Every finding on record at Oakbend Medical Center

Based on observation, interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 2 of 15 residents (Residents #161 and #163) reviewed for advance directives.The facility failed to ensure Resident #161's advance directive status met her directive to healthcare providers to not perform CPR if her breathing or heartbeat stopped. The facility failed to ensure Resident #163 had an out-of-hospital do-not-resuscitate form in his medical record that was consistent with his wishes. This failure could place residents at risk of not having their end-of-life wishes honored and having incomplete records. Findings included:Record review of Resident #161's admission record dated [DATE] revealed she was admitted to the facility on [DATE] with a diagnosis of acute cystitis (sudden inflammation of the bladder, almost always caused by a bacterial infection). She was [AGE] years old. Record review of Resident #161's order inquiry (undated) revealed a physician order for full code status (if a person's heart stops or they stop breathing, the medical team will use all available life-saving measures to attempt to save the person's life) with a start date of [DATE]. Record review of Resident #161's electronic medical record on [DATE] at 1:15pm with the Quality Director revealed Resident #161 had no code status indicated. Record review of Resident #161's paper medical record on [DATE] at 1:45pm revealed there was no OOH DNR (a medical directive indicating that healthcare providers should not attempt CPR if your heart or breathing stops) form in her chart. There was document titled Resuscitation orders/Consent Form. Record review of Resident #161's Resuscitation order/Consent Form (undated) revealed Resident #161 signed the form indicating she requested do not resuscitate. The order was not signed by a physician. In an interview and observation on [DATE] at 1:42pm, Resident #161 said she had a OOH DNR form completed at her home. She said she wished to have DNR status. She showed the surveyor a purple bracelet on her wrist that read, DNR. In an interview on [DATE] at 1:45pm, the DON said that the form in Resident #161's chart was not completed because the physician had not signed it. Record review of Resident #163's admission record dated [DATE] revealed he was admitted to the facility on [DATE] with a diagnosis of closed fracture of epiphysis of proximal fibula (a break in the upper end of the calf bone (near the knee) that has not pierced the skin). He was [AGE] years old. Record review of Resident #163's order inquiry (undated) revealed a physician order for do not resuscitate with a start date of [DATE]. Record review of Resident #163's admission MDS assessment dated [DATE] revealed he had a BIMS (a standardized screening test used by healthcare providers to evaluate a patient's cognitive function, memory, and orientation) of 12, indicating he had no cognitive impairment. Record review of Resident #163's electronic medical record on [DATE] at 1:15pm with the Quality Director revealed Resident #163 had a code status of do not resuscitate. Record review of Resident #163's paper medical record on [DATE] at 1:45pm revealed there was no OOH DNR form in his chart. There was document titled Resuscitation orders/Consent Form.Record review of Resident #163's Resuscitation order/Consent Form dated [DATE] revealed Resident #163 signed the form indicating he requested do not resuscitate. The order was signed by the physician. In an interview on [DATE] at 1:15pm, the Quality Director said the skilled nursing unit was considered out-of-hospital and residents should have an OOH DNR form if this code status was requested. In an interview on [DATE] at 1:45pm, the DON said that the form in Resident #163's chart was the form they used to indicate a resident's code status. She said they did not need an OOH DNR form completed. In an interview and record review on [DATE] at 10:42am, RN A said when a resident was admitted , she asked the resident and the referring hospital about the resident's code status. She said they would refer to the resident's chart to determine code status. She showed the surveyor Resident #163's Resuscitation order/Consent form and said he had a DNR order. Alert and oriented and ask the resident. If the same, then go with what they say. She said if the resident did not have a consent form in the file, then she would treat them as having a full-code status. In an interview on [DATE] at 1:35pm, Resident #163 said he wished to have DNR status.A policy regarding Advance Directives was requested on [DATE] at 2:56pm and was not provided by the time of exit.

Based on interviews, and record review the facility failed to have sufficient and competent staffing to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 4 residents (Residents #1, #3, #4 and # 5) out of 7 residents.The facility failed to ensure a nursing staff responded to the call light in a timely manner on June 14,15,and 16th 2026.This failure could place residents at risk of inadequate supervision, an unsafe environment, falls, serious harm and injury, exacerbations of disease processes, abuse, and death. Findings included:Record review of Resident #1's admission record dated 06/04/2026 revealed she was a [AGE] year-old female admitted with the following diagnoses: CHF (when the heart muscle is unable to pump enough blood to meet the body's needs for blood oxygen which can lead to shortness of breath). CAD (when the veins become narrowed or blocked and causes reduced blood flow to the brain. CVA (when blood flow to a part of the brain is interrupted), anxiety, heart failure and depression.Record review of Resident #1's MDS record dated 06/09/2026 revealed section C-cognition was coded-12-moderate thinking and memory. Functional abilities revealed she used a walker and required supervision and assistance in the following areas: toileting hygiene, upper body dressing, lower body dressing, putting and taking off footwears, toilet transfer, sit to stand, sit to lying, chair/bed-to-chair transfer.Record review of Resident #1's care plan report dated 06/04/2026 revealed: Fall risk. Goal: Stabilize any potential fall injury risk. Intervention: Asses for any side effects of medications particularly those related to sedation, respiration, depression and gait. Apply fall risk precautions, arm band, bed in lowest position, educate patient/family/caregiver about measures that can be taken to prevent falls, trips and slips, ensure call light and personal items are within reach, encourage use of non-slip footwear, implement hourly rounding. Anxiety. Goal: Stabilize patient's feelings of fear, dread or distress. Intervention: Provide patient with support and remain with patient as much as possible. Ineffective breathing. Goal: Stabilize breathing pattern. Intervention: Administer oxygen as ordered, assess and record depth of breathing. Record review of Resident #3's admission record dated 05/27/2026 revealed he was a [AGE] year-old male admitted with the following diagnoses: Acute osteomyelitis right foot toe (bone infection resulting to severe pain, fever and swelling), amputation, anemia( low blood count), CAD ( the veins become narrowed or blocked and causes reduced blood flow to the brain), heart failure, Hypertension (high blood pressure), ESRD (the kidneys no longer function adequately), wound infection, and diabetes (irregular blood sugar levels). Record review of Resident #3's MDS dated [DATE] revealed section C-cognitive pattern was scored-09-moderate thinking and memory. Section GG-Functional abilities revealed he was dependent on staff in the following care areas: toileting and hygiene, lower body dressing, putting on and taking off footwear. Bowel continent revealed he was always incontinent. Record review of Resident #3's care plan report dated 05/27/2026 revealed, Activity intolerance. Goal: To stabilize the resident's risk for developing activity intolerance. Intervention: Perform actions which support a bedbound patient, manage the patient activity as needed. Injury risk. Goal: Stabilize injury risk. Intervention: Take precautions to reduce patient injury. Impaired physical mobility. Goal: Inability to perform independent movement will be stabilized. Intervention: Assist patient with ambulation.Record review of Resident #4's admission records dated 06/02/2026 revealed she was 64-years-old female admitted with the following diagnoses: Syncope fall (sudden temporary loss of consciousness that could lead to falls often caused by a brief drop in blood pressure, Fracture and other trauma, cancer, hypertension (low blood pressure), hip fracture and seizure disorder(abnormal electrical activity in the brain). Record review of Resident #4's MDS dated [DATE] revealed her cognition was coded a 15-normal thinking and memory. Section GG-Functional abilities revealed she required assistance and supervision in the following care areas: toileting, upper and lower body dressing, putting and taking off footwear.Record review of Resident #4's care plan report revealed: Activity intolerance: Goal: stabilize risk of developing activity intolerance. Intervention: Perform actions which support bedbound patients. Medication risk: Goal. Improve, on medication risk. Intervention: Monitor the effectiveness of the medication. Infection risk. Goal: Prevent infection risk. Intervention: Perform practices to prevent the spread of infection and infectious diseases, notify physicians about abnormal vital sign findings. Injury risk. Goal: To be stabilized. Intervention: Take precautions to reduce patient injury.Record review of Resident #5's admission record dated 06/14/2026 revealed he was a [AGE] year-old male admitted with the following diagnoses: Angina (chest pain or discomfort caused by reduced blood flow to the heart), UTI (infection in any part of the urinary system), ESRD (when the kidneys cannot function normally), respiratory condition, surgical wound and diabetes (irregular blood sugar). Record review of Resident #5's MDS dated [DATE] revealed his BIMS score was coded 15-normal thinking and memory. Bowel and bladder revealed he had an indwelling catheter. Required assistance with activities of daily livingRecord review of Resident #5's care plan report dated 06/14/2026 revealed: Fall. Goal: To stabilize any potential fall injury risks. Intervention: Assess for possible risks of falls, assess patient for possible side effects of medications especially those related to sedation, respirations, depression and gait. Apply fall risks precautions-bed in lowest position, orient patient and family to the environment, educate patient/family and caregivers on measures to prevent falls, trips and slips, ensure call light and personal items are within reach, supervise toileting and implement hourly rounding.In an interview with Resident #1 on 06/16/2026 at 06:48 a.m., she said the facility was noted for the long wait time when residents use the call light which lasted for over an hour. She said they left her sitting on the commode for an hour several times. Resident #1 said it happened almost daily, during both shifts. She said she told her family member several times. She said she could be having trouble with her oxygen which sometimes was disconnected. She said she relied on supplemental oxygen for survival. Resident #1 said, she could not go to restroom alone because she was not steady on her feet. She said that she sat on the commode for over an hour, and she felt unsafe and her bottom hurt. Resident #1 said one night she almost fell when staff was helping her back to her bed because she felt weak and tired after waiting for too long. She said, I do not think they have enough staff.In an interview with CNA C at 09:30 a.m., on 06/17/2026 he said responding to call lights was the responsibility of all staff. He said if a call light came on and staff did not attend to the residents in a timely manner; the residents could be impacted physically by falling. CNA C said, if Resident #1 or Resident # 5 had fallen, they could sustain an injury.In an interview with Resident #5 and family member on 06/17/2026 at 10:02 a.m., Resident #5 said he complained about the long wait time each time he used the call light for the previous two days. Resident #5 said staff told him to pull the string when he got to the restroom. Resident #5 said he needed staff assistance to get to the restroom. Resident #5 said when he called from the restroom, staff did not show up on time. Resident #5 said when I called that morning, they came because state was in the building. Resident #5's family member said their main concern was the fact that staff did not respond to the call light in a timely manner.In an interview with RN A on 06/17/2026 at 10:45 a.m., she said responding to the call light was the responsibility of every staff and she expected every staff member to make rounds regularly. She said, we checked on residents frequently. She said she knew the residents were calling because the light above the residents' room would light up as well as the call system at the nursing station. She said there as a unit secretary who would notify staff of the call light. She said if the call light response time was delayed the resident might fall. RN A said consequences of a fall to a resident could be a fracture or death.In an interview with Resident #4 on 06/17/2026 at 12:46 p.m., she thought the facility was short staffed. She said on 06/14/2026 -Sunday there was only one nurse. Resident #4 said she was on a scheduled pain medication and thought other residents too were on scheduled medications. She said when that happened, her pain level increased. She said nurses were supposed to focus on resident care and not answering the phone and call lights. She said If I do not get my pain medication on time it makes me feel more pain. My pain instead of decreasing it increases. She said the nurses did not have enough support to enable them to perform their job efficiently. She said if a nurse had 15 residents there would not be efficient patient care.In an interview with Resident #3's family member on 06/17/2026 at 1:22 P.M., she said they did not see the nurse for the most part of the day. She said they saw the MA who administered medication to Resident # 3. She said it took the staff awhile to come in and Resident #3 could not ambulate. She said if staff failed to respond to the call light in a timely manner, the resident could have fallen and injured his legs or other body parts. She said this happened every day and both day and night shift. She said after waiting for too long she always had to go to the nursing station to request assistance. She said during the weekend on 6/13/26-6/14/26, he did not get his morning medication until about 2:00 p.m. In an interview with the MA on 06/17/2026 at 1:54 p.m., she said she was scheduled to work Monday through Friday and on weekends the nurses had to administer all the medications and provide other resident cares. In an interview with LVN A on 06/17/2026 at 2:00 p.pm., she said rounding on the residents every hour or two hours was the responsibility of every staff. She said if call lights were not answered in a timely manner that would delay care especially for residents who were a fall-risk which could cause injury, or pressure ulcer for residents who required brief change. LVN A said, if a resident fell, that would prolong their stay and they would be depressed. She said call lights were not answered due to insufficient staffing. She said the MA worked Monday through Friday which meant nurses administered all medications and provided care to residents on weekends. She said she was tired more on the weekends, and sometimes she did not feel like returning to work.In an interview with the DON on 06/17/2026 at 2:16 p.m., she said the facility had staff sitting on the hallway and answered the call light quickly. She said the MDS Coordinator did answer the call lights. She said she was notified of the call light concerns. She said if the call light was not answered in a timely manner that would affect the residents' and result in the following: falls, declining health and dissatisfaction. The DON said falls might delay length of stay and increased rehabilitation days. In an interview with the Quality Assurance Supervisor on 06/17/2026 at 5:37 p.m., she said the call light was everyone's responsibility. She said the facility did not have a call light policy.On 06/17/22026 at 07:00 p.m., unable to interview the ADM who was unavailable.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 5 residents (Resident #2 and Resident #4) and 2 of 2 staffs (CNA A, CNA B ) reviewed for infection control. -The facility failed to ensure CNA A proceed soiled linen accord to infection control policies and procedures. On 06/17/2026 CNA A placed Resident #2 soiled linen on the floor with ungloved hands. -The facility failed to ensure CNA B transported clean linen into Resident #4's room following infection prevention guidelines. CNA B held clean linen on her scrub. These failures could place residents at risk for spread of infection and cross contamination to residents causing resident illness and/or distress. Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 4 of 9 residents (Resident #2, #3, #4, and #161) and 2 of 2 staffs (CNA A, CNA B ) reviewed for infection control. 1-The facility failed to ensure CNA A placed soiled linen in a bag and donned PPE before performing soiled linen care for Resident #2 on 06/17/2026. 2-The facility failed to ensure CNA B transported clean linen into Resident #4's room following infection prevention guidelines on 06/17/2026.3-CNA A failed to sanitize her workstation prior to entering/exiting Resident #3's room after leaving/heading to the rooms of other residents on 6/17/26. 4-RN A failed to sanitize her workstation prior to entering/exiting Resident #161's room after leaving/heading to the rooms of another resident on 6/17/26. These failures could place residents at risk for spread of infection and cross contamination to residents causing resident illness and/or distress. Findings included:1.Record review of Resident #2's admission records dated 6/10/2026 revealed he was admitted with the following diagnoses: Hemorrhagic stroke ( when the blood vessels in the brain rupture), cancer, diabetes (irregular blood sugar), CVA (when blood flow supply to the brain is interrupted), and hemiplegia (paralysis that affects the arms and legs).Record review of Resident #2's MDS dated [DATE] revealed his BIMS score was blank. Functional abilities revealed he required assistance in the following care areas: eating, oral hygiene, personal hygiene, toilet transfer, sitting to lying and vice versa, turning and repositioning, chair/bed transfer, and putting on/taking off footwear. Record review of Resident #2's care plan dated 6/10/2026 revealed: Infection risk. Goal: To improve the current infection. Intervention: Notify physicians about abnormal vital signs findings, perform practices to prevent the spread of infections and infectious diseases.Observation of CNA A on 6/16/2026 at 12:45 p.m. CNA A placed soiled linen from Resident #2's bed on the floor. She picked up the soiled linen from the floor with ungloved hands and placed them on the couch.2.Record review of Resident #4's admission records dated 06/02/2026 revealed she was 64 years-old female admitted with the following diagnoses: Syncope fall (sudden temporary loss of consciousness that could lead to falls often caused by a brief drop in blood pressure, Fracture and other trauma, cancer, hypertension (low blood pressure), hip fracture and seizure disorder(abnormal electrical activity in the brain). Record review of Resident #4's MDS dated [DATE] revealed her cognition was coded a 15-normal thinking and memory. Section GG-Functional abilities revealed she required assistance and supervision in the following care areas: toileting, upper and lower body dressing, putting and taking off footwear.Record review of Resident #4's care plan report revealed: Medication risk: Goal. Improve, on medication risk. Intervention: Monitor the effectiveness of the medication. Infection risk. Goal: Prevent infection risk. Intervention: Perform practices to prevent the spread of infection and infectious diseases, notify physicians about abnormal vital signs.Observation of clean linen transportation by CNA B on 06/17/2026 at 09:20 a.m. She transported clean linen to be used for Resident #4's room by carrying them against her scrub.In an interview with CNA B on 06/17/2026 at 09:20 a.m., she said she was told to put clean linen in a bag because everything had to be sanitized. She said, when she carried the clean linen against her scrub, she contaminated the linen. CNA B said when staff carried linen on their scrub, that it could have resulted in cross-contamination from their skin and clothing to the clean linen. She said, if she had any infection on her scrub, it would have been transferred to Resident #4. She said she carried the linen against her scrubs because she was in a rush.In an interview with CNA C on 06/17/2026 at 09:30 a.m., he said, there is a yellow bag that staff should take into the room to place soiled and contaminated linen. He said if soiled linen were placed on the floor, staff could spread infection. He said they were trained to wear gloves, placed soiled linen in a bag and take out of the room to the soiled linen bin. CNA C said if staff placed linen be it clean or dirty on the bare floor, they were violating infection rules. CNA C said he was not told to transport clean line from the linen closet in a bag into the residents' rooms. He said he was told to carry clean linen away from his body with clean hands or anything that could be a source of contamination prevention. In an interview with CNA D on 06/17/2026 at 10;09 a.m., she said to prevent cross-contamination when she removed dirty and soiled linen from the residents' bed she placed them in a bag. She said she would not place them on the floor because that would be considered infection control violation. CNA D said when she had to transport linen from the clean linen closet to the residents' rooms, she made sure the linen did not touch her scrubs.In an interview with CNA A on 06/16/2026 at 12:45 p.m., she said she had to change the linen because the family complained Resident #2 vomited on the linen. She said when she placed the soiled linen on the floor without placing them in a bag and later placed them on the couch, she had transferred bacteria from the linen to the couch. She said that meant violating infection prevention. CNA A said the right thing would have been to place the soiled linen in a bag and take it out after she finished. CNA A said the soiled linen placed on the floor meant cross-contamination and spread of bacteria and staff exposure. She said she was trained to wear PPE when handling soiled linen. She said she did not wear PPE and placed the soiled linen on the floor and later onto the couch because she was in a rush.In an interview with the DON on 06/17/2026 at 2:16 p.m., she said all staff were trained to place soiled and dirty linen in a bag and not on the floor because those types of linen were considered contaminated. She [NAME] if the soiled and dirty linen were not placed in a bag, there was a concern about infection transmission. The DON said staff were trained to carry clean linen away from their body. She said during a process of transporting linen from the clean linen closet to the residents' room, staff had to put the linen in a bag. 3.Record review of Resident #3's MDS dated [DATE] revealed a [AGE] year old male admitted to the facility on [DATE] with a primary diagnosis of amputation. He has the following diagnoses, anemia, CAD (coronary artery disease), heart failure, hypertension (high blood pressure), renal insuffiency (impaired kidney function), diabetes, and wound infection (diabetic foot ulcer). His BIMS score was a 9. He is on enhanced barrier precautions. 4.Record review of Resident #161's MDS dated [DATE] revealed an [AGE] year old female admitted to the facility on [DATE] with a primary diagnosis of acute cystitis (infection of the bladder). Her other diagnoses are heart failure, hypertension, and UTI w/MDRO (urinary tract infection with a multi-drug resistant organism). Her BIMS score is a 15. She is on contact isolation. During observation and interview on 06/17/2026 at 7:44 am RN A entered Resident #161's room, which was on contact isolation for VRE (vancomycin resistant enterococcus), with her workstation (which contained medications). She gave medications to Resident #161 and when finished, exited Resident #161's room without sanitizing workstation. She was about to enter the next resident's room when the surveyor pointed this out to her. RN A stated that she didn't realize that she had done that and that she was just nervous. She said she would make sure she did it going forward. She stated that she had received training on infection control in training when she started, and had also received in services on infection control. She said that the risks to a resident could be the spread of bacteria, viruses, and infection. During observation and interview on 06/17/2026 at 8:04 am, CNA A entered Resident #3's room with her workstation containing resident medications. She failed to sanitize it prior to exit of previous resident's room & entry of Resident #3's room. She gave medications to Resident #3 and when finished, exited Resident #3's room without sanitizing workstation. She was about to enter the next resident's room when the surveyor pointed this out to her. CNA A stated that she didn't realize that she was doing that and that she didn't realize she needed to do that. She stated that she sanitized it prior to med pass and does so afterward. She said she did understand the rationale behind it and would ensure she did it going forward. She stated that she had received training on infection control when she started and had received in services. She said that the risks to a resident could be spreading infection and making them sick. In an interview on 06/17/2026 at 2:00 pm with the DON, she stated that her expectation for her staff is that when they go from one resident's room to another they will perform hand hygiene and sanitize equipment. She said this especially important when going between resident rooms on isolation precautions (contact) due to the fact that antibiotic resistant bacteria can be transmitted which can easily spread hard to eliminate infections which can harm residents. She said that staff know better than this because they have received training on it. In an interview on 06/17/2026 at 3:51pm with the Infection Preventionist, she stated that nurses, med aides, and CNAs all get infection prevention training when they hire on as well as in services and skills fairs where they're checked off for competency. She said that nurses and med aides should be using hand hygiene and sanitizing their carts in between residents during med pass. She said it is especially important when going in/out of isolation rooms to prevent the spread of MDROs (multi-drug resistant organisms). She said the risks to residents if staff are not following these practices is the spread of infection. When told we had observed two different staff doing this within minutes of each other, she stated she had witnessed multiple staff doing this herself (she did not specify when or what action was taken). In an interview on 06/17/2026 at 5:52 pm with Resident #161, when asked what the process is like when staff give her medications she said; staff comes to the room, they knock on the door, they come into the room, they bring their cart in, they put on PPE, scan her bracelet, and then give her the medications as they explain what they are and what they are for. She said that she had not ever witnessed anyone sanitize the cart after entering the room or before leaving. In an interview on 06/17/2026 at 5:55 pm with Resident #3, when asked what the process is like when staff give him medications he said staff comes to the room, they bring their cart in, and then they give him his medications. Resident #3 stated that he had never witnessed staff sanitize the cart after coming into the room or before exiting.Record review of policy: Isolation Precautions effective date 11/2001, last revised 06/2024, section E Contact Precautions subsection 6 Patient Care Equipment page 9 states When possible, dedicate the use of noncriticalpatient-care equipment and items such as a stethoscope,sphygmomanometer, bedside commode, or electronic rectal thermometerto a single patient (or cohort of patients infected or colonized with thepathogen requiring precautions) to avoid sharing between patients. If useof common equipment or items is unavoidable, then adequately clean anddisinfect them before use for another patient.Record review of facility's policy titled: Job Description/Performance Expectation: Skilled Nursing Unit Certified Nursing Assistant; revised on 04/11/2023 stated: The CNA applies safety and infection control principles, environment and all patient care.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 2 hallways (Hall B) reviewed for environmental concerns.-The facility failed to ensure the ceiling in Hall B was free from water buildup, water pooling and a smoke damper leaking water on to the floor on 6/17/26. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.The findings included:In an observation on Hall B on 6/17/26 at 10:04am, the following was observed: -Between rooms [ROOM NUMBERS], there was a ceiling tile that was stained with a brown and yellow stain that was about 7 inches wide and in the shape of one-fourth of a circle. -The lighting panel on the ceiling between rooms [ROOM NUMBERS] had water pooling on the right and left side of the panel.-The smoke damper panel between rooms [ROOM NUMBERS] was leaking water and there was water dropping in a slow stream onto the floor. In an interview on 6/17/26 at 4:40pm, the Facilities Director, when asked about Hall B, he stated that hot air near Hall A met cold air in Hall B and it created moisture. He said the air duct above the hallway was producing water and pooling in the ceiling. Record review of the facility's policy regarding Physical Environment revised on 6/2026 read, (The facility) is committed to providing an environment that is safe, functional and supportive of staff, practitioners and other individuals who enter our buildings. (the facility) assures through our management of the environment, that risks are assessed and identified in order to mitigate and better manage those risks.

Based on interview and record review, the facility failed to maintain an effective pest control program for 2 of 5 residents' rooms (room [ROOM NUMBER] and 19) and surrounding areas reviewed for pests.The facility failed to ensure Resident #4 and Resident #5's rooms were free of pests on 06/14/ 2026 and 06/16/2026.The facility failed to ensure the common shower area was free of pests.This failure could place residents at risk of increased exposure to pests and vector-borne diseases and infections as well as negative reputation of the physical environment of the facility.Findings included: Record review of Resident #4's admission records dated 06/02/2026 revealed she was 64 years-old female admitted with the following diagnoses: Syncope fall (sudden temporary loss of consciousness that could lead to falls often caused by a brief drop in blood pressure, fracture and other trauma, cancer, hypertension (low blood pressure), hip fracture and seizure disorder(abnormal electrical brain disorder). Record review of Resident #4's MDS dated [DATE] revealed her cognition was coded with a 15-indicating normal thinking and memory. Section GG-Functional Abilities revealed she required assistance and supervision with the following care areas: toileting, upper and lower body dressing, and putting and taking off footwear.Record review of Resident #4's care plan report revealed: Activity intolerance: Goal: stabilize risk of developing activity intolerance. Intervention: Perform actions which support bedbound patients. Medication risk: Goal. Improve, on medication risk. Intervention: Monitor the effectiveness of the medication. Infection risk. Goal: Prevent infection risk. Intervention: Perform practices to prevent the spread of infection and infectious diseases, notify physicians about abnormal vital sign findings. Injury risk. Goal: To be stabilized. Intervention: Take precautions to reduce patient injury.Record review of Resident #5's admission record dated 06/14/2026 revealed he was a [AGE] year-old male admitted with the following diagnoses: Angina (chest pain or discomfort caused by reduced blood flow to the heart), UTI (infection in any part of the urinary system), ESRD (when the kidneys cannot function normally), respiratory condition, surgical wound and diabetes (irregular blood sugar). Record review of Resident #5's MDS dated [DATE] revealed his BIMS score was coded 15-normal thinking and memory. Bowel and bladder revealed he had an indwelling catheter. Required assistance with activities of daily livingRecord review of Resident #5's care plan report dated 06/14/2026 revealed: Fall. Goal: To stabilize any potential fall injury risks. Intervention: Assess for possible risks of falls, assess patient for possible side effects of medications especially those related to sedation, respirations, depression and gait. Apply fall risks precautions-bed in lowest position, orient patient and family to the environment, educate patient/family and caregivers on measures to prevent falls, trips and slips, ensure call light and personal items are within reach, supervise toileting and implement hourly roundingIn an interview with Resident #4 on 06/17/2026 at 12:46 p.m., she said she saw 2 roaches on 06/14/2026 in her room. Resident #4 said when she saw the roaches, she felt she was in an unclean environment. She said she had the feeling the roaches would crawl on her body while she slept at night. She said CNA B killed the roaches.In an interview with Resident #5 on 06/17/2026 at 1:02 p.m., he said his family member killed a roach in his room the day before. He said when they saw the live roach, they were startled and paused to imagine where it came from. Resident #5 said with the roach in his room he felt disgusted, anxious and he panicked. He wondered if it was lack of hygiene and wondered if there were other roaches in the building. The family member who was in the room at the time of the interview confirmed she saw the roach.In an interview with CNA B on 06/17/2026 at 1:02 p.m., she said on 06/12/2026 she saw a roach in front of Resident #4's door. She said she killed and discarded the dead roach in a trash but did not notify the nurse because the nurse saw her killing the roach. She said she could not remember the name of the nurse. In an interview with the Case Manager on 06/17/2026 at 1:31 p.m., she said the staff reported concerns with roaches to her and she would call the House Supervisor and notify them of the location. The House Supervisor would then call the exterminator. The Case Manager said staff notified her there were roaches, spiders, and ants in the public shower. She said staff used to complain about spiders, roaches, and ants.In an interview with the DON on 06/17/2026 at 2:16 p.m., she said nobody told her about roaches, and spiders. She said she knew of ants. She said if she was made aware of the roaches and spiders, she would have notified the maintenance supervisor and that would have been taken care of. In an interview with the facility management supervisor on 06/17/2026 at 4;26 p.m., he said the pest control company comes in every Monday of the week. He said the last time pest control was in the building specifically for the SNF department was on 06/09/2026. He said he could not recall the purpose of the pest control.Record review of facility's pest control invoices revealed pest control was in the building on the following dates in 2026 and not specifically on Mondays for roaches, ants and spiders: 04/03-Cafeteria and kitchen, 04/06-kitchen, 04/16-bathrooms, breakrooms and kitchen, 04/17-offices, 5/15-building, 5/21-bathrooms, breakrooms and building, 5/27-kitchen. The pest control record review was not differentiated between the hospital from the SNF.

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate director care staffing information no less frequently than quarterly for one of four quarters reviewed for payroll based journal data. This failure placed residents at risk of not being aware of the facility's staffing information which may result in adverse health outcomes due to low staffing levels. Findings include: Record review of the PBJ Staffing Data Report for Quarter 2 of 2026 (January 1-March 31) generated on 6/17/26 revealed the facility failed to submit data for the quarter. In an interview on 6/17/26 at 5:30pm, the Quality Director stated the coordinator was responsible for submitting staffing data to CMS. She said the previous coordinator told the facility she was submitting the data to CMS. She said they found out that she had not submitted the data and she no longer worked at the facility.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 of 4 residents (Resident #117) observed for infection control. The facility failed to ensure CNA B followed appropriate infection control and hand hygiene procedure during incontinent care for Resident #117 on 05/05/2025. These failures could place the residents at risk for infection. Findings included: Record review of Resident #117's face sheet dated 04/24/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Septic Arthritis to the left knee (bacterial infection in the knee joint) Record review of Resident #117's MDS admission Assessment, dated 04/16/25, revealed that the resident had a BIMS summary score of 15, which indicated that the resident was cognitively intact. Further review revealed that Resident #117 required supervision and touch assistance with toileting. Record review of Resident #117's comprehensive care plan revealed that the resident had an infection related to a compromised immune system and the presence of pathogenic microorganisms. Interventions included proper hand washing using antibacterial soap before and after each care activity and maintaining sterile technique when changing dressings, suctioning, and providing site care, such as an invasive line or a urinary catheter. During an observation on 05/05/25 at 10:21 AM, CNA B walked into Resident #117's room accompanied by CNA J. Both CNA B and CNA J washed their hands and donned (put on) their gown and gloves. CNA B performed catheter care on Resident #117, turned the resident to his right side, and wiped his buttocks three times. She removed the old brief, discarded it in the trash, and applied a new brief. CNA B used the same gloves and did not perform hand hygiene throughout the entire incontinent care process. They doffed (removed)their PPE and washed their hands. CNA B and CNA J thanked the resident and left the room. During an interview on 05/05/25 at 10:21 AM, CNA J said she was unsure why CNA B did not wash her hands or change her gloves while performing catheter care. She said the staff wereare in-serviced on washing their hands and changing gloves when going from dirty to clean. She said the risk of not washing hands and changing gloves during incontinent care could lead to cross contamination. She was unable to recall the last time she was in-serviced on infection control when performing incontinent care. During an interview on 05/05/25 at 10:38 AM, CNA B said she was supposed to wash or sanitize her hands after providing catheter care and when applying a new brief. She said the staff should remove gloves, wash/sanitize their hands, and apply new gloves when going from a dirty brief to a clean brief. CNA B said she realized that she had not changed her gloves and had used the same gloves during the entire process after she had completed incontinent care. She said she had a skill check off on infection control and was educated on hand-hygiene and incontinent care during on-boarding. CNA B said the risk of not changing her gloves and performing hand-hygiene could cause cross-contamination and infection. During an interview on 05/07/25 at 11:55 AM, the unit manager said she expected staff to follow standard precautions, and they should wash their hands before, during, and after providing incontinent/catheter care for all residents. She said the risk of not washing/sanitizing their hands could lead to cross-contamination and/or infection to all residents and staff. During an interview on 05/07/25 at 5:56 PM, the Quality Director said the staff should follow standard precautions and aseptic techniques when providing incontinent/catheter care. She said the staff should wash their hands before placing clean gloves on and wash hands before, during, and after all procedures. The Quality Director said the risk could be infection to other residents and themselves. She said she would be performing re-education and skills checkoff for infection control and incontinent care with all staff. Record review of the facility policy on Infection Control dated 11/2001 (Revised 6/2024) read in part .A. Standard Precautions--Standard Precautions combines the major features of Universal (Blood and Body Fluid) Precautions (designed to reduce the risk of transmission of bloodborne pathogens) and Body Substance Isolation (designed to reduce the risk of transmission of pathogens from moist body substances)and applies them to all patients receiving care in hospitals regardless of their diagnosis or presumed infection status. Standard precautions apply to: · blood, · all body fluids, secretions, and excretions regardless of whether or not they contain visible blood, · non-intact skin, and · mucous membranes. Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals.

Based on observation, interview, and record review, the facility failed to maintain a temperature range of 71 F to 81 F for 14 of 14 residents reviewed for exposure to high temperatures in the facility. -The facility air conditioning system had not been working adequately for up to two weeks. -The temperature of a common area (dining room) used by the residents was above 81 F. This failure placed all residents at risk for hyperthermia (elevated body temperature that could result in stroke or death). Findings Include: Observation on 06/27/2023 at 11:40 a.m. revealed the facility was a ground-floor wing of a multi-story hospital. Entry required walking through the main lobby and hallways. Observation during the walk revealed comfortable temperatures. Upon approaching the SNF section of the hospital, the temperature in the hallway became noticeably warmer. In an interview 06/27/2023 at 11:45 a.m. with the DON, she said the air conditioning problem was reported to HHS that morning (06/27/2023). She said the air conditioner had been repaired in the last two weeks because they were having trouble keeping the 1st floor cool in the areas where resident rooms were occupied with residents. She said no residents had been relocated to an area where the air conditioning was functioning. She said they were waiting for State Office to give permission. After the surveyor asked the facility to review its Emergency Plan that they started relocating residents. Observation on 06/27/2023 at 11:46 a.m. revealed a portable air conditioning unit was near the nurses' station. The thermostat on the unit read 64 F. The thermometer on the unit read 77 F. There was a total of five portable air conditioner units operating in the facility. One was at the nurses 'station, and four were in the hallway of the facility. There was one unit in the hallway by room [ROOM NUMBER], near the nurses' station. There were two units in the hallway near room [ROOM NUMBER], near the center of the hall. There was one unit in the hallway by room [ROOM NUMBER], the furthest occupied room from the nurses' station In an interview on 06/27/2023 at 11:50 a.m. with the hospital Director of Quality Management she said the air conditioner repair company would be at the facility on 06/29/2023. She said the hospital could accommodate the residents on the fourth floor of the hospital, which was currently vacant but equipped. She said she was concerned for the residents because the temperatures were expected to rise to the 100's same day. Observation and interview on 06/27/2023 at 11:55 a.m. with DM A revealed he had a hand-held infrared digital thermometer. During the coolest part of the day (morning) the following temperatures were obtained by DM A at approximately five feet above the floor: room [ROOM NUMBER] 80.2 F room [ROOM NUMBER] 80 F room [ROOM NUMBER] 79 F In an interview on 06/27/2023 at 12:10 p.m. the QC B said the residents would need to be relocated for approximately 1 week. She said the main air conditioners for the facility stopped working yesterday (07/26/2023) around 3:00 p.m. She said the portable units were brought in at that time. In an interview on 06/27/2023 at 12:21 p.m. DM A said the portable units were brought in at 5:30 p.m. the previous day (6/26/23). Observation on 06/27/2023 at 12:55 p.m. revealed residents were being transferred to the fourth floor of the hospital by facility direct care staff. In a meeting on 06/27/2023 at 1:05 p.m. with CNO C, QC B, DM A, the LSC surveyor, and the health surveyor, CNO C said the problems with the main air conditioner began about 2 weeks ago but they were able to move residents around. She said they were able to move residents around within the facility to keep them cool. She said yesterday (06/26/2023) was the first time they could not accommodate by rearranging residents. Observation and interview on 06/27/2023 at 1:15 p.m. revealed a family member visiting Resident #1 in their room. The family member said he was hot in the Resident's room. The Resident agreed. The family member said the news weather had reported hot days with temperature up to the 100s during the week. Observation and interview on 06/27/2023 at 1:35 p.m. revealed Resident #2 in his room. He had a box fan in his room. He said it was hot even with the fan on. He said the portable air conditioner units in the hallways did not cool the room. He said he arrived on 06/14/2023 (ten days ago), and it was hot in the facility then. He said he had not been moved to a cooler room. He said the temperature in his room seemed like 100 degrees in this hot city weather. Observation on 07/14/2023 at 2:18 p.m. with SHVT D revealed he used a facility hand-held infrared thermometer to obtain the temperature of the dining room. The temperature was out of the 71-81 F range. The temperature was 81.4 F at approximately five feet above the floor. Record review of Houston's Weather dated 6/27/23 located at https://weather.com/weather/monthly/l/Richmond+TX?canonicalCityId=14d44e5b5730110f5a865c606dc0defff4abdf0c89fb7ccdb0f881987bef9730 read in part the high temperatures from 06/27/2023 to 07/14/2023 in Richmond Texas ranged from 86 F to 101 F, with the average high temperature being 98 F. The high temperature on 06/27/2023 was 101 F . Record review of the facility Emergency Operations Plan 2021-2023 (page 6) read in part . An Emergency is an unexpected or sudden event. Utility outages are considered emergencies. Emergency Response Plan: Section (page 10) emergency includes staged or total evacuation .

40249 Based on observation, interviews, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for two (Resident #72 and Resident #120) of seven residents reviewed for storage of medications. The facility failed to ensure: -Resident #72's medication was kept in a secure location. Resident #72 had physician's ordered Nystatin (antifungal medication used in skin treatments) powder at the bedside. -Resident #120 medication was kept in a secure location. Resident # 120 had no physician's order for Timolol Maleate Solution 0.5 % eye drops sitting on top of the bedside table. These deficient practices could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: Resident #72 Record review of Resident #72's clinical record revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included necrotizing fasciitis (a bacterial infection that destroys tissue under the skin) of left abdomen. Record review of Resident #72's baseline care plan dated 02/06/2023 revealed: Problem: Impaired skin integrity; Goal: Skin integrity impairment risk stabilized, decreased chances of skin breakdown; Implementation: Assess for adverse effects of medications; Continued review of the care plan did not reveal Resident #72 could keep the Nystatin powder at the bedside. Record review of Resident #72's physician's order dated 02/07/2023 revealed Nystatin powder 100,000 units per Gram. Apply to groin daily. Continued review of the physician's orders did not reveal an order to keep at the bedside. Observation on 02/12/23 at 9:00 AM in room [ROOM NUMBER] B revealed Resident #72 in bed. Resident was not interviewable. A bottle of Nystatin powder 100,000 units per Gram was on a table in the resident room. In an interview on 02/12/2023 at 9:11 AM, LVN A stated Resident #72 did not have a physician's order to keep her Nystatin powder at the bedside. LVN A stated the medication was to be kept in the medication room or on the medication cart. LVN A stated Nystatin powder required a physician's order to administer. LVN A stated it was the responsibility of the nurse to make sure there were no medications at the bedside. LVN A continued and stated the risk of the medication at the bedside was that a visitor or someone who should not have it could take it. Resident #120 Record review of the admission sheet (undated) for Resident #120 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included fall wedge fracture of 1st lumber. Record review of Resident #120's Admission MDS dated [DATE] did not mention the BIMS score. Record review of Resident #120's Baseline care plan, dated 01/31/2023 revealed the following care plan: Problem: Impaired skin integrity Goal: Skin integrity impairment risk stabilized, decreased chances of skin breakdown Implementation: Assess for adverse effects of medications. Resident #120 was not care planned for having meds at bedside. Observation and interview on 02/12/2023 at 8:42a.m., of Resident #120, in her room, revealed a bottle of Timolol Maleate Solution 0.5 % eye drops sitting on top of the bedside table. Resident #120 said her family member brought the eye drops and she administered herself day and night for glaucoma. Record review of Resident #120's physician's order revealed she was not prescribed the above-mentioned medication of Timolol Maleate Solution 0.5 % eye drops. There were no orders for self-administration. Observation and interview on 02/12/2023 at 8:55 a.m., with LVN A, she said residents were not supposed to have any medications at bedside because they could react with any other medications given to them per their orders. LVN A said home meds had to be sent to the pharmacy to verify. Home meds were kept in the med room in their cubie. She said, I have taken care of Resident #120 multiple times. I don't know how the eye drops got in her room. LVN A said the resident did not have orders for it. In an and record review on 02/12/2023 at 1:15 p.m. This Surveyor reviewed Resident #120's physician orders with LVN A. LVN A said the resident did not have an order for eye drops. In an interview on 02/13/23 at 9:50 a.m., the DON said residents were not allowed to have medication in their rooms. She said if a resident was deemed safe to self-administer medication, they would also need a doctor's order. She said she was not aware of Resident #120 having meds at bedside. Record review of the facility's policy, Medication Management Storage, review dated 03/23/2022, read in part Policy: Medications, biologicals, and devices shall be stored to ensure their integrity, stability, and effectiveness. All drugs and biologicals will be controlled, secured, and distributed in accordance with applicable standards of practice and consistent with Federal and State laws and regulations . Medications may be stored only in authorized locations .All drugs and biologicals must be stored in a manner to prevent access by non-authorized individuals . Record review of facilities Home Medications policy (revision/Review Date: 7/2020) revealed read in part: .Procedure: For patients who will bring medications from home to the Skilled Nursing Unit: 1. Their medications must be contained in a bag or container that seals tight. 2. Home Medications must have the appropriate label from the pharmacy. 2. All home medications will be sent to our pharmacy to be verified.6. Patients' home medication must be kept locked up at all times; except when dispensing them. This is a State requirement and can also be a HIPAA violation .

Based on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 7 residents (Resident#122) reviewed for unnecessary drugs. The facility failed to ensure the stop date and diagnosis and/or indication for use was appropriate prior to administering Rocephin, an antibiotic. This failure could place residents receiving medications at risk of a possible adverse drug reaction or hospitalization . Findings included: Record review of Resident #122's face sheet (undated) revealed a [AGE] year-old female admitted to facility on 02/10/2023. Her diagnoses included hepatic encephalopathy (a nervous system disorder brought on by severe liver disease). Record review of Resident #122's Admission MDS dated [DATE] did not mention the BIMS score. Record review of Resident #122's baseline care plan dated 02/10/2023 revealed: Problem: Impaired skin integrity; Goal: Skin integrity impairment risk stabilized, decreased chances of skin breakdown; Implementation: Assess for adverse effects of medications. Resident was not care planned for receiving antibiotics. Record review of Resident #122's physician orders dated 02/11/2023 revealed an order for Ceftriaxone (Rocephin) 1 gram daily at 9:00am. Record review of Resident #122's MAR dated February 2023 revealed resident received Ceftriaxone (Rocephin) 1 gram daily at 9:00am. There was no diagnosis or stop date listed for the medication. Observation of the Med pass on 02/12/2023 at 9:46 a.m., revealed LVN A administered Resident #122's Ceftriaxone (Rocephin) 1 gram administered over 3-5 minutes IV push. In an interview on 02/12/2023 at 11:53 a.m., the LVN A said, I think Resident #122 is on Rocephin for suspected UTI because she had altered mental status when admitted to the hospital. In an interview on 02/13/2023 at 9:30 a.m., this Surveyor reviewed Resident #122's physician order with the DON. The DON said the order for the ABT was missing the diagnosis and the stop date. She said she did not know why the resident was receiving the ABT. In a later interview on 02/13/2023 at 9:50 a.m., she said she texted Resident #122's doctor and he said the ABT was for hepatic encephalopathy. She said the doctor said he would come and add the stop date today. She said the system was when a resident was admitted to the facility the admission orders go to the physician electronically. The physician then noted agreement/changes/discontinued orders. Then the orders were sent to the pharmacy electronically. The pharmacy printed the medications on the MAR and medications were sent to the floor. They should always put a diagnosis for medications. This should have been caught by the pharmacy or the nurse. They would be responsible for ensuring the medications are correct. She said there was no direct policy or protocol for receiving orders for medications.

Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS, in that: The facility failed to submit staffing information to CMS for the 4th quarter of the fiscal year 2022. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. The findings included: Review of the facility's staff roster, undated indicated the following: 1 Administrator 1 Manager 1 MDS 1 MA 5 LVNs 3 RNs 5 CNAs Record review of the facility CMS form 672 (Resident Census and Conditions of Residents) dated 02/12/2023 provided by Director of Quality indicated a total of 7 residents in the facility. Record review of the PBJ Staffing Data Report, FY Quarter 4 2022 (July 1 - September 30), dated 02/10/2023, revealed the facility had failed to submit data for the quarter. In an interview on 2/13/2023 at 9:37 a.m., with Administrator (on phone) and the Director of Quality. Director of Quality said that a Payroll Based Journal had not been submitted. She said in the 4th quarter the facility did not have a DON and the Administrator acted as an interim DON. She said the Administrator was clinical he did not have experience of submitting the staffing report. She said they were familiar with the requirement for reporting staffing to CMS but did not know who did the reporting for the facility. She said the facility did not have a Payroll Based Journal for submission to CMS policy. Record review of the CMS, Electronic Staffing Data Submission Payroll-Based Journal, Long-Term Care Facility Policy Manual, Version 2.6, June 2022, section 1.2 Submission Timeliness and Accuracy, revealed Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. Further review revealed Report Quarter 4 date range as July 1-September 30. Policy manual revealed, Deadline: Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time) after the last day in each fiscal quarter in order to be considered timely.

Based on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 7 residents (Resident #59) reviewed for unnecessary drugs. The facility failed to ensure the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents receiving medications at risk of a possible adverse drug reaction or hospitalization . Findings included: Record review of Resident #59 face sheet revealed an [AGE] year-old male who admitted to facility on 12/16/21. His diagnoses included diabetes, congestive heart failure, and [CONDITION(S)]. Record review of Resident #59's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #59's admit assessment dated [DATE] did not reveal resident had an infection or was on an antibiotic. Record review of Resident #59's history and physical dated 12/17/21 revealed [MEDICATION(S)] 500 mg tablet ([MEDICATION(S)]) to be given daily. There was no indication of a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #59's MAR dated 12/20/21 revealed resident had been receiving [MEDICATION(S)] 500 mg tablet ([MEDICATION(S)]) daily since 12/17/21. There was no diagnosis listed for the medication. During an interview on 12/20/21 at 11:09 AM the LVN A said Resident #59 was on [MEDICATION(S)] but did not know why he was taking it. During an interview on 12/20/21 at 12:10 PM the LVN A said she spoke to the doctor and Resident #59 had a [CONDITION(S)]. She said there was no documentation for the reason he was on the [MEDICATION(S)]. She had looked at the admission paperwork and progress notes. During an interview on 12/20/21 at 3:15 PM the Director of Quality said she had looked for a UA or any lab work to show a [CONDITION(S)] or why Resident #59 was on [MEDICATION(S)]. She said she could not find a reason for the resident to be on the antibiotic. She said the system when a resident was admitted to the facility was the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The pharmacy printed the medications on the MAR and the MAR and medications were sent to the floor. The pharmacy did not necessarily look at diagnoses. She said it appeared the physician added the [MEDICATION(S)] during this process. She said there was no direct policy or protocol for receiving orders for medications. During an interview on 12/20/21 at 4:14 PM the Administrator said the physician verifies and changes orders electronically. They should always put a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This should have been caught by the pharmacy or the nurse. They would be responsible for ensuring the medications are correct.

Based on interviews and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility reviewed for facility assessment. The facility did not have a completed Facility Assessment. This failure could place all residents at risk of a lack of necessary resources. Findings Included: Record review of the facility's records revealed they did not have a facility assessment. During an interview on 12/20/21 at 3:18 PM the Director of Quality said she could not find a facility assessment, so they did not have one. During an interview on 12/20/21 at 4:22 PM the Administrator said he was not aware about a facility assessment. He said he had not completed one since he had been filling in as administrator since March 2021. He said there was no policy for facility assessment that he was aware of.

Based on interviews and record review, the facility failed to ensure the Quality Assessment and Assurance Committee (QAA) meet at least quarterly for 1 of 1 facility reviewed for QA. The facility did not have quarterly QAA meetings, the last meeting was held 2/21. This failure could place residents at risk of quality deficiencies being unidentified and not corrected. Findings included: Record review of the QAA/ Quality Assurance and Performance Improvement Committee (QAPI) meeting sign in sheets indicated the last meeting was held on 2/21. During an interview on 12/20/21 at 2:58 PM the Director of Quality said she did not know how often the meeting was to meet. She confirmed the last meeting was conducted in February 2021. She said they should be following the HHS and CMS policies and guidelines. They did not have a specific policy themselves. During an interview on 12/20/21 at 4:20 PM, the Administrator said he had not done any QAA meetings since he had taken over when the administrator left in March 2021. He said he was unaware of the timing for QAA meetings. He said he was only interim, and this was not his normal job position. He was not an administrator and the facility were looking for one. He did say if the meetings were to be completed quarterly then they should have been done. This would have been 3 meetings missed.

Based on observation, interview, and record review, the facility failed to ensure the resident right to personal privacy and confidentiality of her personal medical records for 1 of 6 residents (Resident #5) of 6 reviewed for privacy and confidentiality in that: -LVN-B did not close Resident #5's room door when providing wound dressing changes. -LVN-C walked away from the medication cart without locking the computer screen leaving resident information exposed. -LVN-C left Resident #5's Resident Care Summary sheet visible on the unattended medication cart. These failures could affect all residents and placed them at risk having their privacy violated and for disclosure of protected health information to unauthorized persons. Findings include: Resident #5 Record review of Resident #5's face sheet revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident # 5's MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating she was cognitively intact. She required limited assistance with dressing. She had no impairment to upper extremity, and one impairment to lower extremity one side. She was always continent of bowel and bladder. She had an infection of foot (eg., [MEDICAL CONDITION], purulent drainage). Record review of Resident # 5's Comprehensive Care Plan dated 08/13/20 revealed she was being care planned for Infection control with an intervention to perform practices to prevent the spread of infections and infectious diseases. Observation on 09/15/20 at 8:28 a.m. revealed LVN-C walked away from her medication computer screen without locking it exposing resident records and leaving Resident #5's Care Summary Sheet visible on top of the medication cart. She returned 4 minues later at 8:32 a.m. Interview on 09/15/20 at 10:25 a.m. with LVN-C said she should not have walked away and left the computer screen visible with the resident health information visible. LVN-C said this was a HIPAA violation. LVN-C said she was nervous and forgot. Observation on 09/16/20 at 9:15 a.m. LVN-B entered Resident #5's room. Without closing the door, LVN B washed her hands and proceeded to change Resident #5's dressings to both feet. There was no privacy provided for Resident #5. Interview on 09/16/20 at 9:40 a.m. LVN-B said she should have closed Resident #5's door for privacy before doing the dressing changes to her feet. Interview with on 09/15/20 at 10:45 a.m. the DON said staff should never leave resident information exposed for the purposes of protecting the resident information. Record review of the NF Policy on Confidentiality of Health Care Information revised July 2020 revealed in part: .It is the policy of the facility to employ physical safeguards to maintain the privacy of PHI in compliance with the standards, implementing guidelines or other requirements of the HIPAA Privacy and Security Rules .Laptop computers shall be kept locked when unattended at the facility .Patient records shall be kept secure and confidential .

Based on observations, interviews 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 3 of 6 residents (Residents #1, #2 and #5) reviewed for infection control in that: -The oxygen tubing for Resident #1 was not dated or bagged while not in use. -Resident #2's IV line on IV poll had no date, time and RN initials on the label. -The facility failed to follow their policy for replacement of administration sets (IV tubing). -Nursing staff were reusing disposable specimen containers to drain JP drains for Resident #2. -LVN-B did not sanitize work space prior to performing dressing changes on Resident #5 or sanitize scissors. -LVN-B did not wash or sanitize hands in between dressing changes for Resident #5. -LVN-B did not dispose soiled dressings of Resident #5 inside of a red biohazard bag. These failures placed all residents on oxygen or receiving wound care at risk for cross contamination, delayed healing, infection, and hospitalization . Findings include: Resident #1 Record review of Resident #1's clinical face sheet revealed a [AGE] year-old male who was admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's MAR for September 2020 revealed it was still in progress due to being newly admitted . Record review of Resident #1's baseline care plan initiated on 9/9/20 revealed Resident #1 was at risk for infection; increased chance of contamination with disease producing germs related to hospitalization . The target solution was to achieve discharge; notify physician about abnormal vital sign findings; perform practices to prevent the spread of infections and infectious disease; teach the patient and family actions and behaviors which enhance the patient's health state and evaluate results of diagnostic studies and report results to MD as ordered. Observation and interview on 9/15/20 at 7:56 am revealed Resident #1 sitting upright on his wheelchair. He was receiving oxygen infusion at 3.0 liters via cannula. The cannula tubing was not dated. It should have been dated. He said he came to the facility because he fell in his kitchen and dislocated his shoulder. He said he thought he arrived on Friday, 9/11/20, but he was not real sure. Observation on 9/15/20 at 1:22 pm revealed Resident #1 laying in his bed. His oxygen tubing was draped and wrapped around the oxygen device located on the wall. The oxygen tubing was not in a bag while not in use. The oxygen tubing was not dated. The oxygen tubing should have been in a bag while not in use and it should have been dated. The oxygen gauge was still set at 3.0 liters. Observation on 9/16/20 at 9:22 am revealed Resident#1 sitting outside his door in his wheelchair. His oxygen tubing was draped and wrapped around the oxygen device located on the wall. The oxygen tubing was not in a bag while not in use. The oxygen tubing was not dated. The oxygen tubing should have been in a bag while not in use and it should have been dated. The oxygen gauge was still set at 3.0 liters. There were personal grooming items on the resident's bed (shaving cream, razor, comb, and eyeglasses). His rolling table was dirty with brown fluid drips that appeared to look like coffee drips. In an interview on 9/16/20 at 9:25 am with Resident #1, he said he could not remember if he had oxygen this morning. In an interview on 9/16/20 at 9:35 am with RN, Assistant Vice President of Nursing, she confirmed Resident #1's oxygen tubing was not in a bag while not being used. She confirmed the oxygen setting was set on 3.0 liters. She confirmed there was no date on the oxygen tubing. She said it was important to date and bag oxygen tubing to prevent infection. Resident #2 Record review of Resident #2's clinical face sheet revealed a [AGE] year-old male who was admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's MAR for September 2020 revealed it was still in progress due to newly being admitted . Record review of Resident #2's care plan initiated on 9/4/20 revealed Resident #2 was at risk for infection; increased chance of contamination with disease producing germs related to hospitalization . The target solution was to achieve discharge; notify physician about abnormal vital sign findings; perform practices to prevent the spread of infections and infectious disease; teach the patient and family actions and behaviors which enhance the patient's health state and evaluate results of diagnostic studies and report results to MD as ordered. Record review of Resident #2's physician orders [REDACTED]. Last dose on 10/14/20. Time critical medication to be administered within 30 minutes of the scheduled dosing time. Observation and interview on 9/15/20 at 8:45 am revealed Resident #2 eating breakfast (bacon, scrambled eggs, banana, apple juice). He had a PICC line on his right arm. He had about 6 packets of Juven 0.97 ounces on his rolling table. His call light was within reach. He said if he pushed the red button, staff came right away. He had a wheelchair and walker that was on loan to him from the facility. He was wearing a fall risk bracelet. There was a midsection brace on top of his end table to his left. There was an IV poll that had a bag with doctor orders printed that said, [MEDICATION NAME] 500 mg IV X40 days last dose 10/14/20; administer within 30 minutes; time critical. Sodium Chloride 0.9% 100 ml. It was dated 9/15/20 and had a time of 2pm, hand written. The tubing said as follows: CHANGE THURSDAY; date: left blank; time: left blank and R.N. initials: left blank. In an interview on 9/15/20 at 9:00 am with Resident #2, he said he was not on oxygen. He said he arrived at the facility about 3 to 4 weeks ago. He said he got O.T. and P.T. to regain his strength. He said he was a fall risk. He said he wore his brace every time he was out of bed. He said the nurse used the 2 specimen containers to measure the amount of liquid coming out of his two small JP drains. Resident #2 said he had not been seen by any doctors since he had arrived. Resident #2 could not recall when the last time the tubing on the IV poll had been changed. Resident #2 said the staff used the specimen containers to pull liquid from his JP drains because they were measuring his input/output of liquids. He said they did it 2 to 3 times per day. He showed this Surveyor his two JP drains. They were located on his right side of his torso. There was fluid and blood in both JP drains. He said he thought they sent it to the lab, but he said he was not real sure. He said he had seen the staff use the specimen containers, wash them, and set them out to dry on paper towels on his restroom sink counter. The specimen containers on his restroom sink counter had blood residual on them and they should have gone out as red bag waste. In an interview on 9/15/20 at 9:01 am with CNA A, she confirmed there were two specimen containers that had been washed and left to dry on Resident #2's restroom counter. She said they should not have been left on the counter. She confirmed that one of them had a brown spot and the blank label had brown smudges. She said specimen containers were not reusable. In an interview on 9/15/20 at 10:29 am with LVN C, she said she worked with Resident #2. She said she did not work at the facility in the last week. She said she emptied Resident #2's JP drains on one occasion. She said she used the specimen containers to do it. She said, but, I did not reuse the specimen containers, but I've seen others wash and reuse them. I don't do that. In an interview on 9/15/20 at 10:45 am with RN, Assistant Vice President of Nursing, she confirmed there were two specimen containers on Resident #2's restroom counter. She confirmed that one container had a brown spot and brown smudges on the blank label. She said the brown spots were dried blood. She said the specimen containers were not reusable. She took a picture of it and said, someone is in trouble. She said they should not be reusing them because they were disposable and not expensive, so it was okay to throw them away. She said re-using them was risk of infection. She said she in-serviced staff on 7/30/20 on the topic of infection control. She said she was going to re-train staff. In an interview on 9/15/20 at 11:16 am with LVN B, she said she drained Resident #2's JP drains. She said she opened the first JP drain and using the specimen container she drained the first one. She said she was gloved up while doing it. She said she emptied the fluid in the resident's toilet; then, she drained the second JP drain. She said she emptied the fluid in the resident's toilet. She said she washed both specimen containers afterwards with soap and water. She said she did not notice the blood spot and smudges on the container after she washed it. She said the specimen containers were reusable. She said the blood smudges did not pose a risk to the Resident #2 because he did not come in contact with the containers. She said it did not pose a risk to herself either because she was gloved up. She said the last time she was in-serviced for infection control was in the summer around May or June. Observation on 9/16/20 at 9:26 am revealed Resident #2 was not in his room. His breakfast tray was on his rolling table. He ate most of his breakfast. There was an IV poll that had a bag with doctor orders printed that said, [MEDICATION NAME] 500 mg IV X40 days last dose 10/14/20; administer within 30 minutes; time critical. Sodium Chloride 0.9% 100 ml. It was dated 9/15/20 and had a time of 2pm, hand written. The tubing said as follows: CHANGE THURSDAY; date: left blank; time: left blank and R.N. initials: left blank. In an interview on 9/16/20 at 9:40 am with RN, Assistant Vice President of Nursing, she confirmed Resident #2's IV poll's tubing had a label that said, change Thursday with blanks on the date, time and RN initials on the label. She said the tubing was supposed to be changed every 72 hours. She said there was no way of telling when the tubing was changed because the nursing staff should have placed a date, time and RN initials on the label. She said with the label reading change Thursday, she didn't know what Thursday was being referred to. She said it was important to change the IV tubing every 72 hours to prevent infection. In a follow-up interview on 9/16/20 at 11:00 am with RN, Assistant Vice President of Nursing, she said the facility's infection report noted the IV line (tubing) on Resident #2 had not been dated, timed and initialed by the charge nurse. She said she went back to find out who was the charge nurse and re-educated her on protocol and told her to go date, time and initial the label on the IV line (tubing). She said she did not know why she did not get it done. Record review of the facility's hospital associated infection report dated 9/11/20 revealed report noted the IV line (tubing) on Resident #2 had not been dated, timed and initialed by the charge nurse. In a follow-up interview on 9/16/20 at 11:20 am with LVN B, she said she told RN B to put a label on the IV line and RN B must have misunderstood. She said RN B put a label on it, but left the date, time and R.N. initials blank. She said it was brought to her attention today and she was re-educated. Record review of Resident #2's intake/output report dated from 9/5 to 9/15/20 revealed LVN B drained Resident #2's JP drains twice daily on 9/5/20. RN B drained Resident #2's JP drains twice daily on 9/5/20. RN B drained Resident #2's JP drains twice daily on 9/6/20. LVN C drained Resident #2's JP drains once on 9/6/20. LVN C drained Resident #2's JP drains twice daily on 9/7/20. LVN B drained Resident #2's JP drains once on 9/7/20. LVN B drained Resident #2's JP drains twice daily on 9/7/20. LVN B drained Resident #2's JP drains twice daily on 9/9/20. RN B drained Resident #2's JP drains twice daily on 9/10/20. RN B drained Resident #2's JP drains once on 9/11/20. RN B drained Resident #2's JP drains once on 9/11/20 and LVN B drained once on same day. LVN B drained Resident #2's JP drains twice daily on 9/12/20. LVN B drained Resident #2's JP drains once on 9/14/20 and on 9/15/20. Record review of the facility's policy titled, Intravascular (IV) Access Care revised on 8/20 read in part . 1. A. OakBend Medical Center will have established guidelines for the changing of intravenous (IV) fluid tubing that will coincide with the Center for Disease Control (CDC) recommendations for the prevention of intravascular catheter-related infection. II. A. 1. Administration tubing will have a tubing label applied with the start date, discard date, and staff initials written on the label. A daily color-coded label will be used to indicate the next change day. (i.e. tubing is started on Sunday and a Wednesday label will be affixed). Record review of the facility's policy titled, Pre-cleaning reusable instruments used in patient care revised on 8/20 read in part . 1. Purpose: OakBend medical center will provide clean and sterile supplies for patient care to promote patient safety. Definition: pre-cleaning - gross soil (e.g., feces, spectrum and blood) shall be removed immediately at point of use. Cleaning is the physical removal of foreign material (e. g., dust, soil) and organic material (e.g., blood, secretions, excretion, microorganisms). Cleaning physically removes rather than kills microorganisms. It is accomplished with water, detergent and mechanical action. Record review of The Centers for Disease Control and Prevention's (CDC's) guidance document, Guidelines for Protecting the Safety and Health of Health Care Workers, NIOSH Publication No. 88-119 located at https://www.cdc.gov/niosh/docs/88-119/pdfs/88-119.pdf read in part . CDC recommends including (c)ontaminated laboratory wastes in a healthcare facility's hazardous waste disposal containers. According to the CDC guidance, (c)ontaminated laboratory wastes include medical specimen containers, slides and cover slips, disposable gloves, laboratory coats, and aprons, to be discarded as hazardous waste. Record review of chapter 29 Code of Federal Regulation located at https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030 read in part . The Bloodborne Pathogens Standard defines regulated waste to mean liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials . (29 CFR 1910.1030(d)(4)(b)). The OSHA requirement for containerization of regulated waste is limited to items which are contaminated with blood or other potentially infectious materials (OPIM). 29 CFR 1910.1030(d)(4)(iii) . Resident #5 Record review of Resident 5's face sheet revealed she was a [AGE] year old female who was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Record review of Resident # 5's MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating she was cognitively intact. She required limited assistance with dressing. She had no impairment to upper extremity, and one impairment to lower extremity one side. She was always continent of bowel and bladder. She infection of foot (eg., [MEDICAL CONDITION], purulent drainage. Record review of Resident # 5's Comprehensive Care Plan dated dated 08/13/20 revealed she was being care planned for Infection control with an intervention to perform practices to prevent the spread of infections and infection diseases. Record review of Resident # 5's Physician order [REDACTED]. Further review revealed an order dated 08/26/20 daily dankins soaked 1/4 inch packing to right foot diabetic ulcer, cover with guaze and kerlix daily and PRN soiling. Further review revealed an order dated 08/13/20 to administer [MEDICATION NAME] ([MEDICATION NAME]) 500 mg intravenous at 6pm daily. Record Review of Resident #5's physician progress notes [REDACTED]. Impression status [REDACTED]. Observation on 09/16/20 at 9:15 a.m. dressing change on Resident #5 by LVN-B. LVN-B entered Resident #5's room washed hands and placed on a clean set of gloves. LVN-B proceeded to get dressing change supplies out of a drawer that had been placed in a gray wash basin inside of a plastic bag. LVN-B placed materials on Resident #5's bedside table without sanitizing the bedside table. During this process, LVN-B had 3 normal saline syringes and dropped one on the floor. LVN-B picked up the syringe off floor and placed on a counter surface in the Resident #5's room. LVN-B proceeded to place a clean plastic incontinent pad underneath resident feet and began to remove soiled dressing with scissors that she did not clean or sanitize. LVN-B removed soilded dressings from both of resident feet and placed soiled material inside of a Resident #5's trash can lined with a regular plastic bag instead of a red biohazard bag. LVN-B then changed gloves and placed on a new set of clean gloves without washing or sanitizing hands. LVB-B began to dress the wounds to Resident #5's feet first starting with the left foot using one of the normal saline syringes to clean resident left great toe amputation following with santyl ointment. LVN-B coverd the left great toe amputation with 4x4, wrapping foot and great left toe amputation with a kerlix dressing and securing with paper tape. LVN-B then moved to Resident #5's right foot without changing gloves and sanitizing hands and began cleaning right foot wound. When done, LVN-B then sanitized resident bedside table and put the normal saline syringe that had fallen on floor in her side pocket. LVN-B washed hands and gathered soiled material and removed from Resident #5's taking to the soiled utility room. Interview on 09/16/20 at 9:40 a.m. with LVN-B said she changed Resident #5's dressings how the Wound Care Team showed her. LVN-B said the reason she did not sanitize or clean scissors before dressing change was because she did not touch resident skin and they were the resident own scissors. LVN-B said the reason why she did not sanitize the bedside table before changing Resident #5's dressings was because, resident supplies were already inside of the wash basin that was inside of a plastic bag. Further interview with LVN-B said a biohazard bag did not have to be used unless the dressing material was soiled with body fluids or drainage. LVN-B said hand washing/hand hygiene was necessary before and after administering care for a resident, if gloves were visible soiled or not intact. LVN-B said she received in-services on Infection Control all the time. LVN-B said she guess she should have sanitized her work space before starting the dressing change as well as sanitizing scissors, and hands in between care to prevent reintroducing bacteria in the wound. Interview on 09/16/20 at 10:40 a.m. with the DON said the NF had a Wound Care Team that the NF shared with the hospital. The DON said the NF staff done the normal daily dressing changes but a wound that was more extensive, the Wound Care Team would do. The DON said she did not know who who was ensuring that the staff were performing adequate dressing changings but the staff done annual competency test every year. Further interview with the DON said when doing a wound dressing change, the nurse need to sanitize work space before and after, wash or sanitize hands in between care, sanitize scissors before and after use, dispose of all soiled materials in a biohazard bag for infection control prevention. Record review of the NF Hand Hygiene Policy revised 10/18 revealed in part: .To establish indications and techniques for hand hygiene in the healthcare setting in order to reduce the risk of transmission of pathogens via hands of helathcare workers. All healthcare workers, both direct and indirect patient caregivers will either use the alcohol-based hand rub provided or soap and water to decontaminate hands while providng care to patients .Specific indications for hand hygiene: before patient care & after contact with patient's skin, before donning gloves and after removing gloves . Record review of NF Policy on Hazaerdous Materials and Waste Management Plan revised February 2016 revealed in part: .To establish and maintain a program that will safely control hazardous materials and waste .to provide a consistent approach for handling of all biohazardous waste .Hazardous waste will include non-liquid tissue and body parts from humans which may contain disease causing agents .Used absorbant materials .absorbant materials include bandages, guaxes, and sponges .

Based on observation, interview and record review, the facility failed to ensure a resident who needed respiratory care was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 residents (Resident #1) reviewed for respiratory care in that: -Resident #1's oxygen tubing was not dated. This failure could affect all residents using oxygen and place them at risk of infection, a decline in health, and hospitalization . Findings Include: Record review of Resident #1's clinical face sheet revealed a [AGE] year-old male who was admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's MAR indicated [REDACTED]. Record review of Resident #1's baseline care plan initiated on 9/9/20 revealed Resident #1 was at risk for infection; increased chance of contamination with disease producing germs related to hospitalization . The target solution was to achieve discharge; notify physician about abnormal vital sign findings; perform practices to prevent the spread of infections and infectious disease; teach the patient and family actions and behaviors which enhance the patient's health state and evaluate results of diagnostic studies and report results to MD as ordered. He was not care planned for oxygen use. Observation and interview on 9/15/20 at 7:56 am revealed Resident #1 sitting upright on his wheelchair. He was receiving oxygen infusion at 3.0 liters via nasal cannula. The cannula tubing was not dated. Resident #1 said he came to the facility because he fell in his kitchen and dislocated his shoulder. He said he thought he arrived to the facility on Friday, 9/11/20, but he was not real sure. Observation on 9/15/20 at 1:22 pm revealed Resident#1 laying in his bed. His oxygen tubing was draped and wrapped around the oxygen device located on the wall. The oxygen tubing was not in a bag while not in use. The oxygen tubing was not dated. The oxygen gauge was still set at 3.0 liters. Observation on 9/16/20 at 9:22 am revealed Resident#1 sitting outside his door in his wheelchair. His oxygen tubing was draped and wrapped around the oxygen device located on the wall. The oxygen tubing was not in a bag while not in use. The oxygen tubing was not dated. The oxygen tubing should have been in a bag while not in use and it should have been dated. The oxygen gauge was still set at 3.0 liters. There were personal grooming items on the resident's bed (shaving cream, razor, comb, and eyeglasses). His rolling table was dirty with brown fluid drips that appeared to look like coffee drips. In an interview on 9/16/20 at 9:25 am with Resident #1, he said he could not remember if he had oxygen this morning. In an interview on 9/16/20 at 9:35 am with RN, Assistant Vice President of Nursing, she confirmed Resident #1's oxygen tubing was not in a bag while not being used. She confirmed the oxygen setting was set on 3.0 liters. She confirmed there was no date on the oxygen tubing. She said it was important to date and bag oxygen tubing to prevent infection and so the staff knew when to change the tubing. She said the facility did not have a policy on dating or changing out oxygen tubing. In an interview on 9/16/20 at 11:40 am with LVN B, she said Resident #1 did not receive oxygen today because he was desaturated. She said he was not on oxygen. She said Resident #1 did not have oxygen yesterday either. She looked at her electronic records and said LVN C had worked yesterday so she did not know if Resident #1 received oxygen on said day. She said the only way Resident #1 could be on oxygen was if he was desaturated. She said Resident #1 had no orders for cardio [MEDICAL CONDITION]. She said nurses have discreet judgment to administer oxygen if saturation was low. She said nursing staff did not date oxygen tubing's. She said she did not know when oxygen tubing's should be changed. In an interview on 9/16/20 at 11:55 am with the Cardiopulmonary Manager, she said the respiratory staffs' responsibility was to assess the residents upon admission and to re-assess every 6 hours. She said the nurses called them upon entry of new admissions to have them assessed for use or non-use of oxygen. She said if a resident needed oxygen, respiratory would follow up with a pulmonologist and reach out to doctors for oxygen orders. She said the respiratory staff did not date oxygen tubing. She said they were changed only as PRN. She said respiratory staff would look for signs of dirty or yellow nasal prongs that would prompt them to change out the tubing. She said oxygen tubings were supposed to be changed on Wednesdays and Saturdays. She said oxygen tubing should be bagged while not in use to prevent infection. She said the facility did not have a policy for dating or changing out oxygen tubing because they just did not date oxygen tubing. Record review of the facility's policies revealed the facility did not have a policy for dating or changing out oxygen tubing.

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 kitchens reviewed for food storage and sanitary conditions in that: -There were no trash receptacles by handwashing sinks. -2 of 3 red sanitizing buckets had no water or sanitizing solution. -Food items were not dated, labeled and/or sealed properly. -Food items in the refrigerator were expired. -Staff did not change gloves when changing tasks. -Equipment (hand sanitizing dispensers and paper towel dispensers) were dirty. These failures could affect all residents who consumed meals from the kitchen and place them at risk for food borne illnes. Findings include: Observation on [DATE] at 6:44 am revealed there was no trash can by the hand washing sink located by the dishwashing station. There was a warming tray that was not was not covered or inverted. Observation on [DATE] beginning at 6:45 am of the kitchen cooler revealed the following: -,[DATE] oz. Sysco Imperial thickened apple juice 46 ounces had no open date; used date was [DATE]. Observation on [DATE] at 6:50 am of the food preparation areas revealed three sanitizing buckets; two of them were empty. They had no water. There should have been water with the appropriate amount of sanitizing solution to clean preparation areas. In an interview on [DATE] at 6:54 am with Cook #1, she said she had just emptied the red bucket because she had just changed the water. She said she got to work that day at 5:30 am. When this Surveyor asked her why she did not change it when it only took a few seconds to refill it, she said, It was my mistake, I should have done that but, I was moving so fast. Observation on [DATE] at 7:00 am, accompanied by Cook #2, of the facility's kitchen refrigerator in the cafe revealed the following: -,[DATE] lbs. bags of french fries not dated or labeled out of original containers with a manufacturer's expired date of [DATE]; Cook #2 confirmed the french fries had no date or label and they had an expiration date of [DATE]. -,[DATE] oz boxes of sliced cheese out of its original box with no label; they were dated [DATE] and used by date by [DATE] and; -3 hamburger buns with a use by date of [DATE] that were not sealed properly. Observation on [DATE] at 7:01 am, accompanied by Cook #2, of the facility's kitchen refrigerator revealed the following: -,[DATE]-lb. bag of Broccoli with no date or label that was out of its original box with an expire date of [DATE]. Observation on [DATE] at 7:01 am, accompanied by Cook #2, of the facility's kitchen freezer revealed the following: -,[DATE] lb. Broccoli cheese casserole not properly sealed; -,[DATE] lbs. chicken not dated or labeled outside of original box; -,[DATE] lbs. Beef patties not properly sealed; -2- 3 lbs. Garlic mashed potatoes not dated or labeled outside of original box; -,[DATE] oz. Cut potatoes no dated or labeled outside of original box; and -3 bags of waffles not dated or labeled outside of original box. Observation on [DATE] at 7:03 am, accompanied by Food Service Supervisor, of the facility's kitchen freezer revealed the rice bin container was not properly sealed. Observation [DATE] at 7:15 am revealed hand sanitizer dispensers in the café and by the handwashing sink in the dishwashing area. Both had layers of caked dirt on them on the frequently touched area where you push to dispense the sanitizer. In an interview on [DATE] at 7:45 am with Food Service Supervisor, she said the kitchen was supposed to have 3 sanitizing buckets; two in the preparation areas and one by the ice machine. She said all three should have had water with sanitizing solution in it. She confirmed the red bucket by the ice machine was empty. She said food service associates were supposed to check to ensure sanitizing buckets were logged and recorded daily. She said Cook #2 got there in the morning by 8:00 am after working the tray line. She said food items should have been dated, labeled and sealed properly. She pointed to signage that was posted in the kitchen which read in part . label, date and rotate, referring to food items. She said it was her responsibility to go behind her staff to check that it was being done properly. She said the protocol for expired food was that it should be disposed of immediately. She said it was everyone's responsibility to throw away expired food items when they saw it. She said the staff had a huddle last week (in-service). Observation on [DATE] at 11:15 am of follow-up visit to the facility's kitchen revealed hand sanitizer dispensers by the dishwashing station and café had a film of caked dirt on the push handle that was frequently touched. In an interview on [DATE] at 11:21 am with Food Service Associate #1, she said she had worked at the facility for [AGE] years. She said she worked at the café. She confirmed the hand sanitizer had a film of caked dirt when it was frequently touched and immediately washed and cleaned dispenser with soap and water. She said her Supervisor provided training last week in a huddle session. Observation on [DATE] at 11:31 am of Food Service Associate #2 revealed she was working the food serving line. She was gloved. She touched utensils, food warmer and food cart and pick up a burger bun to prepare a chop pork sandwich without changing gloves. After surveyor intervention she changed gloves without washing or sanitizing her hands. She washed her hands after surveyor intervention. In an interview on [DATE] at 11:32 am with Food Service Associate #2, she said she had worked at the facility for five years. She said she should have changed gloves, washed her hands and put on new gloves. She said, I should be washing and changing my gloves every time I change tasks. She said not changing gloves between tasks was cross-contamination. She said her supervisor trained her on cross-contamination last week in a huddled session. In an interview on [DATE] at 11:33 am with Food Service Supervisor, she said staff should change gloves every time they changed tasks. She said they should wash their hands before donning gloves. She said she in-serviced staff about 3 to 4 months ago. She said she addressed non-compliance daily as she saw her staff do improper things. Observation [DATE] at 11:15 am revealed hand sanitizer dispensers (in the café and by the handwashing sink in the dishwashing area). Both had layers of caked dirt on the frequently touched area where you pushed to dispense. In an interview on [DATE] at 11:25 am with Food Service Supervisor, she confirmed both hand sanitizing dispensers had layers of caked dirt on the frequently touched area where you pushed to dispense. She said she had just conducted a huddle last week. She said, huddle as in in-service. Record review of the facility's policy titled, Clinical Nutrition Management and Patient Food Services revised on ,[DATE] Section III. Dry Storage of Food read in part, . E. Dry bulk foods may be stored in plastic containers with tight covers or bins which are easily sanitized. The containers are clearly labeled. F. Labels are turned forward. Section IV. Refrigerated/frozen food storage, E. Food to be refrigerated is covered, dated and stored loosely to permit circulation of air. J. Food items are arranged so that older items will be used first. Label and date opened cases of frozen products such as meat patties or frozen vegetables so that they will be used first. K. All foods in the freezer are wrapped in moisture-proof wrapping or placed in suitable container, to prevent freezer burn. L. Leftovers are labeled, dated and refrigerated immediately . Record review of the facility's policy titled, Safety and Sanitation revised on ,[DATE] revealed the facility had a protocol for washing equipment before and after use, daily, weekly, monthly, quarterly and semi-annually. Further review revealed the cleaning and disinfecting of hand sanitizing dispensers and paper towel dispensers were not included in the list of tasks for before and after use, daily, weekly, monthly, quarterly and semi-annually tasks. Record review revealed the facility had no policing for the requirement to have trash receptacles by handwashing sinks. Record review revealed the facility had no policy for ensuring red sanitizing buckets have water and the appropriate amount of sanitizing solution at preparation areas to avoid cross-contamination. Record review of the facility's policy titled, Food Service Infection Control Procedures revised on ,[DATE] read in part . Section II. Procedure, A. Personnel, 1. e). Frequent, careful handwashing by personnel is of prime importance in disease control. Wash hands: 1. e) 2. between handling of dirty dishes or equipment and handling clean food or utensils. 1. e) 5: between handling of cooked and uncooked food. 1. e). 11: In-service classes are held in health education/infection control at least once a year and cover such topics as good handwashing, personal health/hygiene causes of food-born illnesses, proper cleaning of equipment, sources/transmission of infections. Section I. 1. a). All equipment and food contact surfaces used in preparation or service is cleaned and sanitized after each use. Section K. 1.c) Handwashing facilities are in close proximity to food preparation areas and provide hot/cold running water, soap and paper towels . Further review revealed the facility did not have a procedure or protocol did not address the requirement for trash receptacles by handwashing sinks.

Based on observation, interview and record review the facility failed to ensure all resident assessments completed within the previous 15 months in the resident's active record were maintained in the resident's active medical records for 2 of 9 residents reviewed MDS assessments. (CR #29 and Resident #133) in that -MDS assessments for CR #29 and Resident #133 were not accesible to staff and ready to review. These failures affected two residents and placed them at risk of not having their assessments available for review. Findings include: Resident #133: Record review of Resident #133's face sheet revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Further review revealed that the Admission MDS due on 3/12/19 was not available. CR #29: Record review of CR #29's face-sheet revealed an [AGE] year-old male, admitted to facility on 11/07/18. His [DIAGNOSES REDACTED]. He was discharged from the facility on 11/19/18 home with home health without an anticipated discharge. Record review of the MDS assessment section revealed no discharge assessment available. In an interview with the SNF Coordinator on 3/18/19 at 9:15 AM, she said they did not have access to the MDS assessments for any of the residents in the facility at the moment or discharged residents due to their MDS Coordinator being in the hospital and unable to work. The SNF Coordinator said they did not have any access to print or even view the MDS assessments by electronic medical records. She said the MDS Coordinator was the only staff with direct access to MDS assessments. Observation on 03/19/19 at 02:05 PM revealed staff had not provided any medical record information requested and still did not have access to MDS assessments in the EMR and closed record information. In an interview on 3/19/19 at 2:45 PM the SNF Coordinator said that the MDS Coordinator staff had been out since (MONTH) 2019, so the facility was behind doing the assessments too. She said she was aware that medical records and MDS assessments should be readily accessible to State Agency staff. She said the facility did not have a policy for accessing medical records.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles, for 1 of 1 medication room, in that: - 2 multi-dose of expired [MEDICATION NAME] Vials where stored in the medication room's refrigerator. - expired hand sanitizer stored in the medication room's drawer. These failures placed 9 residents at risk of using medications and supplies that do not have the intended therapeutic dosage. Findings Included: Observation in the medication room on [DATE] at 09:45 a.m. with RN I revealed 2 vials of [MEDICATION NAME] Purified Protein in the refrigerator with an open date of [DATE] and expiration date of [DATE]. Further observation at the time revealed 1 liter of hand sanitizer with expiration date of ,[DATE] stored in one of the drawers. In an interview with RN I on [DATE] at 9:50 am she said she did checked the refrigerator but missed the expired vials. RN I said that she was not aware of the expired hand sanitizer and she was not sure who left it in the drawer. Record review of Medication Management-Storage dated (MONTH) 2019 provided by facility read in part: . Open containers of bulk non-[MEDICATION NAME] medications ( such as pint bottle of alcohol, oral liquids, etc.) may be used until the manufacturer's expiration date unless other information is provided by the manufacturer .