Every finding on record at Pine Ridge Health Care LLP

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents with IV (intravenous) lines (Resident #75) and 1 of 2 staff performing fingerstick blood sugar checks (RN F) reviewed for infection control. *The facility did not initiate Enhanced Barrier Precautions (EBP) and ensure staff wore appropriate PPE when providing care on Resident #75 with a midline IV. *The facility did not ensure glucometers were disinfected with the appropriate EPA approved disinfectant by RN F. This failure could place residents at risk for cross contamination and the spread of infection. Findings included: 1. Record review of Physician Orders for May 2026 indicated Resident #75 was a [AGE] year-old male admitted on [DATE]. His diagnoses included chronic obstructive pyelonephritis (a condition where the kidneys become inflamed due to repeated urinary tract infections leading to scarring of the kidneys and symptoms like fever and pain in the back) and urinary tract infection (UTI) (an infection in the kidneys, ureters, bladder, or urethra). Resident #75 had an order on 05/14/26 for Ertapenem Sodium Injection Solution Reconstituted 1Gm intravenously every 24 hours related to UTI until 05/21/26. There was no order for Enhanced Barrier Precautions. Record review of the May 2026 MAR indicated Resident #75's Ertapenem Sodium Injection Solution Reconstituted 1Gm intravenously was initiated on 05/14/26. There was no indication of Enhanced Barrier Precautions. During an observation on 05/18/26 at 10:52 a.m., Resident #75 was in bed. Resident #75 had an IV PICC line (a long, thin tube inserted through a vein in the arm to allow access to the upper large central vein near the heart) to RUE with dressing dated 05/12/26. There was no EBP sign or set up outside of the resident's room. During an observation and interview on 05/19/26 at 8:20 a.m., there was no EBP sign or set up outside of Resident #75's room. CNA G observed entering the room to provide direct patient care to Resident #75 but no PPE was applied. CNA G said Resident #75 was not in any isolation. During an observation on 05/19/26 at 04:40 p.m., RN F provided IV antibiotic administration on Resident #75 who had a PICC line IV. There was no EBP sign or set up outside the resident's door. RN F did not put on PPE except gloves when administering the antibiotic through the IV. RN F said Resident #75 actually had a midline IV (inserted into peripheral veins of the upper arm with the tip located near the armpit) and not a PICC line. She said she would not have done anything different. During an interview on 05/20/26 at 08:50 a.m. LVN H said EBP signage and set up were to be put into place for residents with indwelling devices. She said a resident with a PICC line or midline IV should have EBP set up. She said Resident #75 should have EBP set up because he had a midline IV. During an interview on 05/20/26 at 10:30 a.m., the Administrator and DON said EBP signage and set up was to be put into place with residents who had a PICC line or midline IV. The DON said it must have been overlooked on Resident #75. They said any resident with an indwelling medical device should have EBP in place due to them being at higher risk for exposure to infections. Record review of an Enhanced Barrier Precautions policy revised 12/2024 indicated Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Definitions: Enhanced Barrier Precautions (EBP) Refer to an infection control intervention sign to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.Policy Explanation and Compliance Guidelines:.2. Initiation of Enhanced Barrier Precautions: .b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO.10. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. 2. Record review of the Physician Orders for May 2026 indicated Resident #10 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). Resident #10 had an order dated 04/03/26 to check blood sugar before meals and at bedtime. During an observation and interview on 05/19/26 at 04:54 p.m. RN F conducted finger stick blood sugar on Resident #10. No insulin was required. RN F then cleaned the glucometer with alcohol pads. She said she could use the alcohol wipes and clean for 2 minutes. She said the alcohol pads were a disinfectant. During an interview on 05/19/26 at 05:20 p.m., the DON said alcohol pads were not an approved disinfectant to use on the glucometers. She said they could be used to clean the glucometers but then the disinfectant wipes provided should be used to disinfect the glucometers, She said if the glucometers were not cleaned and disinfected appropriately blood borne pathogens could be transmitted to another resident. During an interview on 05/20/26 at 10:30 a.m., the Administrator said she expected nurses to clean/disinfect the equipment with the appropriate wipes. Record review of a Glucometer Disinfection policy revised 05/20/26 indicated Policy: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees. Definitions:.Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores on inanimate objects. Policy Explanation and Compliance Guidelines: 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use for multi-resident use. 2. The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C, and Hepatitis B virus. 3. Glucometers will be cleaned and disinfected after each use and according to regardless of whether they are intended for single resident or multiple resident use.

Based on observation, interview, and record review, the facility failed to maintain all mechanical and electrical equipment in safe operating condition for 1 of 1 facility kitchen. The vegetable freezer had accumulation of ice build-up with damaged and worn freezer door seals. This failure had the potential to affect residents by placing them at risk for food borne illness.Findings An observation of the vegetable freezer and interview on 05/18/2026 at 9:45 a.m., indicated the temperature was 20 degrees Fahrenheit. The vegetable freezer had excessive amount of ice built-up around the bottoms of door 1 and door 2 and both door seals were worn and torn. The vegetable freezer contained 1 bag of vegetable blend garden on the right top shelf which was soft to touch (defrosting - not frozen solid) and 1 bag of creamy tomato soup which was soft (defrosting - not frozen solid) and a package of buns (soft - not frozen solid). There was a 1/8 inch thick, 6-inches long sheet of ice at the bottom of both freezer doors and on the ceiling of the freezer were multiple frozen water drops. The vegetable freezer had a signage Make sure the doors close after opening. The vegetable freezer had water dripping down the front from around door 1 and 2 bottom seals. The DM said he reported to the maintenance department about a month ago that the vegetable freezer's door seals needed to be replaced but did not have any evidence that a requisition had been made for the repairs needed. During an observation of the vegetable freezer and interview on 05/18/2026 at 11:15 a.m., the temperature was 20 degrees Fahrenheit. The vegetable freezer had excessive amount of ice built-up around the bottoms of door 1 and door 2 and both door seals were worn and torn. The vegetable freezer contained 1 bag of vegetable blend garden on right top shelf which was soft to touch (defrosting - not frozen solid) and 1 bag of creamy tomato soup which was soft (defrosting - not frozen solid) and a package of buns (soft - not frozen solid). There was a 1/8 inch thick, 6-inches long sheet of ice at the bottom of both freezer doors and on the ceiling of the freezer were multiple frozen water drops. The vegetable freezer had a signage Make sure the doors close after opening. The vegetable freezer had water dripping down the front from around door 1 and 2 bottom seals. The DM said he thinks the freezer door may have been left ajar causing the ice build-up and defrosting - not frozen solid foods. During an observation of the vegetable freezer and interview on 05/18/2026 at 2:30 p.m., the temperature was 20 degrees Fahrenheit. The vegetable freezer had excessive amount of ice built-up around the bottoms of door 1 and door 2 and both door seals were worn and torn. There was a 1/8 inch thick, 6-inches long sheet of ice at the bottom of both freezer doors and on the ceiling of the freezer were multiple frozen water drops. The vegetable freezer had water dripping down the front from around door 1 and 2 bottom seals. The MS said he was not aware that the freezer door seals on the vegetable freezer were needing to be replaced. The MS said the water dripping from the door seal was the freezer cycling through a defrost cycle causing the dripping water. The MS said the ice buildup and defrosting food could be related to the damaged door seals and he would replace them. The MS said he replaced the other vegetable freezer door seal about a month ago for a similar concern. During an interview on 05/18/2026 at 4:30 p.m., the DM said that his boss came and toured the kitchen and assessed the vegetable freezer and instructed him to dispose of all the foods that were not frozen solid, so he disposed of approximately $2,000 worth of frozen foods. The DM said if the residents consumed the defrosted or freezer burnt foods it could cause them to become sick. During an interview on 05/18/2026 at 4:45 p.m., the Administrator said that when the DM informed her the vegetable freezer had ice accumulation, defrosting vegetables, and worn and torn door seals, she toured and assessed the vegetable freezer and instructed the DM to dispose of all the foods in the vegetable freezer that were not frozen solid to prevent residents from becoming sick from consuming foods that were defrosted improperly or freezer burnt. She said if the residents consumed the freezer burnt or improperly defrosted food it could cause a widespread facility sickness, so she had the DM dispose of all the food in the vegetable freezer that was not frozen solid. She said she would rather replace the food than have a facility wide sickness. During an observation of the vegetable freezer and interview on 05/19/2026 at 11:45 a.m., the temperature was -2 degrees. No bagged vegetables, soup or buns were observed in the vegetable freezer. The vegetable freezer had no ice buildup noted at door seals and no leaking water observed from the lower door seals. The DM said he removed, disposed of affected vegetable, cleaned the freezer and the MS had replaced the door seals and the temperature was below freezing and no new ice accumulation had been observed. The DM said he would be monitoring the vegetable freezer for temperature control and ice accumulation. Record reviews of the maintenance logs for April and May 2026 indicated no entry to service the vegetable freezer or replace the door seals. Review of the facility's policy Preventive maintenance program dated 05/18/2026 indicated: Policy: A preventive maintenance program shall be developed and implemented to ensure the provision of a safe functional sanitary and comfortable environment for residents, staff, and the public. Policy explanation and compliance guidance: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventive Management (PM) is required. Required PM may be determined from manufacturers' recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 3. If preventive maintenance is required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them. 4. The Maintenance Director shall develop a calendar to assist with keeping track of all tasks. 5. Maintenance requests (for building, equipment, pest, life safety, grounds of facility, other issues) must be communicated in the maintenance book (located at nurse station). Maintenance books have tabs labels to find the area that needs maintenance. 6. Documentation shall be completed for all tasks and kept in the Maintenance Director's office.

Based on observation, interviews, and record review, the facility failed to ensure the services provided met professional standards of quality, for 1 of 2 residents (Resident #76) reviewed for PICC line/midline. *The facility did not ensure LVN B used the appropriate size syringe for the Heparin flush to flush Resident #76's midline. This failure could place residents at risk of increased pressure in the PICC line/midline which can cause catheter damage. Findings included: Record review of a face sheet dated 05/20/26 indicated Resident #76 was a [AGE] year-old male admitted on [DATE]. His diagnoses included cellulitis (bacterial infection of the skin) of left lower leg, chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), hypertensive heart disease (heart problems that arise due to prolonged high blood pressure), and hyperlipidemia (abnormally high levels of fats (lipids) in the blood). Record review of Physician Orders for May 2026 indicated Resident #76 had an order dated 05/15/26 to flush midline (IV inserted into veins of the upper arm with the tip located near the armpit) with SASH (saline flush, antibiotic administration, saline flush, heparin flush (a small amount of a blood thinner used to keep an IV line open so it won't get blocked by blood clots) every shift and as needed; an order dated 05/14/26 for Zosyn Intravenous Solution 3-0.375 Gm/50 ml (Piperacillin Sodium-Tazobactam Sodium in Dextrose) intravenously three times a day; and an order dated 05/19/26 for Vancomycin in Normal Saline Intravenous Solution 1.5-0.9 Gm/250 ml (Vancomycin-Sodium Chloride) intravenously one time a day. Record review of the admission MDS dated [DATE] indicated Resident #76's was still in process.Record review of the Care Plan dated 05/20/26 indicated Resident #76 received IV therapy with goal of will have not have any complications related to IV therapy through the review.During an observation on 05/19/26 at 09:58 a.m., LVN B was removing Resident #76's completed IV antibiotic. LVN B flushed the midline with saline in a 10 ml syringe. LVN B then had a Heparin lock flush 10 U/5 ml in a 5 ml syringe. During an observation and interview on 05/19/26 at 05:00 p.m., RN F was removing a completed IV antibiotic. RN F was using a Heparin lock flush 10 U/5 ml in a 10 ml syringe. RN F said Heparin in a 10ml syringe was always to be used to flush a PICC line, midline, or central line IV. RN F said if a smaller syringe was used it could cause the tip of the catheter to rupture and could release small pieces of the catheter into the blood vessel. RN F said since the end of the catheter was near the heart the pieces could go into the heart and cause complications such as infection. During an interview on 05/19/26 at 05:20 p.m., the DON said she did not realize they had the Heparin flush in a 5 ml syringe for the midline IV lines. She said the tip could rupture and go into the heart. During an interview on 05/20/26 at 01:18 p.m., LVN B said she should have used a 10 ml syringe with the heparin. She said not using a 10 ml could cause the tip of the line to blow out. She said she received training on IVs last year. Record review of a Certificate of Successful Completion indicated LVN B received Management of Central Lines: Current Standards of Practice 4.0 contact hours on 06/27/25. Record review of the Central Venous Access Catheter Flushing, Locking, Removal policy revised 03/27/25 indicated Policy: It is the policy of this facility to ensure central venous access catheters are flushed, locked, and removed with current standards of practice.Compliance Guidelines:.8. Syringes no smaller than 10 ml should be used when assessing patency (the condition of being open) to avoid catheter damage. According to the Texas Board of Nursing Rules 22 TAC S217.11, Standards of Nursing Practice accessed on 05/20/26 at https://www.bon.texas.gov/:Two standards applicable in all practice scenarios include: S217.11(1)(B) Implement measures to promote a safe environment for clients andothers, and S217.11(1)(T) Accept only those nursing assignments that take into considerationclient safety and that are commensurate with the nurse's educational preparation,experience, knowledge, and physical and emotional ability.Additional standards in 22 TAC S217.11 that may be applicable when an LVN chooses to engage in an IV therapy related task include (but are not limited to): (1)(C) Know the rationale for and the effects of medications and treatments andcorrectly administer the same.

Based on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 7 residents (Resident #46) reviewed for respiratory therapy. The facility failed to keep the oxygen concentrator filter clean for Resident #46. This failure could place residents at risk of receiving incorrect or inadequate oxygen support which could result in a decline in health. Findings included: 1. Record review of Resident #46's face sheet dated 05/18/2026, indicated she was a [AGE] year-old female readmitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease (group of progressive lung disease that cause restricted airflow and breathing difficulties) and heart failure (condition in which the heart does not pump blood as well as it should). Record review of Resident #46's most recent significant change MDS assessment dated [DATE] indicated she had a BIMS score of 13 which indicated intact cognition. The assessment indicated medical diagnoses of chronic obstructive pulmonary disease and heart failure and received oxygen therapy while a resident of this facility and within the last 14 days of the look back period. Record review of Resident #46's care plan with a target date of 06/19/2026 indicated she had altered respiratory status related to chronic obstructive pulmonary disease and oxygen therapy with interventions including oxygen therapy, give oxygen as ordered by the physician. Record review of Resident #46's Physicians Order Summary dated 05/18/2026 indicated she was prescribed *oxygen at 2 liters per nasal canula (a thin flexible tube that delivers supplemental oxygen through your nose) for shortness of breath with a start date of 12/17/2025 and change oxygen tubing weekly and check filter every week wash/ replace as needed every Sunday night shift with a start date of 04/23/2026. Record review of Resident #46's Medication Administration Record dated 05/19/2026 indicated change oxygen tubing weekly and check filter weekly, wash/ replace as needed with a start date of 04/22/2025 and initiated as checked by RN E on 05/17/2026. During an observation and interview on 05/18/2026 at 10:45 a.m., Resident #46 was lying in bed with oxygen per nasal canula set at 2 liters/minute to an oxygen concentrator with a black filter on the side soiled with a thick grayish/ white powdery substance. Resident #46 said she wore her oxygen all the time. During an observation and interview on 05/19/2026 at 4:30 p.m., Resident #46 was lying in bed with oxygen per nasal canula set at 2 liters/minute to an oxygen concentrator with a black filter on the side soiled with a thick grayish/ white powdery substance. Resident #46 said she wore her oxygen all the time and the staff changed the oxygen tubing at night sometimes and probably cleaned the filters then. During an observation and interview on 05/19/2026 at 4:32 p.m., with LVN C she said she was providing care for Resident #46 today (05/19/2026). She checked Resident #46's oxygen concentrator filter and removed it. She said it should have been cleaned before now. LVN C said the night shift nurses were responsible for ensuring the oxygen concentrator filters were clean when they changed the oxygen concentrator tubing. She said the day shift nurses were the back up to double check and ensure the oxygen concentrator filters were cleaned. LVN C said she did not check the oxygen concentrator filters but would from now on. She said the oxygen concentrator filter was overlooked. LVN C said she was educated on hire to check the oxygen concentrator filters and ensure they were cleaned. She said the potential resident risk was infection. During an interview on 5/19/2026 at 4:44 p.m., the ADON said the nurses that worked Sunday nights were responsible for ensuring the oxygen concentrator filters were cleaned, and the DON and ADON did spot checks on Monday mornings to ensure the filters were clean. She said Resident #46's oxygen concentrator filter was overlooked. The ADON said all staff were educated to ensure the oxygen concentrator filters were cleaned. She said resident risk was potentially not getting the correct air flow for the oxygen concentrator to work properly. During an interview on 5/19/2026 at 4:48 p.m., the DON said the nurses that worked Sunday nights were responsible for ensuring the oxygen concentrator filters were cleaned, and the UM, ADON and DON spot check to ensure the oxygen concentrator filters were clean. She said she changed all the oxygen concentrators' filters out a month ago. The DON said Resident #46's oxygen concentrator filter was overlooked. She said the staff were educated to ensure all oxygen concentrator filters were cleaned as needed. The DON said the resident risk of soiled oxygen concentrator filters was the resident potentially not getting the correct oxygen concentration. The DON said her expectation was all oxygen concentrator filters cleaned weekly on Sunday nights with the oxygen tubing changes. During an interview on 5/19/2026 at 5:00 p.m., the Administrator said the night nurses were responsible for ensuring all concentrator filters were cleaned weekly and the UM, ADON, and DON did random checks to ensure the concentrator filters were cleaned. She said the nurses were educated to ensure the oxygen concentrator filters were cleaned. The Administrator said the resident risk was minimal; a soiled oxygen concentrator filter could potentially decrease air flow to the oxygen concentrator. She said her expectation was all oxygen concentrators were inspected, cleaned and filters replaced timely. During an interview on 5/20/2026 at 7:55 a.m., RN E said she worked Sunday night (05/17/2026) and was responsible for cleaning Resident #46's oxygen concentrator filter. She said the night was very busy and she overlooked it. RN E said the UM, ADON, and DON were the back up to ensure all oxygen concentrator filters were cleaned. She said she was educated to ensure the oxygen concentrator filters were cleaned Sunday night along with oxygen tubing changes. RN E said the potential resident risk of a soiled oxygen concentrator filter was infection or breathing difficulty. During an interview on 5/20/2026 at 10:09 a.m., the UM said the nurse that worked Sunday night was responsible for changing the oxygen tubing and cleaning oxygen concentrator filters. She said all the nurses were educated on cleaning oxygen concentrator filters. The UM said herself, the ADON, and DON did spot checks to ensure the oxygen concentrator filters were cleaned. She said Resident #46's oxygen concentrator filter was overlooked. The UM said the potential resident risk of a soiled oxygen concentrator filter was that the resident may not get the accurate flow of concentrated oxygen. Record Review of a facility policy dated 03/28/2025, titled, Oxygen Concentrator indicated, . 1. Staff responsible for the use and care of oxygen concentrators receive training on oxygen safety and the functionality of the device.a. Follow manufacturer recommendations for the frequency of cleaning filters and servicing the device.

Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications for 1 of 23 residents (Resident #57) reviewed for unnecessary medications. The facility did not monitor Resident #57's Eliquis (blood thinner) medication for side effects. This failure could place residents at risk for unintended, harmful events attributed to the use of medication without monitoring for side effects.Findings included: Record review of a face sheet dated 05/18/2026 indicated Resident #57 was an [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her diagnoses included chronic embolism (a piece of a clot breaks off and travels and lodges in a different vessel) and thrombosis of deep veins (formation of blood clots within a vessel) and peripheral vascular disease (slow and progressive circulation disorder causing narrowing, blockage or spasm in the blood vessels). Record review of a physician order for Resident #57 dated 05/18/2026 indicated she was prescribed Eliquis 5 mg two times a day for peripheral vascular disease with a start date of 08/05/25. Record review of Resident #57's quarterly MDS assessment dated [DATE] indicated she was severely impaired of cognition with diagnosis of chronic embolism and thrombosis of deep veins and peripheral vascular disease. The assessment indicated she was taking an anticoagulation medication during the lookback period. Record review of the electronic record of Resident #57 from 01/30/2026 to 05/19/2026 did not indicate monitoring for side effects of the anticoagulant medication Eliquis. Record review of the Medication Administration Record of Resident #57 dated 05/19/2026 indicated she received Eliquis 5 mg two times a day for peripheral vascular disease with a start date of 08/04/2025. Record review of Resident #57's care plan with a target date of 09/04/2026 indicated she had a high-risk drug use of anticoagulant medication with interventions including observation for bleeding, and side effects of Eliquis. During an observation on 05/18/2026 at 11:20 a.m., Resident #57 was sitting in a wheelchair confused and unable to answer questions. She had no observed bruising or bleeding. During an interview on 05/20/26 at 9:30 a.m., LVN B said she was providing care for Resident #57 today (05/20/2026). She said Resident #57 received Eliquis twice a day that was given by MA D and should be monitored for side effects. LVN B said Resident #57 was not being monitored in the computer system for side effects of her anticoagulant medication but would add it immediately. She said the nurse putting the order in the system was responsible for adding side effect monitoring and the DON, ADON and UM were the back up to ensure all anticoagulant medications were monitored for side effects in the computer system. She said Resident #57's anticoagulant was overlooked. LVN B said the nurses and MAs were educated to monitor anticoagulant medication for side effects. She said the resident risk of side effects not monitored in the computer system for anticoagulant medication was potential side effects including bleeding. During an interview on 05/20/26 at 9:45 a.m., the ADON said the nurse receiving the order for an anticoagulant medication was responsible for adding the monitoring into the computer system. During the care plan meeting the MDS nurse with the ADON, UM or DON depending on the resident status would check the charts and ensure monitoring was added into the computer system during the chart audit. She said a month or so ago the facility changed the monitoring for side effects out of the Task system and added monitoring into the Medication Administration Record for monitoring and Resident #57's side effect monitoring was removed from the task system but not added into the medication administration record part of the computer system, and it was overlooked. The ADON said nurses and MAs were educated to ensure all anticoagulant medications were monitored for side effects. She said the resident risk of the side effect monitoring not being completed was potential for bruising. During an interview on 05/20/26 at 10:08 a.m., MA D said she gave Resident #57 her Eliquis this morning and she did not have any bleeding side effects. She said the computer does not ask her about side effects of anticoagulants but if she sees a side effect she reports it to the nurse. MA D said the nurses were responsible for documenting side effects in the computer system. She said she was educated to monitor residents on anticoagulant medication for side effects. MA D said the resident risk of not monitoring a resident on anticoagulant medication was the potential for bleeding. During an interview on 05/20/26 at 10:14 a.m., the UM said the nurse admitting the resident was responsible for adding the monitoring to the computer system. She said she was responsible for auditing all new admission and readmission charts to ensure monitoring for side effects was added to the computer system. The UM said Resident #57's side effect monitoring was overlooked during changeover of monitoring out of the TASK area into the other system that added it to the Medication Administration Record for monitoring. She said the nurses and MAs were educated to monitor anticoagulants for side effects and document it. The UM said the resident risk of not monitoring of side effects for anti-coagulant medication was a potential for bleeding. During an interview on 05/20/26 at 10:18 a.m., MDS nurse A said the nurses were responsible for adding monitoring for side effects into the computer system and during the care plan meeting the UM, ADON and DON go over the chart and ensure monitoring was added for all anticoagulant medication. She said Resident #57 was overlooked. MDS Nurse A said the resident risk of not monitoring for side effects in the computer system was potential for increased bruising or bleeding. During an interview on 05/20/26 at 10:25 a.m., the DON said the nurse receiving the order for an anticoagulant medication was responsible for adding side effect monitoring into the computer system and UM checked all new admissions to ensure the side effect monitoring was added. She said during the care plan meeting the MDS nurse, ADON, UM and DON spot checked the orders to ensure side effect monitoring was added into the computer system. The DON said the monitoring was originally under the TASK section of the computer system but was recently removed from TASK and moved into the other section that came out in the Medication Administration Record section. She said Resident #57's monitoring was overlooked. The DON said the nurses were educated to ensure monitoring of side effects was added to the computer system for all anticoagulants. She said the resident risk of not adding side effect monitoring for anticoagulant medications into the computer system was potential for increased bleeding. The DON said her expectation was all anticoagulant medications monitored for side effects and documented in orders. She said Resident #57 should have been monitored for side effects but was care planned for monitoring of side effects. During an interview on 05/20/26 at 10:30 a.m., the Administrator said the nurses were responsible for adding monitoring for side effects into the computer system and the UM, ADON and DON were the back up to ensure the anticoagulant medication was monitored for side effects. She said the nurses were educated to add monitoring into the computer system for anticoagulant medication. The Administrator said Resident #57's anticoagulant medication monitoring for side effects was overlooked during the changeover of monitoring documented under TASK section to monitoring being documented into the Medication Administration Record section of the computer system. She said the resident risk was minimal, a resident could have a side effect. The Administrator said her expectation was all medication needing monitoring to be monitored. Review of a facility policy titled High Risk Medications - Anticoagulants revised 03/20/2025 indicated the following. This facility recognizes that medications, including anticoagulants, are associated with greater risk of adverse consequences than other medications. This policy addresses the facility's collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety.4. The resident's plan of care shall alert staff to monitor for adverse consequences/ Risk associated with anticoagulants include: a. Bleeding and hemorrhage .

Based on observation, interview, and record review, the facility failed to administer parenteral fluids consistent in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, for 1 of 2 (Resident #76) residents reviewed for IV (intravenous: administering fluids or medications directly into a vein) fluids. *The facility did not ensure LVN B used the appropriate size syringe for the Heparin flush to flush Resident #76's midline. This failure could place residents at risk of increased pressure in the PICC line/midline which can cause catheter damage. Findings included: Record review of a face sheet dated 05/20/26 indicated Resident #76 was a [AGE] year-old male admitted on [DATE]. His diagnoses included cellulitis (bacterial infection of the skin) of left lower leg, chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), hypertensive heart disease (heart problems that arise due to prolonged high blood pressure), and hyperlipidemia (abnormally high levels of fats (lipids) in the blood). Record review of Physician Orders for May 2026 indicated Resident #76 had an order dated 05/15/26 to flush midline (IV inserted into veins of the upper arm with the tip located near the armpit) with SASH (saline flush, antibiotic administration, saline flush, heparin flush (a small amount of a blood thinner used to keep an IV line open so it won't get blocked by blood clots) every shift and as needed; an order dated 05/14/26 for Zosyn Intravenous Solution 3-0.375 Gm/50 ml (Piperacillin Sodium-Tazobactam Sodium in Dextrose) intravenously three times a day; and an order dated 05/19/26 for Vancomycin in Normal Saline Intravenous Solution 1.5-0.9 Gm/250 ml (Vancomycin-Sodium Chloride) intravenously one time a day. Record review of the admission MDS dated [DATE] indicated Resident #76's was still in process. Record review of the Care Plan dated 05/20/26 indicated Resident #76 received IV therapy with goal of will have not have any complications related to IV therapy through the review. During an observation on 05/19/26 at 09:58 a.m., LVN B was removing Resident #76's completed IV antibiotic. LVN B flushed the midline with saline in a 10 ml syringe. LVN B then had a Heparin lock flush 10 U/5 ml in a 5 ml syringe. During an observation and interview on 05/19/26 at 05:00 p.m., RN F was removing a completed IV antibiotic. RN F was using a Heparin lock flush 10 U/5 ml in a 10 ml syringe. RN F said Heparin in a 10ml syringe was always to be used to flush a PICC line, midline, or central line IV. RN F said if a smaller syringe was used it could cause the tip of the catheter to rupture and could release small pieces of the catheter into the blood vessel. RN F said since the end of the catheter was near the heart the pieces could go into the heart and cause complications such as infection. During an interview on 05/19/26 at 05:20 p.m., the DON said she did not realize they had the Heparin flush in a 5 ml syringe for the midline IV lines. She said the tip could rupture and go into the heart. During an interview on 05/20/26 at 01:18 p.m., LVN B said she should have used a 10 ml syringe with the heparin. She said not using a 10 ml could cause the tip of the line to blow out. She said she received training on IVs last year. Record review of a Certificate of Successful Completion indicated LVN B received Management of Central Lines: Current Standards of Practice 4.0 contact hours on 06/27/25. Record review of the Central Venous Access Catheter Flushing, Locking, Removal policy revised 03/27/25 indicated Policy: It is the policy of this facility to ensure central venous access catheters are flushed, locked, and removed with current standards of practice.Compliance Guidelines:.8. Syringes no smaller than 10 ml should be used when assessing patency (the condition of being open) to avoid catheter damage.

Based on observations, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for 1 of 18 residents (Resident #41) reviewed for ADLsS. The facility failed to ensure Resident #41's fingernails were trimmed. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of physical, mental, and psycho-social well-being. Findings included: Record review of Resident #1's face sheet dated 03/25/25 indicated he was [AGE] years old, admitted on [DATE], and his diagnoses included diabetes (disease that results in too much sugar in the blood) and end stage kidney disease (kidney failure). Record review of Resident #41's quarterly MDS assessment dated [DATE] indicated a BIMS score of 13 which demonstrated he was cognitively intact. He required one person to assist with bathing and grooming. The section on behaviors indicated no refusal of care was noted. Record review of Resident #41's care plan dated 02/04/25 indicated he had an ADL self-care performance and required 1 staff for personal hygiene; assist as needed. During an interview and observation on 03/25/25 at 1:30 p.m., Resident #41 stated I asked someone to cut my finger nails a couple weeks ago and they never did cut my nails. He said he was unsure who he had asked. He raised his hands up and turned his hands over with palms up. Resident #41's fingernails had a thick dark brown substance on the underside of all the nails. Resident #41's fingernails extended passed the tips of his fingers approximately 1/4 inch to 3/4 inch. Four of his nails were jagged not smooth and all nails were unkempt. During an interview and observation on 03/25/25 at 2:00 p.m., the DON said the nurses were to perform nail care as needed for the residents with diabetes. She looked at Resident #41's fingernails and said they needed to be cleaned and cut to prevent infections. During an interview on 03/25/25 at 2:15 p.m., RN A said she was responsible for nail care for Resident #41, and she said she would clean, and trim nails as needed. She said nail care was not on a certain day of the week. She said she was trained to perform care on the diabetic resident's fingernails to prevent injury. During an interview on 03/26/25 at 8:26 a.m., the Administrator said she expected the staff to follow the facility policy about nail care and assist the residents as need. Record review of the nail care policy dated 12/2024 indicated The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health.3. Routine cleaning and inspection of nails will be provided ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing. 5. b. Only licensed nurses shall trim or file fingernails of residents with diabetes. Procedure: . b. Fill wash basin with warm water. Soak hands/ feet in wash basin for 10 - 20 minutes. c. Gently clean underneath nails with orange stick.

Based on observation, interview, and record review, the facility failed to ensure the resident maintained acceptable nutritional status, such as usual body weight or desirable body weight, unless the resident clinical condition demonstrated this was not possible for one of 18 residents (Resident #12) reviewed for nutritional status. The facility failed to identify Resident #12's significant weight loss over the previous 6 months. This failure could place residents at risk for not receiving care and services to maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of a face sheet dated 03/26/25 indicated Resident #12 was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), cognitive communication deficit (a communication difficulty arising from a cognitive impairment ultimately affecting an individual's ability to communicate),and dysphagia (difficulty swallowing foods and liquids, arising from the throat or esophagus). Record review of physician orders indicated Resident #12's dietary orders included: - 02/20/24: Regular diet with regular texture, thin/regular liquids consistency, and probiotic yogurt at breakfast. - 08/29/24: House shakes two times daily for malnutrition. Give with breakfast and dinner. Record review of Resident #12's monthly weight log indicated her weight on 10/11/24 was 155.2 pounds. Record review of Resident #12's monthly weight log indicated her weight on 11/08/24 was 143.0 pounds. Record review of Resident #12's monthly weight log indicated her weight on 10/11/24 was 155.2 pounds and 03/06/25 her weight was 138.0 pounds indicating a significant weight loss of 11.08% in six months. Record review of the most recent dietician note dated 11/27/24 and signed by the Dietician indicated Resident #12 had a weight loss of 11.51% in 180 days and she was on a regular diet and received house shakes twice daily. Dietician indicated she had talked with the resident's family member, and she felt weight loss was better with facility interventions. Family member assisted the Dietician in picking out food the resident would eat well from the menu. There was no documentation of physician notification of Resident #12's weight loss and no new interventions were put in place. Record review of an annual MDS dated [DATE] indicated Resident #12 had a BIMS score of 0 indicating she had severe cognitive impairment, she was sometimes understood and sometimes understood others, she was dependent for all ADLs, and her weight was 142 pounds. Record review of physician orders indicated Resident #12's dietary orders included: 02/05/25: Magic cup (a special diet frozen dessert cup for adding calories and protein for those experiencing involuntary weight loss). Record review of a malnutrition risk evaluation dated 02/07/25 and signed by LVN C indicated Resident #12 was at risk for malnutrition. Record review of an undated care plan indicated Resident #12 was at risk for malnutrition related to cognition, Alzheimer's disease, and dysphagia. During an observation on 03/26/25 at 7:55 a.m., Resident #12 was sitting up in bed being fed breakfast by CNA E. CNA E repeatedly called Resident #12's name and asked her to wake up and eat. Resident #12 kept her eyes closed but was drinking the house shake offered by the CNA. The CNA said the resident never woke up and ate breakfast well, but she usually drank her house shake and ate less than 25%. She said the resident usually ate 50% or less of her lunch. She said the resident was always fed by a CNA or family and CNAs reported to the charge nurse when a resident ate 50% or less of their meal. During an interview on 03/26/25 at 7:55 a.m., LVN F said the CNAs notified her when the resident eats less than 50% of a meal. She said measures were put in place for Resident #12's weight loss included getting her up to eat in the dining room for lunch and dinner, health shakes, and magic cups. She said the resident usually ate better for her spouse when he visted, bu her usual intake was less than 50% of meals. During an interview on 03/26/25 at 8:10 a.m., the DON said she had put a quality assurance (QA) plan in place in January 2025 because weights were not being monitored consistently. She said she had closed the QA plan 03/21/25 because she was recording and monitoring all weights and running a monthly report which triggered if a resident had a significant loss. She said Resident #12's weights never triggered for significant loss. She said the Dietician also monitored all weights and had not notified her of Resident #12's significant weight loss. She said she would increase Resident #12's weights to weekly instead of monthly and consult the Dietician. She said possible negative outcome for not being aware of the resident's significant weight loss could be the resident continuing weight loss with no additional interventions put in place. During an interview on 03/26/25 at 9:17 a.m., LVN C said she had completed a malnutrition risk assessment for Resident #12 on 02/04/25 while completing her annual MDS. She said the resident triggered for low risk of malnutrition, and she contacted the resident's physician on 02/07/25 and received an order for magic cup three times daily with meals. She said she did not notify the dietician of the risk assessment results and did not notice a significant weight loss. During an interview on 03/26/25 at 11:05 a.m., the Dietician said she noticed Resident #12's significant weight loss while reviewing weights last week. She said she did not notify the DON of Resident #12's significant weight loss because she was still in the process of writing her reports and recommendations to the DON. She said she did not know that a significant weight loss should be reported immediately to the DON because this was her first job in long term care. She said after the DON's call regarding the resident's significant weight loss (after surveyor intervention) she had called Resident #12's family member and obtained consent to begin administration of an appetite stimulant medication. During an interview on 03/26/25 at 11:52 a.m., the Administrator said her expectations was for all weights to be monitored and interventions put in place to slow or stop weight loss. She said of a resident's current interventions were not working she expected the DON to consult the Dietician. She said failure to consult the Dietician could result in additional weight loss. Record review of a facility policy titled Weight Monitoring last revised 03/26/25 indicated . Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Weight analysis: The newly recorded weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% weight change in weight in 1 month (30 days). b. 7.5% change in weight in 3 months (90 days). c. 10% change in weight in 6 months (180 days).

Based on observations, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs to each resident for 1 of 10 residents reviewed for medications. (Resident #111) The facility failed to ensure Resident #111 was not administered a saline IV flush before administration of an IV antibiotic, IV saline, and an IV heparin flush after medication administration (SASH-saline administer, saline heparin) without a physician's order. This failure could place residents at risk of consuming unprescribed medications, harm, and hospitalization . Findings included: Record review of Resident #111's face sheet indicated she was a [AGE] year-old-female admitted [DATE] with a diagnosis of pneumonia (an infection that inflames air sacs in the lungs which may fill with fluid). Record review of Resident #111's Physician orders dated 03/2025 indicated she was to receive antibiotic Azithromycin 500mg intravenously via midline IV catheter one time a day related to pneumonia starting on 03/22/2025 until 3/28/2025 and antibiotic Cefepime HCL 2gm intravenously two times a day related to pneumonia for 7 days. There were no orders for midline intravenous NS 0.9% 10 ml or Heparin 500 units/5 ml (100 units/ml) flushes. Record review of Resident #111's baseline care plan dated 03/21/25 indicated URI (upper respiratory infection)/pneumonia, Goal was to resolve the infection and interventions were to administer antibiotics as ordered. Record review of Resident #111's Admission MDS dated [DATE] was incomplete at this time due to required time frame of completion. Record review of Resident #111's Admission/Readmission Evaluation dated 03/21/25 indicated she received antibiotic therapy and intravenous infusion, and her cognition status was checked for oriented to person, place, self, situation, and time. Record review of Resident #111's March 2025 MAR indicated she received antibiotic Azithromycin 500mg intravenously one time a day at 8:00 a.m. until 03/28/25 with a start date of 03/22/25. There was no indication of the SASH IV flush. She received antibiotic Cefepime HCL 2gm intravenously two times a day for 7 days with a start date of 03/22/25 with no indication of the SASH IV flush. During an observation on 03/26/25 at 8:45 a.m., LVN B prepared and administered Cefepime HCL 2gm intravenously in NS 100 ml at 200 ml per hour to Resident #111. Prior to administration, LVN B flushed Resident #111's midline catheter with NS 0.9% 5 ml. During an observation on 03/26/25 at 9:30 a.m., after completion of Cefepime infusion, LVN B flushed Resident #111's midline catheter with NS 0.9% 5 ml followed by Heparin 50 units/5 ml (10 units/ml). During an interview and record review on 03/26/24 at 9:45 a.m., LVN B said Resident #111 did not have a physician order for flushing her midline and did not have the SASH midline catheter flushes documentation on the MAR. She said it should be. LVN B said the nurse who flushed the IV and administered the antibiotic was responsible for updating and obtaining physician orders to include the SASH into the computer system to show up on the MAR. LVN B said she was educated on following physician's orders, IV administration and documentation with the yearly check offs, sometime in the year 2024 she could not remember the exact date. She said the potential negative outcome of not having or following physician's order for SASH was a nurse may not flush the midline IV in the correct order and the midline IV lumen could clot and not be usable. During an interview on 03/26/25 at 2:04 p.m., the DON said the nurse administering medications intravenous was responsible for ensuring the physician order for SASH was in the computer system for all IV antibiotics before administering the medication and the DON was ultimately responsible for all medication administration. The DON said Resident #111's MAR should have included physician orders for SASH for her IV antibiotic and it was overlooked. The DON said any resident with an IV line was to have physician orders to administer SASH per facility protocol. She said the nursing staff were educated on the IV process and following physician orders during orientation and annually or as needed. The DON said the potential negative outcome of not following physician orders for SASH was a resident's IV line could potentially become occluded, and the line could go bad and cause pain to the resident by having to have a new IV line inserted. The DON said the expectation was for nurses to follow facility policy by obtaining physician orders for SASH and input IV SASH orders in the computer. Record Review of the facility's Physician's Orders policy dated January 2020 indicated, It is the policy of this facility that physician orders are maintained per state and federal regulations. 6. Medications, diets, therapy, or any treatment may not be administered to the patient without a written order from the attending physician. Record Review of the facility's Midline Catheter Flushing, Locking, Removal policy dated March 2025 indicated, Policy: It is the policy of this facility to ensure that midline catheters are flushed, locked, and removed consistent with current standards of practice . 1. The nurse will obtain and/or verify the physician's order for the type of IV solution or medication .3. Midline catheters will be flushed and aspirated for blood return prior to each infusion to assess catheter functionality and prevent complications .4. Midline catheters will be flushed after each infusion to clear infused medication from the lumen. 5. The catheter will be locked after the final flush to prevent catheter occlusion if used intermittently .7. The facility will use a flush such as a heparin flush solution or preservative-free normal saline solution to lock the catheter .

Based observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 18 (Resident #16) residents observed for infection control. The facility failed to ensure LVN B and LVN C followed the EBP (enhanced barrier precautions) for Resident #16. This failure could place the residents at risk of cross-contamination and the development of infection. Findings included: Record review of the face sheet dated 03/25/25 indicated Resident #16 was admitted on [DATE] and was an [AGE] year-old female with diagnoses of heart failure and peripheral vascular disease (blood flow to arms and legs is reduced). Record review of the admission MDS assessment dated [DATE] indicated Resident #16's BIMS score was 15, which demonstrated she was cognitively intact. She had 4 pressure ulcers and was receiving pressure ulcer/injury care. Record review of care plan dated 02/27/25 indicated Resident #16 had a pressure ulcer on 2 of her toes on her right foot. She had stage IV (full skin and tissue loss, exposing muscle, tendon cartilage, and high risk of infection) on the back of her right lower leg and the back of the left lower leg. During an observation on 03/25/25 at 10:00 a.m. to 10:20 a.m., there was an EBP sign on Resident #16's room door indicating Resident #16 was on EBP. LVN B performed treatment and LVN C assisted. LVN B and LVN C did not wear gowns while providing treatments to the back of Resident#16's legs. During an interview 03/25/25 at 10:21 a.m., LVN B and LVN C said they should have worn gowns and had been trained on EBP. They said we were nervous and just forgot. They said the gowns would have prevented spreading infections or soiling their own clothes. During an interview on 03/26/25 at 7:45 a.m., the DON said her expectation was for staff to wear gowns when in close contact with residents who were on EBP. She said when providing wound care to wounds, staff should use gowns and gloves for EBP to prevent spread of infections. During an interview on 03/26/25 at 8:26 a.m., the Administrator said she expected the staff to follow policy and regulations about EBP to decrease infections. Record review of the Enhanced Barrier Precautions dated 12/24 indicated Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities.

Based on observations, interviews, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 laundry room reviewed for essential equipment. The facility did not ensure 1 of 2 washing machines (right washing machine) and 2 of 3 dryers (middle and right dryer) were in safe operating condition. This failure could place the residents at risk of a fire and not receiving their clothes in a timely manner. Findings included: During an observation of the laundry room on 03/26/25 at 12:00 p.m., the washers were washing clothes. One of the 2 washers were missing the cover which left the wiring exposed by the handle of the door. Laundry Staff D said the cover was on top of the washer since it was fixed about a year ago. Two of the 3 dryers had the top cover propped open which exposed the pilot light and the gas burner. The dryers were drying clothes. Laundry Staff D stated, We opened to get heat in the laundry room because it was cold, and the middle dryer needed extra air to keep working. She said the cover should be closed to prevent possible fires. During observation and interview on 03/26/25 at 12:15 p.m., the Laundry Supervisor said she expected the dryer covers up top to be closed to prevent possible accidents. She said the laundry staff should make sure service panels stay closed. During observation and interview on 03/26/25 at 12:25 p.m., the Maintenance Supervisor said the equipment in the laundry should have the covers on and it had been a while since the washer cover plate off. He said he was responsible to put plate back if repair man left it off. He said if the laundry staff was too cold, they can adjust temperature. The Maintenance Supervisor pointed towards the wall in the laundry room at the thermostat and said it is right here. During an interview on 03/26/25 at 12:30 p.m., the Administrator said she was not sure why the service panels were open, and the washer cover was off. She wanted the services covers to be on and closed. She said to prevent accidents, and no accidents had happened yet. Record review of the policy titled Risks of Hazards dated 10/2024 indicated Policy: It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. 2. Maintain all essential mechanical, electrical and patient care equipment in safe operating condition.

Based on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 4 residents (Resident #1) reviewed for neglect. The facility failed to develop and implement a written abuse and neglect policy for reporting abuse or neglect causing serious bodily injury immediately, but no later than 2 hours to the State Survey Agency (THHSC) which resulted in a failure to report an allegation of neglect with serious bodily injury of Resident #1. This failure could place all residents at risk for potential abuse due to unreported allegations of abuse. The findings included: Record review of a face sheet dated 08/7/2024 indicated Resident #1 was [AGE] years old, initially admitted to the facility on [DATE]. Her diagnoses included atherosclerotic heart disease of native coronary artery with other forms of angina pectoris (occurs when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body (arteries) become thick and stiff - sometimes restricting blood flow to the organs and tissues causing chest pain), encounter for palliative care (care given to improve the quality of life of patients who have a serious or life-threatening disease), hypertensive heart disease with heart failure (heart disease caused by chronically high blood pressure), chronic systolic (congestive) heart failure (a condition in which the heart's main pumping chamber (left ventricle) is weak), protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), peripheral vertigo, dementia (loss of cognitive functioning) and anxiety disorder (persistent and excessive worry that interferes with daily activities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of an MDS assessment dated [DATE] indicated Resident #1 was sometimes able to make herself understood and sometimes understands others. She had a BIMS score of 00 (severely impaired cognitively). She required bed and chair alarms (electronic devices) to monitor residents' movement and alert staff when movement is detected. She was dependent for most ADLs. She was always incontinent of bladder and bowel. Record review of Resident #1's care plan dated 06/02/2024 indicated Resident #1 had a risk for falls related to cognition and weakness and has fallen multiple times in the last 3 months. Interventions included to anticipate needs, provide prompt assistance; assure lighting is adequate and areas are free of clutter; encourage to ask for assistance of staff; encourage socialization and activities attendance; ensure call light is in reach and answer promptly; therapy to evaluate and treat per order; educate safety precautions; IDT to review fall risk every 90 days and after each fall; keep call light and frequently used items in reach; notify MD/family of falls; bed alarms when in bed; chair alarms when in use out of bed; continue to monitor incidents and update fall risk factors per policy and procedure; do not leave spilled liquids on the floor; do not leave unattended on Gurney or shower chair; ensure wearing nonskid socks and or shoes; ensure staff member are aware of fall risk; fall mats beside bed; follow facility fall protocol; use physical device for fall prevention; and monitor for signs and symptoms of Vertigo. Record review of Resident #1's progress note authored by LVN E indicated on 08/05/2024 at 5:00 p.m., the resident was found on the floor by aide, resident with laceration on left side of head and laying on floor. Laceration actively bleeding, pressure and dressing applied. Notified EMS for pickup two local ER for evaluation and treatment Hospice and emergency contact notified. Record review of Resident #1's progress note authored by RN B indicated on 08/05/2024 at 5:29 p.m., CNA had just walked out of room, heard noise and walked back found resident on floor laying on left side with large pool of blood under her head. She checked her over found large deep laceration to left temple and held pressure no other lacerations found but resident yelling and swinging arms very combative, checked range of motion of arms and hips no pain with movement stayed with resident until EMS arrived. Record review of Resident #1's progress note authored by RN B indicated on 08/05/2024 at 8:35 p.m., she was notified Resident #1 had sustained a brain bleed during the fall and had been transferred to [name of city] hospital for treatment. During an interview on 08/07/2024 at 1:45 p.m., RN B said she was the charge nurse for Hall 3 (Resident #1's hall) on 08/05/2024 evening shift. She said around 5:00 p.m. she was summoned to Resident #1's room due to resident found on floor (unwitnessed fall) by CNAs. RN B said she completed an assessment and found Resident #1 to have a laceration to left forehead requiring evaluation and treatment. RN B said she applied pressure to laceration and provided pressure dressing and EMS activated. RN B said once Resident #1 was transferred to local ER for evaluation, she completed her documentation and notified the DON (on call management staff) of Resident #1's unwitnessed fall and transfer to local ER. RN B said she later received a call Resident #1 was being transferred to a higher level of care hospital for treatment of a subdural hematoma/hemorrhage. RN B said she texted the DON (on call management staff) with the updated information on 08/05/2024 at 8:30 p.m. when she was made aware. RN B said unwitnessed fall and fall with injury must be reported to management staff immediately to determine if incident is state reportable. RN B said once the incident is reported to management staff, they review the incident to determine if incident must be reported to the state. RN B said she was aware of state reportable time frames for incidents and allegations. RN B said fall with subdural hematoma/hemorrhage would be considered serious bodily injury and should be reported to the state agency. During an interview on 08/07/2024 at 2:15 p.m., LVN E said had received training regarding abuse and neglect and that all allegation of abuse and/or neglect was to be reported to DON, Social Worker/Abuse Coordinator, Administrator or manger on call if after hours. LVN E said they give report and management determines when and if the allegation must be reported to state. LVN E said that during training they emphasized about reporting incidents/allegations immediately because some allegations have a 2-hour window to report to state. During an interview on 08/07/2024 at 2:38 p.m., CNA A said on 08/05/2024 at 4:45 p.m. she found Resident #1 on the floor in her room after hearing a noise and faint ouch, and she immediately went to Resident #1's room found resident lying on her left side with glasses on and bleeding from head. CNA A said she hollered for help and CNA C responded and summoned help from CN. CNA A said both CN's (RN B and LVN E) responded immediately. CNA A said Resident #1 was alert and saying her head hurt, she was swinging her arms and not wanting CN to apply pressure to laceration on forehead. CNA A said they were trying to calm her down by talking to her and holding her hands while CN completed assessment. CNA A said she was trained by facility that all falls were to be reported to CN immediately and once CN completed assessment, they dictated what to do next (send to hospital, get back to bed, etc.). CNA A said that CN would report to upper management if needed. CNA A said that if allegation of abuse occurred would report to CN, DON, Abuse Coordinator or ADM. CNA A said during training they emphasized Social Worker or Abuse Coordinator needed to be notified immediately of any allegations of abuse or serious bodily injury. During an interview on 08/07/2024 at 3:45 p.m., CNA C said she was trained by facility that all falls were to be reported to CN immediately, do not move resident and once CN completed assessment, they dictated what to do next (send to hospital, get back to bed, etc.). CNA C said that CN would report to upper management if needed. CNA C said that if allegation of abuse occurred would report to CN, DON, Abuse Coordinator or ADM. CNA C said during training they emphasized Social Worker/Abuse Coordinator needed to be notified immediately of any allegations of abuse or serious bodily injury. During an interview on 08/07/2024 at 4:15 p.m., the DON said he learned about the incident with Resident #1 on 08/06/2024 when he awoke to read a text message from RN B regarding Resident #1's fall on 08/05/2024 at 6:00 p.m. and another text message on 08/05/2024 at 8:30 p.m. Resident #1 has sustained a subdural hematoma/hemorrhage from fall and was being transferred to a higher left of care hospital. The DON said he was already asleep, and the text messages did not wake him up. The DON said the facility has changed the protocol and the facility staff must call the management on call with any incidents no text messaging. The DON said he should have notified the abuse coordinator or administrator immediately once he received the text or information regarding the severity of the injury from the fall. The DON said due to the severity of the injury sustained with the fall the injury/allegation should have been reported to the state immediately or within 2 hours once facility notified of the severity of the injury. The DON said that the current facility policy does not identify the state reporting timeframes for each incident type and needs to be updated. During an interview on 08/07/2024 at 5:15 p.m., the Abuse Coordinator said she was not made aware of Resident #1's fall with serious bodily injury until the next morning 08/06/2024 when she was reading her incident report emails. The Abuse Coordinator said the CN (RN B) notified the DON (manager on call) via text message of the incident and later the severity of the injury and he did not forward the information until 08/06/2024. The Abuse Coordinator said she completed the report to the state as soon as she was made aware of the incident and the severity of the injury on 8/6/2024 at 10:24 a.m. The Abuse Coordinator said the DON should have immediately notified her once he was aware of the incident and the severity of the injury, and she would have reported it to the state immediately or within 2 hours as required. The Abuse Coordinator was aware of reportable times for incident types of abuse (with or without serious bodily injury) or neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury must be reported immediately but no later than two hours after the incident occurs or is suspected. The Abuse Coordinator said she uses THHSC long-term care regulatory provider letter PL 19-17 for guidance related to reporting abuse and neglect. The Abuse Coordinator said that the facility Abuse and Neglect policy did not identify and describe required reporting timeframes for incidents involving abuse (with or without serious bodily injury) or neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury to be reported immediately but no later than 2 hours after the incident occurs or suspected to THHSC. The Abuse Coordinator said she uses THHSC long-term care regulatory provider letter PL 19-17 for guidance related to reporting abuse and neglect. During an interview on 08/07/2024 at 6:15 p.m., the Administrator said the expectations was for the facility staff to report all suspicions or allegations of abuse or neglect with serious bodily injury immediately to her and/or the abuse coordinator. She said the timeframe for reporting allegations of neglect with serious bodily injury to the state agency was to report within 2 hours of the allegation. The administrator said she or the designee should have reported allegations of abuse to the state agency within 2 hours of the allegation. The Administrator said she uses THHSC long-term care regulatory provider letter PL 19-17 for guidance related to reporting abuse and neglect. The Administrator said that the facility Abuse and Neglect policy did not identify and ensure reporting timeframes of crimes occurring in federally funded long-term care facilities in accordance with Social Security Act as required by state and federal regulations. Record review of TULIP intake for Resident #1 indicated information date received on 08/06/2024 at 10:24 a.m., read the allegation of neglect (fall) occurred on 08/05/2024 at 5:00 p.m. and resident was sent to local hospital for treatment and evaluation, and it was later determined at 08/05/2024 at 8:30 p.m. (14 hours prior) the fall had caused serious bodily injury (brain bleed) and was sent to a [name of city] hospital for treatment. Caller information indicates the reporter of the allegation was the Abuse Coordinator. Record review of the facility's Abuse and Neglect and misappropriation policy dated 06/13/2023 indicated . B. Reporting 1. If an employee witnesses, is notified of or, suspects abuse, the following mandatory steps are taken a. ensure immediate safety of victim b. seek appropriate medical evaluation and treatment c. in cases of sexual and physical abuse protect all potential evidence: secure scene; sexual assault abuse victim must undergo medico-legal examination prior to bathing or changing clothes; identify witnesses; and secure evidence in locked areas. d. notify immediate supervisor, Administrator, Director of Nursing, and abuse coordinator e. notify physician f. report to law enforcement and adult Protective Services as mandated under Texas State law g. notify guardian, legal power of attorney or designated next of kin. h. complete incident report. The facility must ensure that all alleged violations involving mistreatment neglect or abuse including injuries of unknown source and misappropriation of resident property are reported immediately submitted to TDHS, [NAME] TX [PHONE NUMBER].

Based on observation, interview and record review, the facility failed to ensure all alleged violations involving neglect that resulted in serious bodily injury of resident was reported immediately to the administrator or abuse coordinator and to THHSC within the 2-hour period for 1 of 4 residents (Resident #1) reviewed for neglect. The facility failed to ensure allegations of resident neglect with serious bodily injury were immediately reported to the administrator or abuse coordinator and to the State Agency no later than 2 hours after the incident occurred or was suspected. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated 08/7/2024 indicated Resident #1 was [AGE] years old, initially admitted to the facility on [DATE]. Her diagnoses included atherosclerotic heart disease of native coronary artery with other forms of angina pectoris (occurs when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body (arteries) become thick and stiff - sometimes restricting blood flow to the organs and tissues causing chest pain), encounter for palliative care (care given to improve the quality of life of patients who have a serious or life-threatening disease), hypertensive heart disease with heart failure (heart disease caused by chronically high blood pressure), chronic systolic (congestive) heart failure (a condition in which the heart's main pumping chamber (left ventricle) is weak), protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), peripheral vertigo, dementia (loss of cognitive functioning) and anxiety disorder (persistent and excessive worry that interferes with daily activities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of a MDS assessment dated [DATE] indicated Resident #1 was sometimes able to make herself understood and sometimes understands others. She had a BIMS of 00 (severely impaired cognitively). She required bed and chair alarms (electronic devices) to monitor residents' movement and alert staff when movement is detected. She was dependent for most ADLs. She was always incontinent of bladder and bowel. Record review of Resident #1's care plan dated 06/02/2024 indicated Resident #1 had a risk for falls related to cognition and weakness and has fallen multiple times in the last 3 months. Interventions included to anticipate needs, provide prompt assistance; assure lighting is adequate and areas are free of clutter; encourage to ask for assistance of staff; encourage socialization and activities attendance; ensure call light is in reach and answer promptly; therapy to evaluate and treat per order; educate safety precautions; IDT to review fall risk every 90 days and after each fall; keep call light and frequently used items in reach; notify MD/family of falls; bed alarms when in bed; chair alarms when in use out of bed; continue to monitor incidents and update fall risk factors per policy and procedure; do not leave spilled liquids on the floor; do not leave unattended on Gurney or shower chair; ensure wearing nonskid socks and or shoes; ensure staff member are aware of fall risk; fall mats beside bed; follow facility fall protocol; use physical device for fall prevention; and monitor for signs and symptoms of Vertigo. Record review of Resident #1's progress note authored by LVN E indicated on 08/05/2024 at 5:00 p.m., the resident was found on the floor by aide, resident with laceration on left side of head and laying on floor. Laceration actively bleeding, pressure and dressing applied. Notified EMS for pickup two local ER for evaluation and treatment Hospice and emergency contact notified. Record review of Resident #1's progress note authored by RN B indicated on 08/05/2024 at 5:29 p.m., CNA had just walked out of room, heard noise and walked back found resident on floor laying on left side with large pool of blood under her head. She checked her over found large deep laceration to left temple and held pressure no other lacerations found but resident yelling and swinging arms very combative, checked range of motion of arms and hips no pain with movement stayed with resident until EMS arrived. Record review of Resident #1's progress note authored by RN B indicated on 08/05/2024 at 8:35 p.m., she was notified Resident #1 had sustained a brain bleed during the fall and had been transferred to Houston hospital for treatment. Record review of Resident #1's hospital records dated 08/05/2024 indicated transfer in from another hospital for a fall with forehead laceration and subdural hematoma. Cat Scan of head/brain without contrast on 8/06/2024 at 5:12 a.m. indicates a small focal left parietal subdural hemorrhage which is acute in appearance. Assessment and plan indicate resident to be a DNR, has a small subdural present over the left parietal convexity, finding requires no surgical intervention and per family, even if surgery necessary this would not be desired for her. Recommendations: maintain normotension; max Systolic blood pressure 150 mm/hg; avoid all antiplatelets and anticoagulants for 10 days; Keppra regimen for 6 days - may stop at that point if no seizure activity, if seizures occur continue x 90 days and referral to neurology for formal follow up; DVT prophylaxis; neuro-checks as ordered; and no further report CT scans warranted in the absence of precipitous neurological decline. No acute neurological issues. Record review of TULIP intake for Resident #1 indicated information date received on 08/06/2024 at 10:24 a.m., read the allegation of neglect (fall) occurred on 08/05/2024 at 5:00 p.m. and resident was sent to local hospital for treatment and evaluation, and it was later determined at 08/05/2024 at 8:30 p.m. (14 hours prior) the fall had caused serious bodily injury (brain bleed) and was sent to a [name of city] hospital for treatment. Caller information indicates the reporter of the allegation was the Abuse Coordinator. During an observation on 08/07/2024 at 10:15 a.m., Resident #1 was lying in bed, alert but pleasantly confused, unable to answer questions appropriately regarding the fall incident on 08/05/2024. Resident #1 had a laceration approx. 2.5 cm long to her left forehead with suture intact. Forehead laceration and surrounding tissue with bruising and discoloration noted. During an interview on 08/07/2024 at 1:45 p.m., RN B said she was the charge nurse for Hall 3 (Resident #1's hall) on 08/05/2024 evening shift. She said around 4:45 p.m. that evening CNA A had brought Resident #1 from the dining area to take her to the restroom as requested, she frequently request to go to bathroom. During transport CNA A was instructed to assist CNA C to get another resident up to chair for supper. RN B said Resident #1 was in the hallway and was informed CNA A would be right back to help her. CNA A went to room next door to assist CNA C to get another resident out of bed for supper. RN B said Resident #1 was in the hallway close to her room, CNA A came out of other residents' room (within 5 minutes) and explained she was getting supplies to help Resident #1 to the bathroom. RN B said she continued passing medications and within a few minutes she was summoned by CNA C Resident #1 was found on the floor. RN B said she and CNA A had seen Resident #1 sitting in her wheelchair outside of her room just minutes prior to the incident. RN B said when she entered Resident #1's room LVN E, CNA A and CNA C were in the room, Resident #1 was lying on her left side with bleeding noted from laceration on left forehead. RN B said she immediately applied pressure to the forehead laceration in attempts to stop the bleeding. RN B said Resident #1 was upset and swinging her arms to prevent pressure to be applied to forehead laceration, resident repeated said it hurts, it hurts. RN B said she was finally able to stop bleeding and applied pressure dressing to forehead laceration but Resident #1 would not allow staff to obtain vital signs during the incident. RN B said while she was assessing Resident #1 LVN E contacted EMS, MD, and RP. RN B said staff stayed with her and attempted to calm resident by holding her hand and talking to her, she calmed down once the EMS arrived (within 10-15 minutes of incident) and Resident #1 was applied pressure to her forehead laceration at time of transport. RN B said Resident #1 was moving all extremities and no other acute injuries observed during the initial assessment after the fall/incident. RN B said Resident #1 had a history of falls and she was a resident that was watched/monitored closely to prevent falls. RN B said Resident #1 was mobile in her wheelchair and she moves around the facility freely. She said she stays at the nurses' station or CNA's station and the lobby area so staff can keep an eye on her. Resident #1 has a bed and chair alarm to detect excessive movement and room was close to nurses' station to easily detect, observe or hear resident. RN B said Resident #1 required assistance from 1 staff member to transfer to wheelchair but was independent with mobility once in wheelchair. RN B said she notified the DON (management on call) regarding the fall incident shortly after it occurred on 08/05/2024 and then later updated the DON on 08/05/2024 at 8:30 p.m. when information was received resident was being transferred to another hospital due to fall had caused a subdural hematoma/hemorrhage. During an interview on 08/07/2024 at 2:15 p.m., LVN E said she was the charge nurse for the other halls on 08/05/2024 evening shift. LVN E said she was in the dining room passing trays for supper time and CNA C came into dining are requesting assistance because Resident #1 was found on the floor, and she was bleeding. LVN E said she immediately went to Resident #1's room, found Resident #1 lying on the floor on her left side at end of her bed. LVN E said she saw blood under Resident #1's head but was unable to determine amount of blood because the way she was laying. LVN E said began assessing Resident #1 and requested CNA staff to get towels and supplies to help with assessment and to control bleeding. LVN E said RN B entered room within one minute and applied pressure to laceration on the left forehead. LVN E said Resident #1's body alignment appeared straight, knees bent, moving both arms not wanting staff to touch her, and moved both legs. LVN E said she and RN B repositioned head to attempt to assess laceration to left forehead, found forehead laceration deep and would require closure. LVN E said she went to nurses' station and called EMS, RP, MD, hospice, local ER and provided report. LVN E said Resident #1 was at her baseline cognitively of alert and oriented x 1. LVN E said Resident #1 was not her assigned resident, but she was aware Resident #1 had a history of falls and staff monitor her closely to prevent falls. LVN E said interventions for fall prevention include lower bed, fall mats, bed/chair alarms, frequent monitoring, and keep certain residents in site at much as possible. During an interview on 08/07/2024 at 2:38 p.m., CNA A said on 08/05/2024 Resident #1 was up in wheelchair when she came on shift and had been assisted to the bathroom prior to transporting her by wheelchair to the dining room for supper, around 4:30 p.m. Resident #1 requested to go to the bathroom again, she transported Resident #1 back to the hallway by her room. CNA A said she was told by RN B the CN to go help get another resident up for dinner, and CNA A told Resident #1 she would return shortly to help her to the restroom. CNA A said she went to next room and assisted CNA C to get another resident up to chair for dinner as directed by CN. CNA A said after exiting the other resident's room (5-7 minutes later) came by dining area checked on her other assigned residents and started down hall 3 to get supplies, Resident #1 was observed inside her room and instructed her she was getting supplies to take her to the restroom. CNA A said she was at the nearby cart/ben getting supplies to assist Resident #1 when she heard a noise and faint ouch, and she immediately went to Resident #1's room found resident lying on her left side with glasses on and bleeding from head. CNA A said she hollered for help and CNA C responded and summoned help from CN. CNA A said both CN's (RN B and LVN E) responded immediately. CNA A said Resident #1 was alert and saying her head hurt, she was swinging her arms and not wanting CN to apply pressure to laceration on forehead. CNA A said they were trying to calm her down by talking to her and holding her hands while CN completed assessment. CNA A said she did not feel she was trying to go to the restroom because she was found in her room beside her bed not in the restroom area. CNA A said Resident #1 uses a bed and chair alarm but does not recall if the chair alarm sounded. CNA A said chair and bed alarms were checked (turned on and off) when residents were transferred into chair/bed. CNA A said Resident #1 had a history of falls, so she was monitored closely by staff, and measures put in place to prevent falls (lower bed, fall mats, bed and chair alarms and frequent monitoring). During an interview on 08/07/2024 at 3:45 p.m., CNA C said CNA A was coming down the hall with Resident #1 and CN instructed her to help her get the other resident up for supper. CNA A explained to Resident #1 she would help her to restroom as soon as she completed the assigned task. CNA C said CNA A helped her get the other resident up to the chair for supper and exited the room. CNA C said the task of getting resident up did not take more than 5 minutes and CNA A exited the room. CNA C said she completed assisting the resident and exited the room, she heard CNA A hollering for help. CNA C said she entered Resident #1's room and saw CNA A kneeled beside Resident #1, resident on floor with blood under head, went to dining room and got CN (LVN E) and she immediately went to Resident #1's room and instructed her to get towels and supplies and bring to room and find other CN (RN B). CNA C said she quickly collected requested supplies and took them to Resident #1's room and notified CN (RN B) of the incident. CNA C said CN (RN B) was holding pressure to laceration on head trying to stop the bleeding and CNAs were trying to calm the resident my talking to her and holding her hand. CNA C said CN (LVN E) left the room once assessment completed but CN (RN B) stayed with Resident until EMS arrived. CNA C said Resident did not say how she fell just kept saying her head hurt. CNA C said she left the room when CN gave her permission to leave. CNA C said EMS arrived with 10-15 minutes of the incident and transported her out to ER. CNA C said Resident #1 had a history of falls and she was monitored closed to prevent falls, she would sit at the nurses' station or CNA station, stays in lobby/common area so staff at nurses' station could keep her in eyesight. CNA C said Resident #1 was independent with wheelchair mobility but required one person assists for transfers and most care. CNA C said Resident #1 used a bed and chair alarm but does not recall if the chair alarm sounded. CNA C said chair and bed alarms were checked (turned on and off) when residents were transferred into chair/bed. During an interview on 08/07/2024 at 4:15 p.m., the DON said he learned about the incident with Resident #1 on 08/06/2024 when he awoke to read a text message from RN B regarding Resident #1 had a fall on 08/05/2024 at 6:00 p.m. and another text message on 08/05/2024 at 8:30 p.m. Resident #1 has sustained a subdural hematoma/hemorrhage from fall and was being transferred to a higher left of care hospital. DON said he was already asleep, and the text messages did not wake him up. DON said the facility has changed the protocol and the facility staff must call the management on call with any incidents no text messaging. DON said he should have notified the abuse coordinator or administrator immediately once he received the text or information regarding the severity of the injury from the fall. DON said due to the severity of the injury sustained with the fall the injury/allegation should have been reported to the state immediately or within 2 hours once facility notified of the severity of the injury. During an interview on 08/07/2024 at 5:15 p.m., the Abuse Coordinator said she was not made aware of Resident #1's fall with serious bodily injury until the next morning 08/06/2024 when she was reading her incident report emails. The Abuse Coordinator said the CN (RN B) notified the DON (manager on call) via text message of the incident and later the severity of the injury and he did not forward the information until 08/06/2024. The Abuse Coordinator said she completed the report to the state as soon as she was made aware of the incident and the severity of the injury on 8/6/2024 at 10:24 a.m. The Abuse Coordinator said the DON should have immediately notified her once he was aware of the incident and the severity of the injury, and she would have reported it to the state immediately or within 2 hours as required. The Abuse Coordinator was aware of reportable times for incident types of abuse (with or without serious bodily injury) or neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury must be reported immediately but no later than two hours after the incident occurs or is suspected. The Abuse Coordinator said she uses THHSC long-term care regulatory provider letter PL 19-17 for guidance related to reporting abuse and neglect. The Abuse Coordinator said that the facility Abuse and Neglect policy did not identify and describe required reporting timeframes for incidents involving abuse (with or without serious bodily injury) or neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury to be reported immediately but no later than 2 hours after the incident occurs or suspected to THHSC. The Abuse Coordinator said she uses THHSC long-term care regulatory provider letter PL 19-17 for guidance related to reporting abuse and neglect. During an interview on 08/07/2024 at 6:15 p.m., the Administrator said the expectations was for the facility staff to report all suspicions or allegations of abuse or neglect with serious bodily injury immediately to her and/or the abuse coordinator. She said the timeframe for reporting allegations of neglect with serious bodily injury to the state agency was to report within 2 hours of the allegation. The administrator said she or the designee should have reported allegations of abuse to the state agency within 2 hours of the allegation. Record review of the facility's Abuse and Neglect and misappropriation policy dated 06/13/2023 indicated . B. Reporting 1. If an employee witnesses, is notified of or, suspects abuse, the following mandatory steps are taken a. ensure immediate safety of victim b. seek appropriate medical evaluation and treatment c. in cases of sexual and physical abuse protect all potential evidence: secure scene; sexual assault abuse victim must undergo medico-legal examination prior to bathing or changing clothes; identify witnesses; and secure evidence in locked areas. d. notify immediate supervisor, Administrator, Director of Nursing, and abuse coordinator e. notify physician f. report to law enforcement and adult Protective Services as mandated under Texas State law g. notify guardian, legal power of attorney or designated next of kin. h. complete incident report. The facility must ensure that all alleged violations involving mistreatment neglect or abuse including injuries of unknown source and misappropriation of resident property are reported immediately submitted to TDHS, [NAME] TX [PHONE NUMBER].

Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. * The facility did not ensure baking sheets did not have brown and/or black baked on build up and stacked together. * The facility did not ensure the juice dispenser wand did not have cream colored build up inside. * The facility did not ensure a handwashing sink had a trash can for disposable paper towels. * The facility did not ensure skillets did not have brown baked on build up and stacked together. * Cook A did not ensure food was at a safe temperature prior to serving food to residents. * The facility did not ensure muffin pans did not have brown baked on build up and stacked together. These failures could place residents who eat from the kitchen at risk of foodborne illnesses. Findings included: During observations and interviews on 02/12/24 during initial tour of the kitchen at 08:46 a.m. indicated: * There were 25 large baking sheets and 1 half baking sheet with dark brown build up inside the corners, the outside edges, and were stacked together; * There was a juice dispenser wand with cream colored buildup in it. The DM said she had tried to take the wand apart and could not get the buildup out of the wand; * The handwashing sink on the dishwasher side of the wall had no trash can near the sink; and * There were 9 multiple sized skillets with dark brown/black buildup outside stacked together. The DM said she had tried different things to get the buildup off of the baking sheets and skillets. During observations and interviews of the lunch meal service on 02/13/24 indicated: * at 11:15 a.m. there was food already on the steam table-a pan of chicken and rice casserole, 2 pans of broccoli florets, 1 pan of chicken and noodles, 1 pan of beef patties, and 1 pan of fish. * at 11:16 a.m. Cook A was finishing up the pureed chicken and rice casserole, put it in a small steam pan, and placed the pan on the steam table. * at 11:18 a.m. Cook A pureed the broccoli florets. * at 11:22 a.m. Cook A put the broccoli florets in a small steam pan and placed the pan on the steam table. * from 11:25 a.m. to 11:35 a.m. Cook A checked the temperatures of the broccoli florets, the chicken and rice casserole, the pureed chicken and rice casserole, and the pureed broccoli florets. Cook A did not check the temperatures of the pan of chicken with spiral noodles, the pan of beef patties, or the pan of the fish. * at 11:45 a.m. Cook A fixed the first plate with fish tacos using the fish from the pan on the steam table. Surveyor asked Cook A what was the temperature of the fish and she responded it was 187 degrees. Surveyor asked when was the temperature checked on the fish and Cook _ responded when she pulled it out of the oven before being placed on the steam table. Surveyor asked why she did not check the temperature of the fish when she checked the other foods on the steam table and she said she always checked it only when she pulled it out of the oven. * at 11:46 a.m. Surveyor asked the DM about checking the temperature of the fish and she said they always check the fish when it was pulled out of the oven. Surveyor asked DM how would they know if the fish was at the required holding temperature when it sat on the steam table for an extended time before being served to a resident if they did not check it when they checked the other foods. Cook A checked the pan of fish temperature before serving the plate to a resident. Surveyor informed DM the chicken and noodles, beef patties, and fish were not checked for their temperatures before the start of serving the meal. * at 12:00 p.m. the DM acknowledged the muffin pans with dark brown build up on the outside surface and stacked together. She said she had tried to get the buildup off the muffin pans. According to the US Food and Drug Administration Food Code dated January 18, 2023: 2-103.11 Person in Charge. The PERSON IN CHARGE shall ensure that: (I) EMPLOYEES are properly maintaining the temperatures of TIME/TEMPERATURE CONTROL FOR SAFETY FOODS during hot and cold holding through daily oversight of the EMPLOYEES' routine monitoring of FOOD temperatures; 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5 C (41 F) or less. .4-6 Cleaning of Equipment and Utensils 4-601 Objective 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 6-301.20 Disposable Towels, Waste Receptacle. A HANDWASHING SINK or group of adjacent HANDWASHING SINKS that is provided with disposable towels shall be provided with a waste receptacle

Based on observations, interviews, and record review, the facility failed to ensure that residents who needed respiratory care was provided such care, consistent with professional standards of practice for 3 of 18 residents reviewed for respiratory care and services. (Residents #6, #265, and #314) The facility failed to obtain a physician order for oxygen administration for Resident #6, Resident #265, and Resident #314. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of a face sheet dated February 2024 indicated Resident #6, admitted [DATE], was an [AGE] year-old female with diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning) and hypertensive heart disease without heart failure (changes in the structure and function of the heart as a result of chronic blood pressure elevation with symptoms including shortness of breath). Record review of an admission MDS assessment dated [DATE] indicated Resident #6 had a BIMS score of 3 indicating severely impaired cognition and received oxygen therapy on admission and while a resident. Record review of an undated care plan indicated Resident #6 had an altered respiratory status/difficulty breathing with interventions included used oxygen continuously per physician orders. Record review of physician orders dated February 2024 did not indicate Resident #6 received oxygen therapy. During an observation on 02/11/24 at 10:45 a.m. Resident #6 was lying in bed wearing oxygen at 2.5 liters/minute per nasal canula (a device that delivers extra oxygen through a tube into the nose). During an interview on 02/13/24 at 2:45 p.m., LVN D said she was the nurse who admitted Resident #6. She said the resident arrived at the facility by ambulance and received oxygen at the time of admission. She said Resident #6 reported receiving oxygen during her hospital stay. She said she had left the supplemental oxygen order off the admission orders in error, and it should have been included. She said she was in-serviced on physician orders to include oxygen orders. She said not having an order for oxygen could result in the resident receiving too much or too little oxygen and the oncoming staff may be unaware the resident was receiving oxygen therapy. 2. Record review of physician orders dated February 2024 indicated Resident #265, admitted [DATE], was [AGE] years old with a diagnosis of Chronic Obstructive Pulmonary Disease (a group of diseases that cause airflow blockage and breathing-related problems) and dependence on supplemental oxygen (when there is not enough oxygen in your bloodstream to supply tissues and cells, then you need supplemental oxygen to keep your organs and tissues healthy). The orders did not indicate the resident was receiving supplemental oxygen. Record review of the admission MDS assessment dated [DATE] indicated Resident #265 was alert and oriented with a BIMS of 14 (indicates no cognitive impairment) and received oxygen therapy on admission and while a resident. Record review of an undated care plan indicated Resident #265 had an altered respiratory status/difficulty breathing related to COPD. One of the interventions was to administer oxygen continuously per physician orders. Record review of physician order dated 02/13/24 (after surveyor intervention) indicated Resident #265 was to receive oxygen at 3 liters per minute (LPM) per nasal cannula (NC) continuously. During an observation and interview on 02/12/24 at 11:22 a.m., Resident #265 was sitting up in her wheelchair in her room. She was receiving oxygen at 3 LPM per NC. She said she received her oxygen continuously and that nursing changed the humidifier bottle and tubing weekly. During an interview on 02/13/24 at 2:32 p.m., LVN D said she was the nurse who admitted Resident #265. She said the resident arrived at the facility by ambulance and was receiving oxygen at the time of admission. She said the resident reported receiving oxygen prior to her hospitalization and during her hospital stay. She said she had left the supplemental oxygen order off the admission orders in error, and it should have been included. She said not having an order for oxygen could result in the resident receiving too much or too little oxygen. 3. Record review of a face sheet dated February 2024 indicated Resident #314, admitted [DATE], was an [AGE] year-old female with diagnoses of dementia and hypertensive heart disease without heart failure. Record review of an Admission/ Readmission Evaluation (48 hour Care Plan) indicated Resident #314 received oxygen at 2 liters/ minute by nasal canula chronic. Record review of physician orders dated February 2024 did not indicate Resident #314 received oxygen therapy. During an observation and interview on 02/11/24 at 9:44 a.m. Resident #314 was lying in bed wearing oxygen at 3 liters/minute per nasal canula. Resident #314 said she had only been here 3 days, but her oxygen was monitored by staff. During an interview on 02/13/24 at 11:02 a.m., the DON said Residents #6, #265, and #314 had no physician order for supplemental oxygen. He said the orders were left off in error and there should be an order to indicate LPM ordered and to administer the oxygen by NC. He said he expected orders to be recorded timely and accurately. He said the possible negative outcome of not having a physician order for oxygen was the resident could receive too much or too little oxygen. He said the admission nurse was responsible for entering all admission orders into the system and the Unit Manager was responsible for double checking admission orders for accuracy. During an interview on 02/13/24 at 2:45 p.m., LVN E said she was the nurse who admitted Resident #314. She said the resident arrived at the facility by ambulance and was receiving oxygen at the time of admission. She said she left the supplemental oxygen order off the admission orders in error, and it should have been included. She said not having an order for oxygen could result in the oncoming staff not being unaware the resident received oxygen therapy. During an interview on 02/13/24 at 4:09 p.m. the administrator said his expectation was for all physician orders including oxygen therapy to be completed accurately and timely. He said the DON was ultimately responsible for physician order accuracy. During an interview on 02/14/24 at 8:15 a.m. the Unit Manager said the admission nurse was responsible for inputting all physician orders including oxygen orders into the computer system. She said she was responsible for double-checking the orders for accuracy. The Unit Manager said the oxygen orders were overlooked for Resident's #6, #265, and #314. She said all the nurses were in-serviced on the importance of inputting all physician orders into the computer. She said the risk of oxygen orders not in the system was staff may not be aware the resident was receiving oxygen therapy. Record review of an Oxygen Administration policy dated 02/13/23 indicated: . Oxygen is administered under orders of a physician. 41057

Based on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were evaluated for services for 2 of 3 residents reviewed for PASRR (Residents #04 and #50). * The facility did not have an accurate PASRR Level 1 Screening (P1) for Residents #04 and #50 upon admission therefore a PASRR Evaluation (PE) was not conducted. This failure could place residents who have a diagnosis of mental disorder, developmental disability or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: 1. Record review of a face sheet dated 02/14/24 indicated Resident #04 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included anxiety and mood disorder. Record review of a PASRR Level 1 (P1) dated 06/01/21 indicated Resident #04 was negative for MI. During an interview on 02/14/24 at 09:45 a.m. the SW said she would fill out the P1 if a resident came from home and she was responsible for reviewing P1s from the hospital. She said she did not realize Resident #04's P1 was negative. She said anxiety disorder and mood disorder were diagnoses that would trigger for a positive P1 and require a PE to be done by the LMHA to determine if they meet criteria for PASRR. 2. Record review of a face sheet dated 02/13/24 indicated Resident #50 was a [AGE] year-old male admitted on [DATE]. His diagnoses included psychotic disorder with delusions (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality) (delusions-belief or altered reality that is persistently held despite evidence or agreement to the contrary), anxiety disorder (persistent and excessive worry that interferes with daily activities), and depressive disorder (mental illness that negatively affects how you feel, the way you think and how you act). Record review of the admission MDS assessment dated [DATE] indicated Resident #50 had active diagnoses of anxiety disorder, depression, and psychotic disorder. Record review of a P1 dated 08/24/23 indicated Resident #50 had dementia primary diagnosis marked no and MI was marked no. The P1 was done by facility SW. Record review of the EMR indicated Resident #50 had no PE. During an interview on 02/14/24 at 09:45 a.m. the SW said the diagnoses of psychotic disorder, psychosis, and anxiety disorder would trigger for a positive P1 and require a PE to be done. She acknowledged that she had marked on Resident #50's P1 that dementia was not a primary diagnosis. She said she should have marked his P1 yes for MI. She said she reviewed P1s when a resident admitted from the hospital. During an interview on 02/14/24 at 11:45 a.m. the DON said he did not routinely review the P1s but if he did notice one was not accurate then he would let the SW know so she could get it corrected. He said he expected the P1s to be correct when a resident admitted . A Resident Assessment-Coordination with PASARR Program dated 12/06/17 and revised 02/14/24 indicated: Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. .6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority

Based on observations, interviews, and record reviews, the facility failed to ensure nurse aides were able to demonstrate competency in providing incontinence care necessary to care for 1 of 1 CNAs (CNA B) observed for incontinent care. * CNA B did not change gloves, sanitize/wash hands between glove changes, touched clean items with dirty gloves, and did not completely clean Resident #04 when providing incontinent care. This failure could place residents who required incontinent care at risk for an unsanitary environment, cross contamination, and infection. Findings included: During an observation and interview on 02/12/24 at 09:50 a.m. CNA B provided incontinent care to Resident #04. CNA B donned gloves, opened a bag for trash, and placed it on the foot of the bed. CNA B then grabbed the clean brief and opened it placing it on the bag for trash. CNA B opened the dirty brief, pushed the front down between resident legs, and tucked the sides under the resident. CNA B opened a package of disposable wipes and pulled out 2 wipes. CNA B wiped down the left groin, folded over the wipes, and with clean side of wipes she wiped down the left groin. CNA B pulled out 3 more wipes from the package and wiped from the front down the middle of the resident's peri area. CNA B she rolled the resident to her left side and pulled out more wipes from the package with the same gloves. CNA B took the wipes and wiped the rectal area. The wipes had feces on them. CNA B then without changing gloves pulled clean wipes out of the package and wiped the rectal area again. CNA B did not wipe the right buttock or right hip. CNA B removed the dirty brief under the resident and without changing gloves or performing hand hygiene grabbed the clean brief and placed it under the resident. CNA B then rolled the resident to her right side and pulled out the clean brief. CNA B did not clean the resident left hip or buttock and closed the brief. CNA B rolled the resident to her back, placed the dirty brief into the trash bag and doffed her gloves placing them in the bag, and tied the bag closed. CNA B without sanitizing/washing her hands pulled the resident gown down, covered her with the sheet and blanket, and adjusted the bed. CNA B then washed her hands and exited the room. CNA B said she would not have done anything different with the incontinent care provided to Resident #04. During an interview on 02/14/24 at 10:20 a.m. LVN C said the CNAs should change their gloves between clean and dirty procedures. She said they were to either sanitize or wash their hands between glove changes. She said they were to wash their hands when entering and exiting resident rooms. She said they should not touch clean items with dirty gloves. She said they should pull wipes from the package before they start incontinent care. She said the residents' buttocks and hips should be cleaned because the urine goes everywhere on them in the brief. She said touching clean items with dirty hands/gloves could spread infection. She said residents should be cleaned completely or they could have lingering odors. During an interview on 02/14/24 at 11:45 a.m. the DON said staff were to sanitize hands between glove changes unless there was feces then they should wash their hands. He said staff should change gloves at least between clean and dirty procedures. He said they should not touch clean items with gloves after touching dirty items. He said staff should not pull clean wipes from the package using the soiled gloves. He said when staff cleaned a resident, they should clean both hips and both buttocks. He said cross contamination could spread infection and not cleaning completely could result in skin issues. An Incontinent Care Policy and Procedure dated 06/15/23 indicated: II. Procedural guidelines: A. Wash hands. Wear gloves and follow standard precautions. D. Don gloves: prior to contacting potentially contaminated items. E. Remove soiled linens/brief: place in bag for disposal. F. Cleanse resident from front to back using a new wipe for each area. G. Cover resident to protect their dignity, remove soiled gloves and sanitize or wash hands. H. Apply new gloves and apply new brief and dry clothing A Hand Hygiene policy dated 06/14/23 indicated: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. .3. Alcohol-based hand rub with 60-95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. .6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. b. Gloves: .iv. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn

Based on interviews and record reviews, the facility failed to ensure the right to formulate an advance directive was provided for 2 of 2 residents reviewed for advanced directives. (Residents #50 and #164) The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Residents #50 and #164. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state. Findings included: 1. Record review of a face sheet dated [DATE] indicated Resident #50 was a [AGE] year-old male admitted on [DATE]. His diagnoses included hypertensive heart disease without heart failure (heart problems that occur because of high blood pressure that is present over a long time). He was designated as DNR. Record review of the current MDS assessment dated [DATE] indicated Resident #50 was alert to person, place, and time with a BIMS of 05 indicating he had severely impaired cognition. Record review of physician orders for February 2024 indicated Resident #50 had an order dated [DATE] for DNR. Record review of the EMR for Resident #50 had a scanned OOH-DNR dated [DATE] missing the printed name of his agent, a Medical Power of Attorney. 2. Record review of face sheet dated [DATE] indicated Resident #164 was a [AGE] year-old male admitted on [DATE]. His diagnoses included hypertensive heart disease with heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs). He was designated as DNR. Record review of physician orders for [DATE] indicated Resident #164 had an order with a start date of [DATE] for DNR. Record review of the EMR for Resident #164 had a scanned OOH-DNR dated [DATE] missing the date the physician signed the form. During an interview on [DATE] at 10:31 AM, Resident #164 said he received hospice services and did not want CPR if he passed away. During an interview on [DATE] at 01:25 p.m. the SW said she or the MR staff would obtain the DNRs. She said OOH-DNR forms should be complete with signatures, dates, and printed names or they would be invalid. She said Residents #50 and #164 would be deemed a Full Code indicating they would have CPR initiated. During an interview on [DATE] at 01:30 p.m. the MR staff said she and the SW would obtain the DNRs. She acknowledged Residents #50's OOH-DNR was missing the printed name of the agent initiating the form and #164's OOH-DNR was missing the date the physician signed it. She said Resident #164 brought the OOH-DNR form with him when he was admitted . She said it should have been reviewed upon admission for accuracy and completeness. During an interview on [DATE] at 03:05 PM, the DON said he was unaware of the inaccurate DNRs. He said the DNRs had to be complete, or they were invalid. He said these issues would make the residents a full code. He said as a result of an inaccurate DNR the residents would have lifesaving procedures performed when they did not want them. He said he would expect the DNRs to be completed when they were obtained and reviewed for completion if a resident were admitted and brought one with them. Record review of the Out-of-Hospital Do-Not-Resuscitate Order accessed on [DATE] at https://www.hhs.texas.gov/regulations/forms/advance-directives/out-hospital-do-not-resuscitate-ooh-dnr-order indicated on page 2: Instructions for Issuing An OOH-DNR Implementation: The OOH-DNR Order may be executed as follows: In addition, The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals

Based on interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 2 of 13 residents (Residents #23 and #57) reviewed for MDS assessment accuracy. * The facility did not accurately code Resident #23's MDS assessment for smoking. * The facility did not accurately code Resident #57's MDS assessment for weight loss. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1. Record review of a face sheet dated 02/13/24 indicated Resident #23 was a [AGE] year-old female admitted on [DATE]. Record review of the Baseline Care Plan dated 11/30/23 had no indication Resident #23 was a smoker. Record review of the Smoking Evaluation dated 12/04/23 indicated Resident #23 had not smoked cigarettes, pipe, cigar, tobacco, or used electronic vapor in the last 3 months. Record review of the admission MDS dated [DATE] indicated Resident #23 was marked yes for tobacco use. This section was signed by the MDS Coordinator on 12/07/23. During an interview on 02/14/24 at 09:55 a.m. the MDS Coordinator said she was working on 2 residents' MDS and she had mixed them up on the smoking section. She said Resident #23 should have been marked no for current tobacco use. 2. Record review of a face sheet dated 02/12/24 indicated Resident #57 was an [AGE] year-old female admitted on [DATE]. Record review of the EMR indicated Resident #57's weight on: * 11/30/23 was 146.2 lbs in a wheelchair; * 12/01/23 was 146.6 lbs in a wheelchair; and * 12/08/23 was 143.6 lbs in a wheelchair Record review of the MDS dated [DATE] indicated Resident #57 had a weight loss of 5% in one month or 10% in 6 months and was not on a physician-prescribed weight-loss regimen. This information was signed by the MDS Coordinator on 12/06/23. Resident #57 had not been in the facility for a month on 12/06/23. During an interview on 02/14/24 at 09:55 a.m. the MDS Coordinator said weight loss section was checked in error for Resident #57. During an interview on 02/14/24 at 11:45 a.m. the DON said he signed the MDS as completed. He said he did not check the accuracy of the MDS. He said he expected the staff who filled in the sections of the MDS to ensure the information was accurate. He said the inaccurate MDS could give an inaccurate picture of the residents' needs for care. An MDS 3.0 Completion policy dated 02/13/24 indicated: Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. 4. Care Plan Team Responsibility for Assessment Completion: a. Interdisciplinary Responsibility for Completion of MDS Sections: ii. Persons completing part of the assessment must attest to the accuracy of the section they completed by signature and indication of the relevant sections

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents (Resident #04) observed for incontinent care. * CNA B did not change gloves, sanitize/wash hands between glove changes, touched clean items with dirty gloves, and did not completely clean Resident #04 when providing incontinent care. This failure could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of a face sheet dated 02/14/24 indicated Resident #04 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included urinary incontinence and mixed irritable bowel syndrome. Record review of an MDS assessment dated [DATE] indicated Resident #04 had severely impaired cognition with a BIMS score of 03 (0-7 severely impaired), she was dependent for toileting hygiene, she was dependent for rolling to the left and right side, and she was always incontinent of bladder and bowel. Record review of a care plan dated 12/11/23 for last review indicated Resident #04 had an ADL Self Care Performance Deficit requiring extensive assistance of 1 staff member for toilet use, rolling left and right in bed evaluation at substantial/maximal assistance, toileting hygiene evaluation at dependent, and was incontinent of bladder and bowel. During an observation and interview on 02/12/24 at 09:50 a.m. CNA B provided incontinent care to Resident #04. CNA B donned gloves, opened a bag for trash, and placed it on the foot of the bed. CNA B then grabbed the clean brief and opened it placing it on the bag for trash. CNA B opened the dirty brief, pushed the front down between resident legs, and tucked the sides under the resident. CNA B opened a package of disposable wipes and pulled out 2 wipes. CNA B wiped down the left groin, folded over the wipes, and with clean side of wipes she wiped down the left groin. CNA B pulled out 3 more wipes from the package and wiped from the front down the middle of the resident's peri area. CNA B she rolled the resident to her left side and pulled out more wipes from the package with the same gloves. CNA B took the wipes and wiped the rectal area. The wipes had feces on them. CNA B then without changing gloves pulled clean wipes out of the package and wiped the rectal area again. CNA B did not wipe the right buttock or right hip. CNA B removed the dirty brief under the resident and without changing gloves or performing hand hygiene grabbed the clean brief and placed it under the resident. CNA B then rolled the resident to her right side and pulled out the clean brief. CNA B did not clean the resident left hip or buttock and closed the brief. CNA B rolled the resident to her back, placed the dirty brief into the trash bag and doffed her gloves placing them in the bag, and tied the bag closed. CNA B without sanitizing/washing her hands pulled the resident gown down, covered her with the sheet and blanket, and adjusted the bed. CNA B then washed her hands and exited the room. CNA B said she would not have done anything different with the incontinent care provided to Resident #04. During an interview on 02/14/24 at 10:20 a.m. LVN C said the CNAs should change their gloves between clean and dirty procedures. She said they were to either sanitize or wash their hands between glove changes. She said they were to wash their hands when entering and exiting resident rooms. She said they should not touch clean items with dirty gloves. She said they should pull wipes from the package before they start incontinent care. She said touching clean items with dirty hands/gloves could spread infection. During an interview on 02/14/24 at 11:45 a.m. the DON said staff were to sanitize hands between glove changes unless there was feces then they should wash their hands. He said staff should change gloves at least between clean and dirty procedures. He said they should not touch clean items with gloves after touching dirty items. He said staff should not pull clean wipes from the package using the soiled gloves. He said cross contamination could spread infection. An Incontinent Care Policy and Procedure dated 06/15/23 indicated: II. Procedural guidelines: A. Wash hands. Wear gloves and follow standard precautions. D. Don gloves: prior to contacting potentially contaminated items. E. Remove soiled linens/brief: place in bag for disposal. F. Cleanse resident from front to back using a new wipe for each area. G. Cover resident to protect their dignity, remove soiled gloves and sanitize or wash hands. H. Apply new gloves and apply new brief and dry clothing A Hand Hygiene policy dated 06/14/23 indicated: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. .3. Alcohol-based hand rub with 60-95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. .6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. b. Gloves: .iv. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn