for breakfast, changed, etc. He was advised to follow care plans and CNA duties to better assist residents with care, skin integrity, and dignity while in their facility. Record review of the facility counseling document dated 09/02/24, titled Understanding Job Expectations revealed CNA A was reported for not using correct hand hygiene when providing resident care. Also noted at times not wearing proper PPE while providing resident care. A family member voiced concerns twice about a resident being left in his wheelchair and not laid down to bed or toileted after lunch. The resident was found on the 2 occasions with puddles of urine on the floor before 3 pm. CNA A was instructed to ensure to wear gloves while providing resident care and to ensure to use proper hand hygiene. CNA A was advised that gloves and hand hygiene were an important part of Infection Control because they protected both patients and healthcare workers from exposure to potentially infectious material. Gloves should be worn even if a patient seemed healthy and had no signs of germs. ICP nurse would be spot checking him to ensure he was performing tasks accordingly. He was told if he continued to have difficulty with not using proper hand hygiene or using PPE, it may lead up to disciplin1ry action and/or termination of employment. There were no other disciplinary actions documented in CNA A's personnel file. There was no documentation of CNA A's termination date. An email received from the present ADM stated, CNA A's termination was a progressive process. Our Administrator at the time spoke with him one on one following the incident. After this, we increased supervision of the care provided by providing spot checks. Then, we began to notice gaps in CNA A's performance, so we followed our companies progressive process and moved to term with his last day worked being 12/30/2024. Record review of nurse's notes dated 09/04/24 at 12:04 am revealed Antibiotic follow up: Resident #1 on Flagyl day 5 of 14 due to C. difficile in the stool. No adverse reactions noted, remains under isolation, continuing to monitor stools. Record review of nurse's notes dated 09/06/20 at 2:57 am: Resident #1 remains on contact isolation for C-diff and did have an explosive bout of loose/liquidy stool this shift it came out of brief and onto lines and clothing. Resident #1 had to have gown changed as well. Bowel sounds very active and an odor. Day 7 of 14 of Cipro. Afebrile (no fever) at 97.4 F. Record review of the PIR (Provider Investigation Report) dated 09/07/24 questions asked to CNA A by the previous ADM revealed: Why weren't you wearing required PPE (resident positive for C-Diff) answer: I just didn't think of it, she was very impatient and wanted to be changed right away. Why didn't you cover her up? answer: I was just grabbing the sheets from the closet, so I didn't plan on leaving her in that position, I was going to change her sheets right at that moment and continue care. Record review of the facility policy revised October 2018, titled, Policies and Practices-Infection Control. Policy statement: This facility's infection con1rol policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation 1. This facility's infection control policies and practices apply equally to all personnel .2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the facility. b. Maintain a safe, sanitary, and comfortable environment .c. Establish guidelines for implementing Isolation Precautions, including standard and transmission-based precautions. E. Maintain records of incidents and corrective actions related to infections. Record review of the facility policy revised February 2018, titled, Perineal Care Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure: 5. Personal protective equipment (e.g., gowns, gloves, mask, etc.) Steps in the Procedure 2. Wash and dry your hands thoroughly. 5. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet. 6.Avoid unnecessary exposure of the resident's body. 7. Put on gloves. 9. Discard disposable items .10. Remove gloves and discard .11. Wash and dry hands thoroughly. 12. Reposition the bed covers .16. Wash and dry your hands thoroughly. Record review of the facility policy revised October 2023, titled, Handwashing/Hand Hygiene. Policy statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. 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 a. immediately before touching a resident; c. after contact with blood, body fluids, or contaminated surfaces. d. after touching a resident; e. after touching the resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal. 3. Wash hands with soap and water: a. when hands are visibly soiled; and b. after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. 5. The use of gloves does not replace hand washing/hand hygiene. Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. Record review of the facility policy revised October 2018, titled, Personal Protective Equipment. 4. A supply of protective clothing and equipment is maintained at each nurse's station. PPE required for transmission-based precautions is maintained outside and inside the resident's room. as needed. 6. Employees who fail to use personal protective equipment when indicated may be disciplined in accordance with personnel policies. A Past Non-Complainace (PNC) at a second level was identified on 04/25/25. The non-compliance began on 09/07/24 and ended on 09/07/24. The facility had corrected the non-compliance before the investigation began on 04/11/25.

Based on interviews and record review, the facility failed to consult/ notify the physician when the resident experienced a significant change in their physical status for one (Resident #1) of five residents reviewed for physician notification of changes. The facility failed to consult with/notify the physician after Resident #1 displayed significant changes in condition on [DATE] such as lethargy, vomiting, a decrease of oxygen saturation of 85%, irregular lung sounds and after requiring resuscitation efforts. Resident #1 expired on [DATE]. On [DATE] at 4:45 PM, an immediate jeopardy was identified. While the IJ was removed on [DATE] at 2:35 PM, the facility remained out of compliance at a scope of pattern with a severity of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk of a delay in medical treatment, decline in health, and/ or death. Findings included: Record Review of Resident #1's Admission Record revealed an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included fracture of the ilium (the large bones of the pelvis/ the hip bones), pubis (the bottom part of the hip bones in the center of the pelvis), and the sacrum (the large triangular bone at the base of the spine), falls, atrial fibrillation (irregular heart beat), heart failure, cardiac pacemaker (a small, battery powered device that helps the heart beat in a normal rate and rhythm), and generalized muscle weakness. Record review of Resident #1's Comprehensive MDS dated [DATE] revealed a BIMS score of 14, which indicated that Resident #1 was cognitively intact. Resident #1 required partial/moderate assistance with personal hygiene, bed mobility, laying to sitting, sitting to standing, chair/bed transfer, toilet transfer, and tub/shower transfer. Resident #1 required substantial/ maximal assist with toileting hygiene, showering/ bathing self, upper and lower body dressing and putting on/ taking off shoes. Record Review of Resident #1's Skilled Nursing Note dated [DATE] at 7:35am indicated Resident #1 was alert and oriented x3 (able to answer at least 3 of the questions usually asked (name, place, time, situation) to assess a person's mental status and orientation), communicated verbally with clear speech, and was able to understand and be understood when speaking. Record review of Resident #1's Care Plan dated [DATE] and [DATE] revealed FOCUS: Resident #1 uses antidepressant medication (Paxil) r/t (related to) Depression initiated on [DATE]. INTERVENTIONS included Monitor/document/report adverse reactions to antidepressant therapy: nausea/vomiting, fatigue, and appetite loss. FOCUS: Resident #1 has congestive heart failure (CHF) initiated on [DATE]. INTERVENTIONS included monitor/document/report any signs/symptoms of congestive heart failure: dry cough, weakness and/ or fatigue, lethargy, and disorientation. FOCUS: Resident #1 has bladder incontinence r/t benign prostatic hypertrophy (enlarged prostate). INTERVENTIONS included Monitor/ document for signs/symptoms of UTI (urinary tract infection): increased temperature and altered mental status. Record review of Resident #1's progress notes revealed the following entries: (All entries created by RN A unless otherwise noted) Health Status Note- Effective: [DATE] at 4:30pm Created: [DATE] at 3:18pm Family member with patient, quite concerned about his lethargy. NP contacted and Paxil order discontinued. Nurse Advanced Skilled Evaluation- Effective: [DATE] at 5:00pm Created: [DATE] at 11:31pm Mental status: Resident #1 is lethargic. Oriented to person. Lethargic: new. Mood and Behavior: Resident#1 has flat affect. Flat affect- Recent change in mood. Nutrition: Decrease in fluid intake noted. Change in appetite noted. No signs or symptoms of possible swallowing disorder. Health Status Note- Effective: [DATE] at 6:00pm Created: [DATE] at 3:22pm This note is a follow up to: [DATE] at 4:30pm Health Status Note Patient's color is now pink. Still lethargic but talking with family member. Taking PO (by mouth) water well. Awaiting supper. Family member remains at bedside. Grips remain strong and equal. Opens eyes better, more vocal. Health Status Note- Effective: [DATE] at 6:36pm Created: [DATE] at 12:37am Family member here at bedside. Concerned about Resident #1s status. SBAR Summary for Providers- Created by LVN D- Effective: [DATE] at 6:49pm Created: [DATE] at 11:31am Situation: The change in condition reported on this CIC (change in condition) Evaluation are/were: Altered mental status. At the time of evaluation resident vital signs were Respiratory rate: 24, Temp 100.6. Outcomes of Physical Assessment: Positive findings reported on the resident evaluation of this change in condition were: Mental Status Evaluation: Altered level of consciousness. Functional Status Evaluation: Decreased mobility. Neurological Status Evaluation: Altered level of consciousness. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: What do you recommend Health Status Note- Effective: [DATE] at 7:35pm Created: [DATE] at 11:15pm Called to patient's room. Patient choking on emesis and also coughing up partially digested drink from earlier in the evening. (Not currently eating or drinking anything.) Health Status Note- Effective [DATE] at 7:45pm Created: [DATE] at 3:31pm After briefly returning to the desk, checking texts for phone messages, doctor's recommendation-called directly back to room. Health Status Note- Effective: [DATE] at 7:48pm Created: [DATE] at 3:37pm Patient looking pale, encouraged to deep breathe, and cough. Following commands. Family member concerned, states that she does not want Resident #1 resuscitated if he should need it. States that she has the paperwork in her apartment in IL (Independent Living). Health Status Note- Effective: [DATE] at 7:51pm Created: [DATE] at 11:18pm Patient having difficulty coughing. O2 (oxygen) sat (saturation) drop to 85%. O2 brought into room at ,d+[DATE] l/min (liters per minute) via nasal cannula. Suction equipment brought to room. Health Status Note- Effective: [DATE] at 7:56pm Created: [DATE] at 3:46pm Losing all color, suction and respiratory breathing started. Family member remains adamant about not reviving him, however no paperwork reflects this in skilled paperwork. No out of hospital decisions on CPR/ -no code status. Resident #1's status is full code. Still has pain response. CPR started and heart resuscitation started. Pacemaker beats felt. Health Status Note- Effective: [DATE] at 8:00pm Created: [DATE] at 11:19pm CPR in progress. 911 called. Health Status Note- Effective: [DATE] at 8:05pm Created: [DATE] at 11:21pm CPR started by EMS after detecting pacemaker only functioning on patient's own rhythm. Health Status Note- Effective: 050624 at 8:06pm Created: [DATE] at 3:48pm Family member gone to apartment with second family member to obtain paperwork. She told EMS that she did not wish for CPR to be continued. Health Status Note- Effective: [DATE] at 8:37pm Created: [DATE] at 11:11pm All measures stopped at 8:37pm by EMS team. Last correspondence to the MD about Resident #1's condition was on [DATE] at 6:49pm and stated, Resident #1 had a cough and lethargy. On [DATE] at 6:58pm the MD responded; however the response was not seen by facility staff until after 8:37pm on [DATE]. In an interview with the family member on [DATE] at 10:46am, the family member presented paperwork for Resident #1 that included a Living Will that stated Resident #1 would not want artificially supplied food and water or other life-sustaining procedures should he have an incurable or irreversible condition caused by injury, disease, or illness certified to be a terminal condition by two physicians and where the application of life-sustaining procedures would serve only to artificially prolong the moment of my death. Family member presented an Out of Hospital Do Not Resuscitate Form for Resident #1, however it was not filled out or signed. The facility did not have a copy of Resident #1's Living Will and did not have a completed Out of Hospital DNR form. In an interview on [DATE] at 1:43pm, LVN B stated on [DATE], sometime before 8:00pm, she was getting things together for her hall when RN A told her that Resident #1's oxygen saturation was dropping and she was looking for an oxygen concentrator for him. LVN B stated RN A got a portable oxygen cylinder and went back to Resident #1's room. LVN B stated she finished putting stuff in her cart and locked it and went to Resident #1's room. LVN B stated when she walked into the room, RN A was on the opposite side of the bed with the pulse oximeter on Resident #1's hand that was closest to her. LVN B stated that Resident #1's breathing sounded like a boiling pot of water and that RN A told her the oxygen saturation was getting better. LVN B stated she told RN A that they should probably transfer Resident #1 to the hospital because he probably needed more suction than the facility could do. RN A told LVN B to call 911. LVN B stated she went out to the desk to call 911 so she would be able to read his information directly off the computer to the 911 operator. LVN B stated once she got off the phone with 911, she went back into the room to help with Resident #1. LVN B stated when the paramedics arrived, she left the room. In an interview on [DATE] at 2:21pm, RN A stated that on [DATE] at around 4:15 to 4:30pm, Resident #1's family member had told her that she was concerned about him because the last two days (the 5th and 6th) he had been more lethargic than she had noticed before and that he was not responding to her when she talked to him. RN A stated that she went in to check on Resident #1 and he did respond to her. RN A stated Resident #1 had one episode of nausea and vomiting around 5:00pm but then he was ok and drank some water. RN A stated that at about 7:35pm, Resident #1's family member came out to the nurse's station and asked RN A to come into Resident #1's room because she thought he was choking. RN A stated she had no doubt that Resident #1 aspirated because the head of his bed was down and he had vomited. RN A stated she put the head of the bed almost straight up and Resident #1 was projectile vomiting and was coughing. RN A stated at about 7:45pm, she thought that he was just about over it but then he started looking like he was not doing well, and his oxygen saturation was getting low in the 80s, so she went to get some oxygen and checked the message from the MD. RN A stated she did not take the phone with her back to the room. RN A stated that LVN B came into the room with the suction and crash cart. At approximately 8:00pm, LVN B went out to call 911 from the desk phone then went back into the room to help with CPR (Cardiopulmonary resuscitation). RN A stated the paramedics arrived at about 8:05pm and continued CPR and Resident #1's family members went to the wife's apartment on the independent living side of the facility to get Resident #1's DNR (Do not resuscitate) paperwork. The paramedics were on the phone with medical control (a physician at a local emergency room that will give the paramedics at the scene specific orders for treatment if/ when necessary) while doing CPR on Resident #1. RN A stated that the paramedics stopped doing CPR and pronounced Resident #1 deceased at approximately 8:37pm at the direction of Medical Control. RN A stated the paramedics then left and she cleaned up the resident for the family. RN A stated she contacted the NP prior to 5:00pm about Resident #1's lethargy and first episode of vomiting and the NP discontinued the Paxil. RN A stated she texted the NP after 5:00p because she wanted to get lab and x ray orders because of Resident #1's fever but did not get an answer so she the texted the MD from the work phone. RN A stated the MD's answer was, What do you recommend, but that she did not see that until after the code at 8:37pm. RN A stated that she stated in her text to the MD that Resident #1 had had an episode of nausea and vomiting and that he had a low grade fever for two days on her shift and requested some lab work or x rays. RN A stated she was surprised when the MD texted back with, what do you recommend. RN A stated she did not try to call the MD because she did not have the phone with her. RN A also stated she did not direct LVN B to contact the physician because LVN B was busy with contacting 911 then with helping with Resident #1. In a phone interview on [DATE] at 4:11pm, the MD stated that he had gotten a text message from the facility on [DATE] at 6:49pm that said, Resident #1 has cough and lethargy'. The MD stated he texted back and asked, what do you recommend? hoping that the facility would give him some more information because the first text was very vague. The MD stated the next text he received was at 8:43pm and stated, Resident #1 suddenly aspirated and 911 was called. The MD stated he then received a text at 8:45pm that said, Resident #1 was coded for 37 minutes and deceased . The MD stated the next and final text message he received at 9:37pm stated, ER (emergency room ) stopped CPR at 8:37pm. The MD stated that he did not understand the aspiration because he was not aware and had not been told that Resident #1 had been vomiting. The MD stated that was the only communication he received from the facility and that he did not see a missed call from the facility before the first text message at 6:49pm. In a phone interview on [DATE] at 9:14am, the MD stated in this situation, he would have expected to be contacted when the resident was looking worse and about Resident #1 being a full code and the family member not wanting CPR done. The MD also stated he would expect the facility to contact the NP or on call person as soon as there had been a change in Resident #1's condition. The MD stated if the NP or on call person was unavailable, the facility should have contacted him directly after Resident #1 aspirated and his condition was worsening. The MD stated if he had the information that was initially sent to the NP on Resident #1's condition, he would have asked for labs, and asked further questions as more information would have been needed at that time. The MD further stated if the facility had contacted as soon as Resident #1 aspirated, he would have had him sent to the emergency room immediately to be treated. The MD stated he was not certain that sending Resident #1 to the emergency room would have had a different outcome, but it was possible. In an interview on [DATE] at 5:15pm, the DON stated that she had taken a picture or screen shot of the text messages from the facility phone from [DATE] and had them on her phone. The DON read the text messages with times and content out loud to this state surveyor but did not allow visual confirmation. The following was what was read: 5:12pm the NP was notified about Resident #1's lethargy, that he had been started on Paxil a week ago, and the family wants to discontinue it. Also, Resident #1 running low grade temp. Flu and COVID negative. 5:22pm the NP texted back, Yes, that's fine. 5:46pm text to NP, Update temp of 100.6, has had cough. Incontinent, not new, has several wounds that require care, not particularly new. 5:48pm text to NP, Do you want labs or x ray done? (There was no response from the NP to the 5:46pm or 5:48pm texts) The DON stated, there was possibly an unanswered phone call placed to the MD, between 5:48pm and the next text that was sent. 6:49pm text to MD, Resident #1 has cough and lethargy. 6:59pm response text from MD, what do you recommend? The DON stated, I'm speculating here that the wording on the 6:49 text was just very basic cough and lethargy because Resident #1 at that point was already having some increased trouble and RN A was back in the room taking care of the resident, educating the family, and was trying to get some guidance from the NP or MD. The DON stated that there was a mobile phone belonging to skilled nursing that was supposed to be carried by one of the nurses. The DON explained if the desk phone rang and no one answered within a few rings, it would forward to the unit's mobile phone so the nurses can still be communicated with. The DON stated the phone was not specifically assigned to someone; the nurses just decided between them who would carry it. The DON stated that it appeared that no one had the phone with them that evening. The DON stated there was no policy regarding carrying the mobile phone, it was just a verbal thing that one of the nursing staff has that phone. The DON stated she felt that RN A had attempted to contact the physician prior to 7:35pm but did not follow up because she was busy with Resident #1 and did not have the phone with her. Review of the facility's Change in a Resident's Condition or Status Policy dated ,d+[DATE] read in part: 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): d. significant change in the resident's physical/ emotional/ mental status; g. need to transfer the resident to a hospital/ treatment center; i. specific instruction to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself with intervention by staff or implementing standard disease- related clinical interventions (is not self-limiting) b. impacts more than one area of the resident's health status. c. requires interdisciplinary review and/ or revision to the care plan. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/ mental condition or status. On [DATE] at 5:45pm, the ADMIN was asked for the facility's training or in-service information on physician notification or resident change in condition but did not provide it. When asked for it; however, the ADMIN gave me a sheet of paper that read: Mandatory Nurse Training [DATE]th at 1:30pm AL (Assisted Living) Board Room Change in Condition SBAR documentation *Please plan on attending; class should be approximately 30 minutes in length* The ADMIN stated that this training had already been on the schedule prior to this investigation. This was determined to be an immediate jeopardy on [DATE] at 4:45 PM. The administrator was notified. The administrator was provided with the IJ template on [DATE] at 4:45 PM. The following Plan of Removal submitted by the facility was accepted on [DATE] at 11:00 AM and indicated the following: Facility Plan of Removal 1. Surveyors identified the physician notification policy was not followed, and the physician for one resident was not notified of changes in condition. 2. All Residents were at risk for being affected by the same deficient practice. An audit was conducted to identify residents with Advanced Directives specifically who has DNR orders versus Full Code Orders and a binder created to easily identify these residents in the event of an emergency. All residents and/or their responsible parties are being interviewed to determine if they have experience similar delays in service as a result of communication deficits. 3. The Director of Nurses was educated by the Administrator on the facility Policy and Procedure for Notification of Changes to the Physician including the When to Call and Care Pathways resources. The remaining Facility Nursing staff will be educated by the Director of Nurses/Designee on the Policy and Procedure for Notification of Changes to the Physician via live training, and distance training to complete will all LVN's and RN's. Any Nursing Staff employee who cannot be contacted will be immediately removed from the schedule until which time they were contacted or prior to their next scheduled shift, whichever was sooner. 4. The education effectiveness will be monitored by conducting Mock Code Drills, with various shifts, to determine if the correct procedure was followed. A Mock Code Drill will occur once on each shift the first week ([DATE] through [DATE]) for a total of three drills, and then once weekly on one of the three shifts for three weeks. After this a Mock Code Drill will be conducted on a random shift once monthly every month. These drills will be documented on the attached form and filed in the Mock Code Drill Log. The Mock Code Drills will be conducted by the Director of Nurses/Designee. 5. The Plan of removal (including all education) will be completed by 11:59 PM on [DATE]. Record Review on [DATE] revealed: DON Education by Administrator SBAR/Change in Condition Evaluation/Notification to Physician ? Any change in condition noted on any resident requires proper assessment, documentation, and notification as follows: o Full nursing assessment to include V/S o Initiate an e-interact change in condition evaluation o Notification by phone call is the facilities preferred method of communication and the first attempt is made to both the physician and NP, if leaving a recorded voice message is an option, a detailed message including the changes in condition will be recorded. o The next attempt in communication will be a text message stating the resident has had a change in condition and request for a call back for full details. o When a call back has been requested, the nurse will keep the mobile phone with them until the call back is received. o Except in emergency situations, the nurse will attempt to call again within 30 minutes. In emergency situations requiring immediate intervention, the nurse will initiate 911. o All emergency situations will be reported to the physician and NP. o Notification of responsible party/family member o Document all findings and conversations in the appropriate location in the SBAR. o Each shift should provide follow up documentation until the change of condition is resolved. o Refer to the When to Call Binder for Guidance and Care Path Assessments. ? If the physician or NP provides orders to send the resident to the ER for evaluation, you are to initiate and complete an E-interact transfer to hospital evaluation. ? Once completed, print the transfer form, and send it with other documents with the resident. If unable to send with resident, obtain the fax number when you call report to the hospital and send via fax. ? Watch the following video on completing an E-Interact Change in Condition Evaluation/SBAR (or watch by clicking the link if remote). Interviews on [DATE] with licensed staff that worked on various shifts included: 12:25 PM - RN E 12:28 PM - RN F 12:55 PM - LVN G 1:17 PM - RN H 1:26 PM - LVN I 1:35 PM - LVN J 1:38 PM - LVN K 1:44 PM - LVN L 1:50 PM - RN M 2:58 PM - RN A All licensed staff interviewed were able to identify the process for changes of condition, notifying the physician on resident change of condition, and that the preferred physician contact was by telephone, not text. All staff stated they were to carry the phone with them if they placed a call to the physician that was not answered or if there was a resident in critical condition. Staff stated that if they were not able to contact a physician and it was an emergent situation, they would call 911. Staff stated if there was a resident emergency situation, the charge nurse would take the lead role, and delegate tasks to assisting staff members. All staff stated they had participated in a mock code drill. Interviews on [DATE] with unlicensed staff that worked on various shifts included: 12:59 PM - CNA N 12:59 PM - CNA O 1:04 PM - CNA P All unlicensed staff interviewed stated if a resident had an emergent situation, they would pull the call light to get a nurse and check for a pulse. The charge nurse would go in and take charge and delegate tasks to the assisting staff. All staff stated they had participated in a mock code drill. Verification of Plan of Removal on [DATE] revealed: 1. Record review of all resident's code status who were at risk for being affected by the same deficient practice was conducted. Record review of audits that were conducted to identify residents with advanced directives specifically residents who had DNR orders versus full code orders. A binder was created to easily identify these residents in the event of an emergency. Record review of the code status binder was reviewed which have been placed at the nurse's stations. 2. Through interviews and record review, the Director of Nurses was educated by the Administrator on the facility Policy and Procedure for Notification of Changes to the Physician including the When to Call and Care Pathways resources. The remaining Facility Nursing staff was interviewed on the educated conducted by the Director of Nurses/Designee on the Policy and Procedure for Notification of Changes to the Physician. Through interviews nursing staff employees who could not be contacted was immediately removed from the schedule until they were trained on the policies and procedures for Notification of Changes, and when to call the physician. 3. Record review of in-services was of the Mock Code Drills, of various shifts was conducted. Through interviews, A Mock Code Drill will occur once on each shift the first week ([DATE] through [DATE]) for a total of three drills, and then once weekly on one of the three shifts for three weeks. After this, a Mock Code Drill will be conducted on a random shift once monthly every month. These drills will be documented on the attached form and filed in the Mock Code Drill Log. The Mock Code Drills will be conducted by the Director of Nurses/Designee. Interviews were conducted with staff members on various shifts on the Mock Code Drill and all staff members were able to identify the procedures put into place if a resident were to code. Record review of the Mock Code Drill binder was conducted. In an interview on [DATE] at 12:00pm, the Administrator stated that in-service began on [DATE] with staff and no staff were allowed back on the floor until training on resident change of condition/SBAR, preferred MD notification which was by phone and not through text and staff have conducted a mock code drill which was conducted yesterday and another one was scheduled for [DATE]. The administrator stated that if a nurse has placed a call to the physician, then that nurse was to keep the phone on them until physician contacts that nurse back with directions. The Administrator stated that the Mock Drill binder would be kept by nursing administration/IDT (Interdisciplinary Team) and a mock code drill would be conducted and reviewed monthly after the second mock code drill was conducted. The Administrator stated if concerns were identified it would be discussed immediately and addressed as it would become part of the QAPI meeting discussions. The Administrator was informed the Immediate Jeopardy (IJ) was removed on [DATE] at 2:35 PM. The facility remained out of compliance at a scope of pattern with a severity of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy and confidentiality of his or her personal and medical records for four (Residents #1, Resident #2, Resident #3, and Resident #4) of four Residents reviewed for privacy issues, in that: 1. RN A did not lock her electronic health record computer screen on 07/06/2024, exposing Resident #1, Resident #2, Resident #3, and Resident #4's medical records to the community residents and visitors. This failure could place residents at risk for embarrassment, poor self-esteem, and unmet needs. The findings included: Record review of Resident #1's Face Sheet dated 07/06/2024, initially admitted on [DATE], and readmitted on [DATE] documented an [AGE] year-old female with the following diagnoses of: cerebral infarction (stroke), hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness) and vascular dementia (cognition impairment) Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 06- meaning a severe cognitive impairment and was substantially reliant of on staff for all ADLs. Record review of Resident #2's Face Sheet dated 07/06/2024, initially admitted on [DATE], and readmitted on [DATE] documented an [AGE] year-old female with the following diagnoses of: acute respiratory failure (breathing failure), heart failure, and dyspnea (shortness of breath). Record review of Resident #2's Quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 15- meaning cognitively aware and was dependent/substantially reliant of on staff for all ADLs. Record review of Resident #3's Face Sheet dated 07/06/2024, initially admitted on [DATE], and readmitted on [DATE] documented an [AGE] year-old male with the following diagnoses of: Alzheimer's disease (cognitive impairment), and dementia (cognition impairment). Record review of Resident #3's Quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score left blank indicating unable to complete interview and was dependent of on staff for all ADLs. Record review of Resident #4's Face Sheet dated 07/06/2024, initially admitted on [DATE], and readmitted on [DATE] documented an [AGE] year-old female with the following diagnoses of: Alzheimer's disease (cognitive impairment), and chronic obstructive pulmonary disease (constricted airway making breathing difficult). Record review of Resident #4's Quarterly MDS dated [DATE] revealed Resident #4 had a BIMS score of 03-meaning a severe cognitive impairment and was substantially reliant of on staff for all ADLs. During an observation on 07/06/2024 at 3:33PM upon initial observation into the SNF unit, there were multiple clinicals staff members near the nursing station. RN A was positioned in front of a mobile cart with computer screen displaying residents' pictures and names. RN A then vacated her mobile medication cart leaving her computer screen easily visible and accessible. Upon further inspection the computer screen displayed Resident #1, Resident #2, Resident #3 and Resident #4's names, pictures with distinctive yellow background coloration which was initially visible from approximately 10 feet away. Further inspection of screen revealed what Resident #1, Resident #2, Resident #3 and Resident #4 looked like, their name, with immediate accessibility to click onto any resident's profile to access multiple residents' confidential information, including name, date of birth , primary physician, and health related documentation. The name of the intended user of the computer was RN A. During an interview on 07/06/2024 at 3:43PM MA A stated when you login to the electronic health record you have a blank login screen, once logged in pictures of all residents will be seen. MA A stated it is necessary to lock the electronic health record screen to hide pictures and room numbers of all residents so that no non-staff member will have access to private and confidential resident information. MA A stated locking the electronic health record screen when leaving are preventative measures to protect all resident's privacy. MA A stated privacy is important to keep everyone records confidential. MA A stated no non-staff member person should be able to see resident screen information. MA A stated if a non-staff member person had access to every resident's medical file, they could access a resident's medication list, diagnosis, nurse's notes, name, date of birth , or vitals, which would compromise a resident's right to privacy. MA A stated a resident could wish for no one to know they were living at the facility, and if the nurse's computer screen was not locked, a non-staff person could recognize the electronic health record picture and spread the information compromising a resident's right to privacy which could make the resident feel embarrassed. MA A was presented a photograph of an unlocked computer screen that displayed pictures and names, with a yellow background. MA A responded to the picture by stating it was a picture of an unlocked electronic health record screen, which displayed multiple residents name and date of birth . During an interview on 07/06/2024 at 3:51PM, RN A stated she accidentally left her computer screen unlocked with she was notified that a resident was requesting medication for pain. RN A stated she forgot to close/lock the screen lock but should have locked the screen to keep non-staff members from having access to resident confidential medical records. RN A stated non-staff members should not be able to see names and pictures of resident because that is a part of confidential medical records and could attain sensitive information. RN A stated she will ensure to be more cognitively aware of ensuring residents right to privacy. RN A stated if a non-staff member were to attain residents' confidential information it could affect them negatively and could infringe on HIPPA regulations to protect a resident's right to privacy. During an interview on 07/06/2024 at 6:00PM the Administrator stated when asked if a resident's information should be accessible to people who are non-staff members, he stated it depends. The Administrator stated when asked would a resident's name, date of birth , primary physician, vital signs be considered information that would be considered confidential information, the Administrator stated if it fell under the definition on the facility's Residents Rights policy, then it would. The Administrator stated, when asked, does resident information fall under the definition of confidential information, no definitive answer was given, and was referred to review the facility's policy regarding Resident's Rights. Record review of the facility's Resident Rights policy revised dated February 2021, revealed, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; t. privacy and confidentiality;

Based on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy and confidentiality of his or her personal and medical records for four (Residents #1, Resident #2, Resident #3, and Resident #4) of four Residents reviewed for privacy issues, in that: 1. RN A did not lock her electronic health record computer screen on 07/06/2024, exposing Resident #1, Resident #2, Resident #3, and Resident #4's medical records to the community residents and visitors. This failure could place residents at risk for embarrassment, poor self-esteem, and unmet needs. The findings included: Record review of Resident #1's Face Sheet dated 07/06/2024, initially admitted on [DATE], and readmitted on [DATE] documented an [AGE] year-old female with the following diagnoses of: cerebral infarction (stroke), hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness) and vascular dementia (cognition impairment) Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 06- meaning a severe cognitive impairment and was substantially reliant of on staff for all ADLs. Record review of Resident #2's Face Sheet dated 07/06/2024, initially admitted on [DATE], and readmitted on [DATE] documented an [AGE] year-old female with the following diagnoses of: acute respiratory failure (breathing failure), heart failure, and dyspnea (shortness of breath). Record review of Resident #2's Quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 15- meaning cognitively aware and was dependent/substantially reliant of on staff for all ADLs. Record review of Resident #3's Face Sheet dated 07/06/2024, initially admitted on [DATE], and readmitted on [DATE] documented an [AGE] year-old male with the following diagnoses of: Alzheimer's disease (cognitive impairment), and dementia (cognition impairment). Record review of Resident #3's Quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score left blank indicating unable to complete interview and was dependent of on staff for all ADLs. Record review of Resident #4's Face Sheet dated 07/06/2024, initially admitted on [DATE], and readmitted on [DATE] documented an [AGE] year-old female with the following diagnoses of: Alzheimer's disease (cognitive impairment), and chronic obstructive pulmonary disease (constricted airway making breathing difficult). Record review of Resident #4's Quarterly MDS dated [DATE] revealed Resident #4 had a BIMS score of 03-meaning a severe cognitive impairment and was substantially reliant of on staff for all ADLs. During an observation on 07/06/2024 at 3:33PM upon initial observation into the SNF unit, there were multiple clinicals staff members near the nursing station. RN A was positioned in front of a mobile cart with computer screen displaying residents' pictures and names. RN A then vacated her mobile medication cart leaving her computer screen easily visible and accessible. Upon further inspection the computer screen displayed Resident #1, Resident #2, Resident #3 and Resident #4's names, pictures with distinctive yellow background coloration which was initially visible from approximately 10 feet away. Further inspection of screen revealed what Resident #1, Resident #2, Resident #3 and Resident #4 looked like, their name, with immediate accessibility to click onto any resident's profile to access multiple residents' confidential information, including name, date of birth, primary physician, and health related documentation. The name of the intended user of the computer was RN A. During an interview on 07/06/2024 at 3:43PM MA A stated when you login to the electronic health record you have a blank login screen, once logged in pictures of all residents will be seen. MA A stated it is necessary to lock the electronic health record screen to hide pictures and room numbers of all residents so that no non-staff member will have access to private and confidential resident information. MA A stated locking the electronic health record screen when leaving are preventative measures to protect all resident's privacy. MA A stated privacy is important to keep everyone records confidential. MA A stated no non-staff member person should be able to see resident screen information. MA A stated if a non-staff member person had access to every resident's medical file, they could access a resident's medication list, diagnosis, nurse's notes, name, date of birth, or vitals, which would compromise a resident's right to privacy. MA A stated a resident could wish for no one to know they were living at the facility, and if the nurse's computer screen was not locked, a non-staff person could recognize the electronic health record picture and spread the information compromising a resident's right to privacy which could make the resident feel embarrassed. MA A was presented a photograph of an unlocked computer screen that displayed pictures and names, with a yellow background. MA A responded to the picture by stating it was a picture of an unlocked electronic health record screen, which displayed multiple residents name and date of birth. During an interview on 07/06/2024 at 3:51PM, RN A stated she accidentally left her computer screen unlocked with she was notified that a resident was requesting medication for pain. RN A stated she forgot to close/lock the screen lock but should have locked the screen to keep non-staff members from having access to resident confidential medical records. RN A stated non-staff members should not be able to see names and pictures of resident because that is a part of confidential medical records and could attain sensitive information. RN A stated she will ensure to be more cognitively aware of ensuring residents right to privacy. RN A stated if a non-staff member were to attain residents' confidential information it could affect them negatively and could infringe on HIPPA regulations to protect a resident's right to privacy. During an interview on 07/06/2024 at 6:00PM the Administrator stated when asked if a resident's information should be accessible to people who are non-staff members, he stated it depends. The Administrator stated when asked would a resident's name, date of birth, primary physician, vital signs be considered information that would be considered confidential information, the Administrator stated if it fell under the definition on the facility's Residents Rights policy, then it would. The Administrator stated, when asked, does resident information fall under the definition of confidential information, no definitive answer was given, and was referred to review the facility's policy regarding Resident's Rights. Record review of the facility's Resident Rights policy revised dated February 2021, revealed, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; t. privacy and confidentiality;

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. The facility failed to ensure dietary staff facial hair was fully covered by beard restraints. The facility failed to ensure dietary staff used proper hand hygiene during meal preparation. The facility failed to ensure refrigerated food items were dated and properly sealed. The facility failed to ensure pantry food items when opened were dated and properly sealed. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation and interview on 03/26/2024 at 10:01 a.m. during initial tour (DD and dietician present) of the main kitchen the walk-in refrigerator revealed a bag of green onions open with in a zip lock which was open to air, not dated, tray rack with 2 trays of raw broccoli, 1 tray of apple slices, and 2 trays of sliced white cheese, all trays were covered with plastic wrap and not dated when prepared or to be discarded. The DD stated these items should have open dates, preparation dates along with discard dates as to when to be thrown out. Observation of the main kitchen pantry revealed 2 bags of pasta noodles wrapped in plastic wrap not dated, a zip lock bag of cheese crackers not dated, half bag of pine nuts on the top shelf of the pantry with a discard date of 03/10/2024, 25 pound bag of whole grain brown rice with less than a quarter of the bag left not sealed opened to air not dated, and a 50 pound bag of light brown sugar quarter of the bag remaining not sealed open to air not dated. The dietician stated the item past the discard date she figured had not been used or the staff would have noticed and thrown them out. The dietician further stated the times which were opened to air and not sealed should have been sealed due to it could allow for pest to get in them, however she had not noticed any pest. The DD stated all the items in the pantry when opened should be sealed with a zip lock bag, plastic wrap or placed in a bin with an open date and discard date. The dietician further stated by sealing the items would protect against food borne illnesses. Observation 03/26/2024 at 10:17 a.m. revealed Cook B enter the main kitchen pantry from the stove and meal preparation area with his beard restraint/guard under his chin leaving his approximately 1-inch chin hair exposed. During an interview on 03/26/2024 at 10:30 a.m. Cook B stated his beard guard will slide down his face. Cook B further stated his beard guard keeps the hair from his face from going into the food which could be bad for residents if he was sick and could make residents sick. Cook B stated by not wearing it properly could affect the safety of the food. Observation and interview 03/26/2024 at 11:20 a.m. DS A was observed in the satellite kitchen with the side of his beard past his jaw along his neck with 1 inch facial hair exposed preparing drinks and placing desserts on trays. DS A when asked about his facial hair restraint (beard guard) not covering the rest of his facial hair adjusted his beard restraint/beard guard however, due to hair located past his jaw line and on the side of his neck had difficulty covering it. DS A stated the reason for wearing a beard restraint was to keep hair from going into the food and kept the residents from getting sick. DS A stated the restraint prevented cross contamination of food and drinks. Observation and interview on 03/26/2024 at 11:38 p.m. DD was observed to also have facial hair growth beyond the jaw line. DD stated usually the kitchen staff are to maintain the beard or facial hair and adjusted his beard restraint/guard. Observation and interview on 03/28/2024 at 10:34 a.m. revealed in the main kitchen pantry a 50-pound bag of stone-ground whole wheat torn at the top open look to be about 3/4 of the bag remaining however, the executive chef stated she thought the bag had just been torn when placed on the shelf and was still full. The dietician stated the wheat should have been in a bin. Observation on 03/28/2024 at 3:16 p.m. revealed Cook C at the 3 compartments sink rinsing off a pan was called by another cook due to his having pasta in a strainer in the sink and cold water running over it. Cook C came over to the sink turned off the water and then began shaking the strainer, placed it back down in the sink, stuck his gloved hands into the strainer then began scooping up the pasta then releasing it back into the strainer with his hands without having washed his hands or changed his gloves. Cook C then took the strainer over to the stove began scooping the pasta out with a spoon placing in the pan on the stove then stirring it. During an interview on 03/28/2024 at 3:20 p.m. Cook C stated he should have washed his hands and changed gloves to prevent contamination. Cook C further stated he had received training regarding cross contamination. During an interview on 03/28/2024 at 3:25 p.m. the DD stated the cook should have washed his hands and changed his gloves, he then further stated the cook would need more education. During an interview on 03/29/2024 12:14 p.m. with the ADM stated when items are opened and stored items should be dated and sealed to air depending on the food. The ADM further stated being exposed to air could affect the quality of food can affect the palatability of it. The ADM stated according to their policy anytime producing food or handling food hair restraints should be worn and if in a food prep area. The ADM stated the purpose of hair/facial restraints was to prevent hair from coming in contact with food to prevent risk of cross contamination. Review of facility policy section, Production, Purchasing, Storage, subject Food and Supply Storage, date issued 05/95 and revised 04/2024, read Policies: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Procedures: Cover, label and date unused portions and open packages. Dry Storage: Store foods in their original packages. Foods that must be opened must be stored in NSF approved containers that have tight fitting lids . Review of facility Hourly Team Member handbook, no date, read section 5.1 Personal Appearance and Handwashing, For all Associates: Facial hair must be kept neatly trimmed, For Associates working in food service accounts: Hair nets or hats should be worn as appropriate. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

44020 Based on interviews, 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 includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 residents (Resident #6, Resident #10) of 12 residents reviewed for care plans. 1. The facility failed to ensure Resident #6's bowel status was reflected in the resident's care plan (undated). 2. The facility failed to ensure Resident #10's code status was not reflected in resident's care plan. These deficient practices could place residents at risk of not receiving proper care and services. The findings included: 1. Record review of Resident #6's electronic face sheet dated 03/26/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), transient cerebral ischemic attack (a brief stroke-like attack wherein symptoms resolve within 24 hours. It causes paralysis in face, arm, or leg usually on one side of the body, slurred speech, double vision or blindness, and loss of balance or coordination) and atherosclerotic heart disease (condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall). Record review of Resident #6's quarterly MDS assessment with an ARD of 02/22/2024 reflected he was always incontinent of bowel. He scored a 05/15 on his BIMS which signified he was severely cognitively impaired. Record review of Resident #6's comprehensive person-centered care plan (undated) did not reflect he was incontinent of bowel. Interview on 03/29/2024 at 09:00 a.m. with CNA D revealed he collaborated with Resident #6 since the resident was admitted and Resident #6 was always incontinent of bowel. Interview on 3/29/2024 at 11:31 a.m. with the MDS Coordinator, she stated that she was not able to locate Resident #6's bowel status in his care plan, and she did not know how it was missed. She stated the care plan communicated to other providers what type of care the resident required, and it could be missed otherwise. Interview on 03/29/2024 at 12:50 p.m. with the DON, she stated the care plans needed to address what care the resident required, and Resident #6's care plan did not address he was incontinent of bowel. She stated the care plan was a tool of communication for others about the care of a resident, and if it were not accurate, care could be missed. 2. Record review of Resident #10's face sheet, dated 03/29/2024, revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included: cerebral infarction due to thrombosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and type 2 diabetes mellitus with hyperglycemia, muscle. Record review of Resident #10's Admission 5-day MDS assessment, dated 02/27/2024, revealed the resident's BIMS score was 3, which indicated severe cognitive impairment. Record review of Resident #10's Texas OOHDNR (out of hospital do not resuscitate) form dated and notarized on 02/23/2024 and completed with physician signature on 03/11/2024. Record review of Resident #10's physician order summary, dated 03/29/2024, revealed an order dated 02/27/2024 for DNR. Record review of Resident #10's care plan, with the last care plan with an initiated date of 03/22/2024 revealed Resident #10's code status of DNR had not been care planned. During an interview on 03/29/2024 at 11:37 a.m. the MDS coordinator stated she was unable to located Resident #10's code status care plan as she reviewed the care plan. MDS coordinator further stated the SW usually completes the code status care plan and would be something the care team would review during care plan meetings. During an interview on 03/29/2024 at 12:38 p.m. the SW stated she had been waiting to get the Texas OOHDNR back signed and did not remember to initiate the care plan. The SW further stated she did typically complete the code status care plans and they were reviewed during care plan meetings. During an interview on 03/29/2024 at 12:54 p.m. the DON stated the facility has many other tools the staff use regarding care, so it was hard for answer the importance of a care plan. The DON further stated the care plan collaborates resident's care. The DON stated the facility did not have a policy regarding Comprehensive Care Plans they followed the RAI manual. Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in section 2-44, Care plan completion based on the CAA process is required for OBRA-required comprehensive assessments. It is not required for non-comprehensive assessments (Quarterly, SCQA), PPS assessments, Discharge assessments, or Tracking records. However, the resident's care plan must be reviewed after each assessment, as required by S483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

44020 Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments person-centered care plan to reflect the current condition for 2 of 12 residents (Resident #8 and Resident #88) reviewed for care plan revisions. 1. The facility failed to ensure Resident #8's care plan was updated to reflect she was not on contact isolation for shingles. 2. The facility failed to ensure Resident #88's care plan was updated to reflect DNR (do not resuscitate) code status. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1. Record review of Resident #8's electronic face sheet dated 03/27/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: acute respiratory failure, pneumonia, dyspnea, and zoster without complications (onset date) 12/08/2023. Record review of Resident #8's significant change MDS assessment dated [DATE] did not reflect under the section of Active Diagnoses she had shingles. She was checked to have pneumonia. She was not a candidate for a BIMS which signified she was severely cognitively impaired. Record review of Resident #8's comprehensive person-centered care plan (undated) reflected Focus, Elder requires contact isolation r/t shingles. Observation on 03/26/2024 at 09:45 a.m. of Resident #8 in her room revealed there was no sign on her door or isolation bin outside of her room. She was lying in bed. During an interview on 03/26/2024 at 09:50 a.m. with Resident #8, stated she was not on isolation and she was at one time, but could not remember when. During an interview on 03/29/2024 at 11:35 a.m. the MDS coordinator stated Resident #8's care plan should not reflect she was on contact isolation for shingles. She stated, she did not recall when the resident was on contact isolation, but the care plan needed to be updated as soon as she was taken off in order to be accurate to show what care she required at this time. During an interview on 03/29/2024 at 12:50 p.m. the DON stated Resident #8's comprehensive care plan should have been updated right away to show she was no longer on isolation. She stated she did not remember when the resident was on isolation, but it was a while back. 2. Record review of Resident #88's face sheet, dated 03/29/2024, revealed she was admitted to the facility on [DATE] with diagnoses which included: acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with (acute) exacerbation, heart failure unspecified, dependence on supplemental oxygen, essential (primary) hypertension, and peripheral vascular disease. Record review of Resident #88's Admission 5-day MDS assessment, dated 03/25/2024, revealed the resident's BIMS score was 15, which indicated cognition intact. Record review of Resident #88's Texas OOHDNR (out of hospital do not resuscitate) form dated and completed 03/20/2024. Record review of Resident #88's physician order summary, dated 03/29/2024, revealed an order dated 03/20/2024 for DNR. Record review of Resident #88's care plan, with the last care plan with an initiated date of 03/19/2024 and target date of 06/25/2024 revealed Resident #88's full code status care planned and had not been revised to reflect current DNR code status. During an interview on 03/29/2024 at 12:02 p.m. the MDS coordinator stated code status was a DNR for Resident #88. The MDS coordinator further stated Resident #88's care plan had not been signed yet; it did say full code. The MDS coordinator stated the care plan should have been updated with the current code status. The MDS coordinator stated the care plan should have been updated as soon as possible once the OOHDNR was signed, and the SW was responsible for the code status care plan. The MDS coordinator stated the care plan was important to the staff to be able to look at the resident's needs. During an interview on 03/29/2024 at 12:41 p.m. the SW stated the team had their own sections of the care plan they would go in and update. The SW stated Resident #88 had discussed during the initial care plan she wanted to be a DNR, of which it was completed. The SW stated she just forgot to change Resident #88's care plan. During an interview on 03/29/2024 at 1:01 p.m. the DON stated importance was to have current information available to the staff. The DON further stated the SW updated the code status care plans. The DON further stated care plans were revised on review or immediately and there were different parts of the care plan that had different time frames. The DON stated the facility did not have a policy regarding Comprehensive Care Plans they followed the RAI manual. Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in section 2-44, Care plan completion based on the CAA process is required for OBRA-required comprehensive assessments. It is not required for non-comprehensive assessments (Quarterly, SCQA), PPS assessments, Discharge assessments, or Tracking records. However, the resident's care plan must be reviewed after each assessment, as required by S483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observation, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 resident (#6) out of 24 residents reviewed for MDS assessments. Resident #6's quarterly MDS assessment dated [DATE] did not accurately reflect he had Hospice as a service provider and he was not on a therapeutic diet. This deficient practice could affect residents with MDS assessments and could result in inaccurate care. The findings included: Record review of Resident #6's electronic face sheet dated 03/26/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), transient cerebral ischemic attack (a brief stroke-like attack wherein symptoms resolve within 24 hours. It causes paralysis in face, arm, or leg usually on one side of the body, slurred speech, double vision or blindness, and loss of balance or coordination) and atherosclerotic heart disease (condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall). Record review of Resident #6's quarterly MDS assessment with an ARD of 02/22/2024 inaccurately reflected he was on a therapeutic diet and did not reflect he received hospice care. He scored a 05/15 on his BIMS which signified he was severely cognitively impaired. Record review of Resident #6's comprehensive care plan (undated) reflected Focus .Elder has been placed on hospice services. Further review reflected he was on a regular diet, minced texture and soft with regular consistency and thin liquids. Record review of Resident #6's Active Orders as of: 03/06/2024 reflected Regular diet Minced and Moist texture, Regular consistency with a start date of 02/22/2023. Further review reflected, admit to hospice services with a date of 12/22/2022. Observation on 03/29/2024 at 08:45 a.m. Resident #6 in his room, assisted by CNA D with his breakfast. He had raisin bran cereal with milk and a poached egg on his tray. Interview on 03/29/2024 at 0850 a.m. with CNA D revealed he collaborated with Resident #6 since the resident was admitted , and he was on a regular diet and received hospice services at least twice a week. Record review of Resident #6's meal ticket (undated) reflected Regular diet, minced texture and soft with regular consistency. During an interview on 03/29/2024 at 11:35 a.m. the MDS coordinator stated she made a mistake and considered the other parts of Resident #6's diet such as fortified shakes as a therapeutic diet, and she marked hospice services, but not in the section that indicated current services for the resident. She stated MDS accuracy was important due to it leading to the resident care plan and care could be missed. During an interview on 03/29/2024 at 12:50 p.m. the DON stated the MDS nurse is accountable for the MDS's and she reviewed them, but the MDS nurse was the one who signed them for accuracy. She stated Resident #6's MDS was inaccurate because he was on a regular diet and not a therapeutic one, and he was on hospice services. She said this was important because the MDS directed the care reflected in the resident plan of care. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 reflected The RAI process has multiple regulatory requirements . (1) the assessment accurately reflects the resident's status.