Every finding on record at Pinecrest Retirement Community

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Residents #26, Resident #4, and Resident #8) and 4 of 7 staff (CNA H, LVN C and CNA F, and CNA G) reviewed for infection control.The facility failed to ensure CNA H followed infection control measures during dining service on 7/06/2026.The facility failed to ensure CNA H properly handled soiled linens and clothing for Resident # 26 on 7/06/2026.The facility failed to ensure CNA H properly cleaned Resident #26's soiled wheelchair cushion on 7/06/2026.The facility failed to ensure LVN C properly cleaned a glucometer (used to check blood sugars) or use a barrier for her supplies when she checked the blood sugar of Resident #4 on 7/7/2026.The facility failed to ensure CNA F and CNA G followed enhanced barrier precautions while providing incontinent care to Resident #8 on 7/7/2026.The facility failed to ensure CNA F changed gloves and performed hand hygiene while providing incontinent care to Resident #8 on 7/7/2026.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: 1. During an observation on 07/06/2026 at 12:09 PM CNA H was in the dining room and was passing resident trays and pushing residents' wheelchairs to the tables without performing hand hygiene between each task. During an observation on 7/06/2026 at 12:13 pm CNA H left the dining room to pass trays on the hall. She entered room [ROOM NUMBER] and set up his tray and then left the room without hand hygiene. She then passed a meal tray to room [ROOM NUMBER]. She left room [ROOM NUMBER] and returned to the dining room without hand hygiene and proceeded to help residents in the dining room. During an interview on 7/06/2026 at 12:20 pm CNA H said she was a new CNA and had been trained on infection control measures. She said hands should be washed or sanitized between tasks and after handling resident equipment and items. She said she was overwhelmed and just forgot to perform hand hygiene. She said that poor hand hygiene can cause infections to spread. During an interview on 7/06/2026 at 12:31 pm LVN A said that she was responsible for oversight in the dining room and the CNAs know to wash or sanitize their hands between resident trays and after handling resident items or equipment. She said she had not noticed that CNA H was not performing hand hygiene and would talk to her. She said poor hand hygiene could cause the spread of infections. 2. Record review of Resident #26's facility face sheet, dated 7/07/2026, indicated Resident #26 was a [AGE] year-old female, admitted [DATE], with diagnosis of hypertensive heart disease. Record review of Resident #26's quarterly MDS assessment, dated 6/04/2026, revealed a BIMS score of 09 that indicated Resident #26 had moderately impaired cognition. Record review of Resident #26's comprehensive care plan, revision date 9/23/2025, indicated Resident #26 was incontinent and at risk for urinary infections. During an observation on 7/06/2026 at 3:50 pm CNA H transferred Resident #26 from her wheelchair to her bed. Resident #26's clothing and wheelchair cushion were soiled with urine and feces. CNA H provided incontinent care but during care she threw the soiled linen and pants onto the floor. CNA H then stepped on the soiled items when going back and forth from the bathroom. She then wiped the wheelchair cushion with an incontinent wipe and did not use any form of disinfectant on the cushion. During an interview on 7/06/2026 at 4:09 pm CNA H said she had been trained on handling soiled clothing and linens and she did not know she could not put them on the floor but thinking about it she should have put them in a bag. She said she did not recognize that she had been stepping on the soiled items and that could cause the spread of infections. She said regarding the wheelchair cushion she was not trained on cleaning with any special product and just wiped it with a wipe. She said she could see that being unsanitary and could lead to infections. Record review of a competency training report dated 6/05/2026 indicated CNA H had been trained on meal tray setup, infection control measures for universal precautions, hand hygiene and cleaning resident care equipment.3. Record review of an admission Record for Resident #4 dated 7/7/2026 indicated she admitted to the facility on [DATE] and she was [AGE] years old with diagnoses of displaced supracondylar fracture with intracondylar extension of lower end of left femur (a break in the femur just above the knee that extends into the knee joint), type 2 diabetes (a condition where the body resists insulin or does not produce enough of it causing high blood sugar) and hypertension (high blood pressure). Record review of active physician orders for Resident #4 dated 7/7/2026 indicated an order for blood sugar checks before meals and at bedtime related to type 2 diabetes with a start date of 5/31/2026. Record review of an admission MDS Assessment for Resident #4 dated 6/6/2026 indicated she did not have any impairment in thinking with a BIMS score of 15. During the 7 day look back period she received insulin injections 4 of the 7 days. Record review of a care plan dated 6/9/2026 for Resident #4 indicated she had diabetes mellitus. Interventions included to check fasting blood sugar as ordered by the doctor. During an observation on 07/07/2026 at 11:12 am, LVN C removed a tray from the medication cart that consisted of alcohol prep pads, lancets, and a glucometer. The glucometer had a small spot of dried blood on the front. She entered Resident #4's and placed the tray of supplies on the resident's overbed table without placing a barrier between the tray and the table. She sanitized her hands and placed gloves on her hands; she cleaned Resident #4's 2nd digit on her left hand with an alcohol prep pad and then pricked it with a lancet and checked her blood sugar. LVN C removed her gloves and placed them in the trash and sanitized her hands. LVN C exited the room and placed the tray with the glucometer back inside the medication cart without cleaning it. During an interview on 7/7/2026 at 11:23 am, LVN C said she had been employed at the facility for a month. She said during the observation of her checking Resident #4's blood sugar she should have cleaned the tray and glucometer before she placed it back in the medication chart. She said the glucometer should be cleaned between resident use and should have some type of barrier between the tray and the overbed table. She said there could be a risk of cross contamination and infections. She said she had a skills check off with the use of a glucometer a few weeks ago. She removed the tray of supplies from the medication cart and cleaned the glucometer and tray with a sanidex wipe. She said she was not sure why she did not clean the equipment before or after she checked Resident #4's blood sugar and placed it back in the cart. Record review of a competency skill checklist dated 6/10/2026 for LVN C indicated she was competent on cleaning and storing equipment. 4. Record review of a face sheet dated 7/08/2026 for Resident #8 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia and hemiparesis following cerebral infarction (total or nearly complete paralysis on one side of the body), Type 2 Diabetes Mellitus (a problem in the way the body regulates and uses sugar as a fuel), and seizures (a sudden change in behavior, movement, or consciousness caused by abnormal electrical activity in the brain). Record review of a Quarterly MDS assessment dated [DATE] for Resident #8 indicated she had severe impairment in thinking with a BIMS score of 04. She was always incontinent of bladder and always incontinent of bowel. Record review of a care plan revised 01/14/2025 for Resident #8 indicated an ADL self-care performance deficit. She required the total assist of direct care staff members for ADL completion for toilet use. A care plan revised on 5/26/2025 indicated Resident #8 required enhanced barrier precautions related to Pseudomonas Aeruginosa MDRO (an opportunistic pathogen that causes healthcare-associated infections such as pneumonia, bloodstream infections, urinary tract infections, and surgical site infections, MDRO strains are resistant to multiple antibiotic classes). During an observation on 7/7/2026 at 11:30 AM, CNA F and CNA G entered the room of Resident #8 to provide incontinent care. A sign indicating that Resident #8 was on enhanced barrier precautions was visible at room entrance and personal protection equipment was located next to entrance door. CNA F and CNA G washed their hands in Resident #8's bathroom and put on clean gloves. Supplies were in a plastic bag on the over bed table. CNA G assisted with positioning and supporting Resident #8 during care. CNA F opened the brief and pulled it down between Resident #8's thighs. CNA F removed a wipe from wipe container and wiped the resident's right inner thigh and folded it over and wiped the left inner thigh and placed the wipe in the trash. CNA F removed a wipe from the wipe container and wiped up the middle of the vagina from front to back. CNA G rolled Resident #8 onto her right side. CNA F removed wipes from the wipe container and wiped Resident #8's perineal area from front (vagina) to back (buttocks) and placed wipe in the trash. CNA F rolled the soiled brief under Resident 8's buttocks and removed soiled brief as Resident 8 rolled more to right side with assist from CNA G. CNA F removed soiled brief and placed it in the trash. CNA F placed clean brief under Resident #8 and rolled Resident #8 to her left side. CNA F positioned clean brief under Resident #8. Resident #8 was rolled onto her back, and the brief was secured by CNA F and CNA G and the resident was repositioned in the bed. CNA F and CNA G removed their gloves and exited the room. CNA F and CNA G failed to wear a gown while providing incontinent care to Resident #8. CNA F failed to change gloves or sanitize hands during incontinent care. During an interview with CNA F on 7/7/2026 at 11:45 AM, she stated she has been employed with the facility for a few months. She stated that she and CNA G should have put on a gown prior to providing incontinent care due to resident being on enhanced barrier precautions. She stated she also should have changed gloves during incontinent care but was nervous due to being observed. She said that not changing gloves and performing hand hygiene could increase risk of contaminating the residents clean brief and cause risk of urinary tract infections. She stated that not wearing PPE during care could put herself, other staff and other residents at risk of infection. During an interview with CNA G on 7/7/2026 at 11:55 AM, she stated she has been employed with the facility for a few months. She stated that she and CNA F should have put on a gown prior to providing incontinent care due to resident being on enhanced barrier precautions. She stated the other CNA should have changed her gloves and used hand sanitizer after cleaning resident and before placing clean brief on resident. She said not changing gloves and performing hand hygiene could increase risk of contaminating the resident's clean brief. She stated that not wearing a gown during care could put herself, other staff and other residents at risk of infection. Record review of a CNA Proficiency Skills Check dated 04/2026 for CNA F indicated she was satisfactory in perineal care for a female along with infection control on hand washing and PPE use. Record review of a CNA Proficiency Skills Check dated 04/2026 for CNA G indicated she was satisfactory in perineal care for a female along with infection control on hand washing and PPE use. During an interview on 7/8/2026 at 11:06 am, the ADON said she was the IP for the facility. She said communication to staff for EBP included special instructions that were verbal and the information was also in the residents' charts. She said staff were instructed to look at the residents' doors for signage that indicated what type of precautions were needed and to stay in contact with staff, so they were aware. She said there was also a physician order to mark off on the TAR, and it was visible for them to see. She said when staff provided care to a resident on EBP they should wear gowns and gloves and the signage on the doors also instructed the staff on the proper techniques to use. She said she was responsible for training staff on infection control practices. She said hand hygiene should be done between passing meals trays from resident to resident. She said staff were taught to bag linens and take the linens to the soiled linen room and never placed them on the floor and they should not be stepped on. She said staff should disinfect equipment before entering the room and the med carts had trays that included all the supplies needed to check a blood sugar for a resident. She said staff should perform proper hand hygiene before and after checking a blood sugar and wipe down the equipment before placing back in the medication cart. She said there was a risk for cross contamination and spreading of germs if staff did not follow the appropriate infection control practices. She said the staff had been in-serviced on proper procedures for infection control. During an interview on 7/8/2026 at 11:30 am, the DON said when staff provided care to a resident on EBP they should wash their hands before and after care. She said residents who were on EBP had carts of supplies that included gowns and gloves and if direct care was provided to a resident on EBP, then staff had to wear gowns and gloves. She said when gloves were removed staff should wash or sanitize their hands. She said there was a risk of transmission of infections and increased risk to the elders if staff did not follow the appropriate infection control practices. She said when staff changed tasks from dirty to clean, gloves should be removed and hand hygiene performed and staff should never touch clean items with dirty gloves. She said blood sugar testing equipment should be cleaned before and wait for the appropriate time to dry. She said after the equipment was used the staff should clean the equipment again before being placed back in the medication carts. She said staff could use wax paper as a barrier to place items on or if they used the trays that were in the medication carts they could wipe down and clean the tray before placing it back in the carts. She said staff should sanitize hands between passing meal trays. She said soiled linens should be placed in a bag and not on the floor and if equipment like beds needed to be cleaned, they should use a sanitizer to clean the equipment and notify housekeeping to clean after. She said if a wheelchair was dirty the staff should do the same thing and using an incontinent care wipe would not be sufficient to clean a wheelchair cushion and they should use a sanidex wipe. During an interview on 7/8/2026 at 11:45 am, the Administrator said the IP for the facility was the ADON who was responsible for training staff on infection control. She said the staff were trained all the time on infection control and the DON/ADON had been conducting audits for months. She said staff were trained in how to handle soiled linens, cleaning resident use items, on EBP, cleaning equipment like glucometers, and hand hygiene. She said there was a risk of spreading infections to the residents in the facility. She said she expected the staff to not have any issues with infection control practices with continued education, competency checks, and continued observations. Record review of a facility policy titled Blood Glucose (Glucometer) Testing, Quality Control, and Cleaning revised June 2026 indicated, .The facility maintains an accurate, reliable, and standardized blood glucose monitoring program. Cleaning and Disinfection: 1. Community glucometers are cleaned and disinfected after every resident use using the manufacturer-approved disinfectant or sanitation solution. Record review of a facility policy titled Room Tray Delivery, dated 1/2026 indicated, .Meals will be delivered to and retrieved from all residents in a timely, organized, safe and sanitary manner. Alcohol based hand sanitizer is used immediately after delivery of a tray and before delivering the next resident tray . Record review of a facility policy titled cleaning and disinfection of Resident-Care Items and Equipment, dated September 2022, indicated, .durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection. 5 Reusable items are cleaned and disinfected or sterilized between residents (for example: stethoscopes, durable medical equipment). Record review of a facility policy titled Laundry and Bedding, Soiled, dated September 2022, indicated, .Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. I. All used laundry is handled as potentially contaminated using standard precautions (e.g., gloves and gowns when sorting). a. Contaminated laundry is bagged or contained at the point of collection (i.e., location where it was used). Record review of a facility policy titled Handwashing/ Hand Hygiene revised August 2019 indicated, .Use of an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations.h. before moving from a contaminated body site to a clean body site during resident care . j. after contact with blood or bodily fluids.m. after removing gloves. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. The policy also indicated, Perform hand hygiene before applying non-sterile gloves and after removing gloves. Record review of a facility policy titled Enhanced Barrier Precautions revised June 2026 indicated, Enhanced barrier precautions apply when a resident is infected or colonized with a CDC-targeted MDRO, but does not have a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained . 8. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include: .d. changing briefs or assisting with toileting .

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 4 (Residents #42) residents reviewed for thickened liquid diets.The facility failed to ensure Resident #42 was not served thin liquids on 7/06/2026.This failure could place residents who received thickened liquid diets at risk of difficulty swallowing, possibly resulting in choking. Findings Included:Record review of Resident #42's facility face sheet, dated 07/06/2026, indicated Resident #42 was a [AGE] year-old male, admitted [DATE], with diagnosis of Dysphasia (difficulty with swallowing).Record review of Resident #42's admission MDS assessment, dated 06/08/2026, revealed a BIMS score of 14 that indicated Resident #42 had intact cognition. He required assistance with his ADLs.Record review of Resident #42's comprehensive care plan, dated 6/16/2026, indicated Resident #42 required a therapeutic diet related to dysphagia.Record review of a physician order dated 07/06/2026 revealed Resident #42 required a regular diet, soft mechanical texture, honey thick consistency.Record Review of Speech Language Therapist note for Resident #42 dated 07/06/2026 indicated A diet assessment was completed to evaluate the patient's tolerance of prescribed diet textures and liquid viscosity, as well as swallowing efficiency and safety during oral intake. The patient consumed a mechanical soft diet consisting of scrambled eggs, sausage with gravy, oatmeal, and thin liquids via cup without overt signs or symptoms of aspiration. The SLP provided verbal cues to encourage consistent use of cyclic ingestion throughout the meal to enhance swallowing safety. A trial of regular-textured bacon was also completed, and the patient tolerated it without overt s/s of aspiration . The patient should continue to consume all meals in the dining room with staff assistance to maximize safety and promote adherence to swallowing precautions.During an observation on 07/06/2026 12:20 PM LVN D prepared tea for resident #42 with premixed thickener during lunch service. Tomato soup ladled into a bowl and LVN D reviewed the meal with orders listed on Resident #42's tray card. The liquid soup was not thickened. Resident #42 was feeding himself and the soup dripped off the spoon in small droplets. The soup was not thickened to honey texture before serving.During an interview 07/07/2026 10:22 AM the Dietary Manager said that the tray card indicates the diet ordered per physician or dietician, including instructions for thickened liquids. The Dietary Manager said the nursing staff adds liquid thickener to the drinks or soups before serving the residents. He said residents that get regular liquids instead of thickened liquids could choke or aspirate.During an interview on 07/07/2026 at 11:10 AM SLP E said that the nursing staff is responsible for adding thickener to thin liquids for Resident #42, which required honey thickened liquids due to swallowing precautions. She said that soups, drinks and milk on cereals should be thickened before serving. SLP E said she would ensure an in-service was provided to all staff responsible for providing hydration and meals to residents with diets that included thickened liquids included what drinks or soups required thickening. She said residents that are served regular liquids instead of thickened liquids could aspirate.During an interview on 07/07/2026 at 11:20 AM, LVN D said she should have added thickener to the soup served to Resident #42 yesterday at lunch. She said that she added thickener to Resident #42's tea but did not consider the need for thickener in his soup. She said she would consult with the SLP before serving Resident #42 his lunch tray. She said the resident could aspirate if served thin liquids.During an interview on 07/07/2026 at 2:44 PM, ADON said she was responsible for ensuring the nursing staff was trained and carried out appropriate dietary interventions. She said she would meet with the SLP and develop an in-service for nursing staff regarding adding thickening agents in the residents' liquids. The ADON said the risk to Resident #42 was aspiration and pneumonia.During an interview on 07/07/2026 2:47 PM, the DON said she would ensure an in-service was provided to all staff responsible for providing hydration and meals to residents including what drinks or soups required thickening.During an interview on 07/07/2026 3:30 PM, the Administrator said she expected each resident with prescribed thickened liquid diet, receive the ordered diet and not have thin liquids provided to them. She said the risk to the resident was aspiration.Record review of a facility policy titled Clinical Nutritional Services-Thickened Liquids revised date January 2025 indicated, . Thickened liquids will be available for those who have difficulty swallowing thin liquids. Liquids will be thickened to the degree specified in the physician or designee's orders.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 2 medication storage rooms (The Arbors) reviewed for pharmacy services.The facility failed to remove expired influenza vaccines from the refrigerator in the medication room in The Arbors on 7/7/2026.These failures could place residents at risk for the unsafe administration of medications, not receiving prescribed doses of ordered medications and not receiving the intended therapeutic benefit of the medications.Findings include:During an observation on 7/7/2026 at 10:41 am, LVN A was in the medication room for The Arbors. The refrigerator revealed (3) boxes of influenza vaccine for 2025-2026 lot #AX615A that expired 6/30/2026.During an interview on 7/7/2026 at 10:41 am, LVN A said the nurses were responsible for checking the medication rooms and should be done daily. She said she was not aware the medication room had flu vaccines that were expired. She said residents could get a counter effect or multiple things could happen that could cause an unintended effect if residents were given medications that were expired. She said she would discard the vaccines.During an interview on 7/7/2026 at 11:06 am, RN B said she had been employed at the facility for a year. She said the night shift nurses were responsible for checking the medication rooms for expired medications. She said if an expired medication were given, a resident could have some type of reaction. She said she was not aware the medication room for The Arbors had influenza vaccines that were expired and they should have been discarded before now.During an interview on 7/8/2026 at 11:02 am, the ADON said the nurses were responsible for checking the medication rooms at night that included expired meds. She said she was aware of the expiring flu vaccines and had instructed the staff before the end of June 2026 to remove the vaccines and they did not. She said if residents were given vaccines that were expired, the medicine may not work efficiently, or they could have a reaction. During an interview on 7/8/2026 at 11:25 am, the DON said the nurses were responsible for checking the medication rooms daily on the night shift that included checking for expired meds. She said she was aware the flu vaccines would be expiring by July 1, 2026, and staff were told to remove them, and they did not. She said a resident could have an adverse reaction or a side effect if they were given an expired vaccine. She said no one received the expired flu vaccines and she notified the NP and the medical director that they had been removed. During an interview on 7/8/2026 at 11:45 am, the Administrator said the pharmacist along with the DON/ADON were all responsible for checking the medication rooms and they should be checked weekly for expired meds. She said residents could have an adverse reaction if given expired medications and she expected her staff to dispose of expired medications immediately. Record review of a facility policy titled Medication Labeling and Storage revised June 2026 indicated, .The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. 6. Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date .

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #8) reviewed for infection control.The facility failed to ensure CNA A and CNA B followed contact precautions, changed their gloves, and did not touch clean items with dirty gloves when incontinent care was provided to Resident #8 on 2/18/2026.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of an admission Record for Resident #8 dated 2/18/2026 indicated she was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of chronic systolic heart failure (the heart's inability to pump effectively), anemia (decreased red blood cell production), and osteoporosis (brittle bones).Record review of active physician orders for Resident #8 dated 2/18/2026 indicated she had an order for enhanced barrier precautions that started on 1/16/2026.Record review of a care plan for Resident #8 revised on 2/16/2026 indicated she was on contact isolation precautions related to an abnormal UA and was on antibiotics. Interventions included following facility isolation policy.Record review of a Significant Change MDS assessment dated [DATE] indicated Resident #8 had moderate impairment in thinking with a BIMS score of 10. She required partial/moderate assistance with toileting hygiene and was always incontinent of urine/bowel.During an observation on 2/18/2026 at 9:20 am, at the room of Resident #8 there was a sign on the door for contact precautions. CNA A and CNA B entered the room and did not wash or sanitize their hands and donned (put on) gloves. Neither staff donned a gown. CNA A pulled Resident #8's pants down to her ankles and opened her brief and pulled it down between her thighs. CNA A removed a wipe from the package and wiped her left inner thigh, right inner thigh and down the middle of her vagina from front to back. CNA B rolled Resident #8 onto her right side and removed a wipe from the package and wiped her rectal area from front to back and removed the brief and placed it in the trash. CNA B placed a clean brief under the resident's buttocks without changing her gloves and applied barrier ointment. The brief was secured, and the resident was repositioned in bed. Her pants were pulled back up. The room had two boxes with biohazard bags that were yellow and red in color, and it also had a container of PPE that included N95 masks, gowns, and face shields. CNA B removed her gloves and placed them in the trash and washed her hands. CNA A removed her gloves and placed them in the trash.During an interview on 2/18/2026 at 9:32 am, CNA B said she had been employed at the facility since August 2025. She said she had a skills check off on hire. When asked about the incontinent care that was provided to Resident #8, she said she should have changed her gloves when she changed from touching dirty items and then clean items. She said she did not notice the sign on the door for contact precautions and did not wear a gown when care was provided. She said she did not think about it. She said she should have washed or sanitized hands before care was started. She said she thought she could wear the same pair of gloves during the care if they were not visibly dirty with feces and if they were she would change them. She said she had been observed by nursing staff and never changed her gloves during care that was provided. She said there could be a risk of cross contamination if they did not change gloves or wear a gown when a resident was on contact precautions.Record review of a CNA competency skill checklist for CNA B dated 8/15/2025 indicated she was observed performing perineal care and infection control.During an interview on 2/18/2026 at 9:36 am, CNA A said she had been employed at the facility since March 2025. She said there was a sign on Resident #8's door but she did not pay any attention to it. She said she should have worn a gown when care was provided. She said she should have sanitized or washed her hands before care was started. She said she should have changed her gloves during care after handling dirty items. She said she thought she could wear the same gloves if they were not visibly soiled with feces and she thought they were clean. She said she had a skills check off on hire. She said there was a risk for cross contamination and spreading infections to residents if staff did not change gloves during care.Record review of a CNA competency skill checklist for CNA A dated 9/5/2025 indicated she was observed performing perineal care and infection control.During an interview on 2/18/2026 at 11:26 am, the ADON said she had been employed at the facility since August 2025 and was in her current position since December 2025. She said she was the IP for the facility and responsible for training staff on infection control. She said staff were trained monthly on infection control that included basic hand hygiene, and perineal care. She said Resident #8 was on EBP for MDRO with a current active infection that placed her on contact precautions that were implemented on 2/13/2026 and prior to that had a different sign on the door for EBP. She said if a resident was on contact precautions then that meant the resident had a MDRO and required signage on their doors along with proper disposing bins and PPE in the rooms. She said staff should wear appropriate PPE that included a gown and gloves if a resident was on contact precautions. She said hand hygiene should be performed before, during, and after care was provided. She said gloves should be changed before changing tasks from dirty to clean. Staff should wash their hands between glove changes. She said at no point should staff wear the same gloves from beginning to the end of care nor should they touch clean items with dirty gloves. She said the facility started in-services with the two staff (CNA A and CNA B) on proper hand hygiene and perineal care. She said there was a risk for staff to receive infections or spread infections to other residents. She said the staff were trained per policy with performing hand hygiene and changing gloves.During an interview on 2/18/2026 at 12:00 pm, the DON said she was made aware of the care that was provided to Resident #8 and CNA A, and CNA B were provided 1:1 education on proper care and procedure. She said they conducted monthly random audits on perineal care and hand hygiene. She said if a resident was on contact precautions, then staff should wear a gown and gloves when care was provided. She said hand hygiene should be performed before going in the room, during care, between glove changes, after touching dirty items and when care was completed. She said if a resident was on contact isolation, then the staff needed to wash their hands with soap and water but could use sanitizer unless stool was involved. She said at no point should staff wear the same gloves and touch clean items with dirty gloves when care was provided. She said new hires were placed with a lead trainer and they completed a skills check-off and if there were any remediation the lead trainer would let the ADON or her know and if they needed more training they would get a nurse, ADON/DON, to provide training. She said there was a risk of spreading infections to other residents. She said if staff were not trained in the proper steps, it could cause an infection to other residents.During an interview on 2/18/2026 at 1:15 pm, the Administrator said the IP was the ADON and she along with the DON were responsible for training staff on policies and procedures with infection control. She said staff should not wear the same gloves during care provided to residents. She said staff were trained on hire and monthly during random audits observed performing skills. She said there was a risk of infections if staff did not follow policy with infection control and glove changes. She said if residents were on EBP staff should wash hands and wear gowns and gloves.Record review of a facility policy titled Enhanced Barrier Precautions dated August 2022 indicated, .Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. A. gloves and gowns are applied prior to performing the high contact resident care activity. 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include: f. changing briefs.Record review of a facility policy titled Isolation-Initiating Transmission-Based Precautions revised August 2019 indicated, .Transmission-Based Precautions may include Contact Precautions. D. Determines the appropriate notification on the room entrance door; e. ensures that protective equipment (i.e., gloves, gowns, masks, etc.) .Record review of a facility policy titled Handwashing/Hand Hygiene revised August 2019 indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: a. before and after coming on duty; b. before and after direct contact with residents; i. after contact with a resident's intact skin; j. after contact with blood or bodily fluids.

Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 2 of 5 staff (CNA A and CNA B) reviewed for competent nursing care.The facility failed to ensure CNA A and CNA B were able to demonstrate competency in the skill of hand hygiene when they failed to perform hand hygiene and change their gloves during incontinent care provided to Resident #8 on 2/18/2026.These deficient practices affect residents who depend on nursing care and could place residents at risk for infection and harm.The findings included:Record review of an admission Record for Resident #8 dated 2/18/2026 indicated she was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of chronic systolic heart failure (the heart's inability to pump effectively), anemia (decreased red blood cell production), and osteoporosis (brittle bones).Record review of a Significant Change MDS assessment dated [DATE] indicated Resident #8 had moderate impairment in thinking with a BIMS score of 10. She required partial/moderate assistance with toileting hygiene and was always incontinent of urine/bowel.Record review of a care plan for Resident #8 revised on 2/16/2026 indicated she had a UTI with interventions to check at least every 2 hours for incontinence.During an observation on 2/18/2026 at 9:20 am, CNA A and CNA B entered the room of Resident #8 and did not wash or sanitize their hands and donned (put on) gloves. CNA A and CNA B provided incontinent care and wore the same gloves during the entire procedure that included changing the resident's brief that was soiled with urine, cleaning the perineal and rectal area, applying barrier ointment to the resident's perineal, applied a clean brief, touched the resident and her clothing.During an interview on 2/18/2026 at 9:32 am, CNA B said she had been employed at the facility since August 2025. She said she had a skills check off on hire. When asked about the incontinent care that was provided to Resident #8, she said she should have changed her gloves when she changed from touching dirty items and then clean items. She said she thought she could wear the same pair of gloves during the care if they were not visibly dirty with feces and if they were she would change them. She said she had been observed by nursing staff and never changed her gloves during care that was provided. She said there could be a risk for cross contamination if they did not change gloves.Record review of a CNA competency skill checklist for CNA B dated 8/15/2025 indicated she was observed performing perineal care and infection control.During an interview on 2/18/2026 at 9:36 am, CNA A said she had been employed at the facility since March 2025. She said she should have changed her gloves during care after handling dirty items. She said she thought she could wear the same gloves if they were not visibly soiled with feces and she thought they were clean. She said she had a skills check off on hire. She said there was a risk for cross contamination and spreading infections to residents if staff did not change gloves during care.Record review of a CNA competency skill checklist for CNA A dated 9/5/2025 indicated she was observed performing perineal care and infection control.During an interview on 2/18/2026 at 11:26 am, the ADON said she had been employed at the facility since August 2025 and was in her current position since December 2025. She said she was the IP for the facility and responsible for training staff on infection control and risk management. She said staff were trained monthly on infection control that included basic hand hygiene, and perineal care. She said hand hygiene should be performed before, during, and after care was provided. She said gloves should be changed before changing tasks from dirty to clean. Staff should wash their hands between glove changes. She said at no point should staff wear the same gloves from beginning to the end of care nor should they touch clean items with dirty gloves. She said the facility started in-services with the two staff (CNA A and CNA B) on proper hand hygiene and perineal care. She said there was a risk for staff to receive infections or spread infections to other residents. She said the staff were trained per policy with performing hand hygiene and changing gloves.During an interview on 2/18/2026 at 12:00 pm, the DON said she was made aware of the care that was provided to Resident #8 and CNA A, and CNA B were provided 1:1 education on proper care and procedure. She said they conducted monthly random audits on perineal care and hand hygiene. She said hand hygiene should be performed before going in the room, between glove changes, after touching dirty items and when care was completed. She said at no point should staff wear the same gloves and touch clean items with dirty gloves when care was provided. She said new hires were placed with a lead trainer and they completed a skills check off and if there was any remediation the lead trainer would let the ADON or her know and if they needed more training they would get a nurse, ADON/DON to provide training. She said there was a risk of spreading infections to other residents. She said if staff were not trained in the proper steps, it could cause an infection to other residents.During an interview on 2/18/2026 at 1:15 pm, the Administrator said the IP was the ADON and she along with the DON were responsible for training staff on policies and procedures with infection control. She said staff should not wear the same gloves during care provided to residents. She said staff were trained on hire and monthly during random audits observed performing skills. She said there was a risk for infections if staff did not follow policy with infection control and glove changes.Record review of a facility policy titled Staffing, Sufficient and Competent Nursing revised August 2022 indicated, .Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. 3. Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas: o. Infection control.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 main facility kitchen and 3 of 3 satellite kitchens (HC Arbor, HC Woodlands, Rehab). The dietary staff did not accurately test and log the dish machine for hot water sanitizing on 06/01/25 and the morning of 06/02/25. DA B served food without taking the holding temperatures on the rehab unit. Cook C did not take holding temperatures in the main kitchen on the foil covered plates and on any of the alternate food items. DA D served food whose temperatures were below appropriate holding temperatures on HC Arbor. She did not take temperatures on all 4 foil covered plates with food items. DA D used gloved hands to serve rolls, French fries, chicken strips, and onion rings after handling other items in the satellite kitchen on HC Arbor. DA E did not take holding temperatures on the alternate food items on HC Woodlands before serving. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During an observation and interview in the main kitchen on 06/02/2025 at 10:25 AM, the assistant FSM said the dish machine was a high temperature sanitizing unit. At 10:25 AM a rack of dishes was sent through the dish machine and the temperature dials did not move. The thermometer device that rode through the machine noted the high temperature to be 156 degrees. A second run was performed and the temperature registered 136 degrees. The assistant FSM said they would call maintenance to come check the machine. During a record review and observation in the main kitchen on 06/02/2025 at 10:30 AM, the log sheet for documenting the wash/rinse temperatures for the dish machine was observed hanging on the dish room door. One entry had been made for breakfast on 06/01/2025. No entries were made for the noon and evening meals on 06/01/2025. No entry had been made for breakfast temperatures on 06/02/2025 although all dishware and silverware from breakfast had been washed and returned to the satellite kitchens. DW A said at that time he had not taken the wash/rinse temperatures that morning. The assistant FSM said they would bring back all the dishware and silverware from the satellite kitchens and sanitize them in the 3-compartment sink, air dry them and return them to the satellite kitchens. During an observation on 06/02/2025 at10:32 AM, the 3-compartment sink was prepared, tested and was sanitizing at 400 ppm. During an interview on 06/02/2025 at 10:37 AM, DW A said they had been having trouble with the temperatures fluctuating on the dish machine. He said they would go way down low and then come back up. He ran another rack of items through the dish machine and the wash temperature was 175 degrees and the rinse temperature was 160 degrees. He said he had not told anyone about the temperature discrepancies. He said he had not tested the sanitizing on the dish machine that morning even though he had washed all of the dishes from the satellite kitchens. During an interview on 06/02/2025 at 10:45 AM, the FSM said their old chemical dish machine that had been removed from another part of the kitchen had a heater booster on it to keep the temperatures elevated. He said the water heater supplying the kitchen was also shared with the independent living. He said they had no problems with temperatures when they had the old chemical dish machine hooked up with the heater booster. He said he would get a plumber to move the heater booster to the current dish washing machine. He said they had been using the new machine without the heater booster for about 4 months. He gave no reason as to why the staff had not recorded the wash and rinse temperatures. During an observation and interview on 06/02/2025 at 12:23 PM DA B on the Rehab unit served a lunch plate of Salisbury steak, mashed potatoes, and broccoli salad without taking the holding temperatures. He was asked if he had taken the holding temperatures already and he said he had not taken any temperatures. He said they took the temperatures in the back and he said he normally took the temperatures before he served the food. His temperature log book indicated he had not taken the temperatures on the food for the noon meal on 06/02/2025 before serving any food. During an interview on 06/02/2025 at 1:15 PM, the FSM said a plumber was to come next week to install the hot water booster to the dish machine. He said they would continue to wash and rinse in the dish machine and keep an eye on the fluctuating temperatures and if the temperatures dropped below the required levels they would utilize the 3-compartment sink for sanitizing while the machine recovered and the temperature returned to the acceptable sanitizing temperature of 180 degrees. During an observation and interview on 06/03/25 at 11:10 AM, [NAME] C began taking holding temperatures for food items to be taken to the 3 satellite kitchens (HC Arbor, HC Woodlands, and Rehab units). The stainless-steel steam table pans were being held in heated food transport units before being transported. The HC Arbor heated food transport unit contained 4 foil covered plates and [NAME] C said those were puree and she did not take the temperatures on those plates. She said the dietary person on the unit would take the temperatures and put it in the microwave if it needed to be re-heated. During an interview on 06/03/2025 at 11:30 AM, the FSM said the dish machine was a single-tank stationary rack, dual-temperature machine and he said both dishwashers were re-trained on 06/02/25 on the logging procedures and communicating issues with temperatures to management. He said the hot rinse should reach 180 degrees for sanitizing. He said the dietary servers were re-trained on the morning of 06/03/25 on taking holding temperatures before food was served to the residents on the units. During an observation on 06/03/2025 at 11:40 AM, the heated food transport unit brought the folllowing food items to the HC Arbor unit: chicken and dumplings, spinach, and puree soup, and was placed on the steam table. The 4 foil covered plates were placed in a heated cabinet. DA D said she needed to go back to kitchen and get her vegetable soup and rolls that were not placed on the cart. DA E took the heated food transport unit with her food items to the HC Woodlands unit. During an observation and interview on 06/03/2025 at 11:50 AM, holding temperatures were taken on the HC Woodlands unit after the stainless-steel pans for the main entrée had been placed on the steam table. At 12:05 PM DA E said she had chicken strips, French fries and onion rings in pans still in the heated transport unit. She did not take any holding temperatures on these items. During an observation and interview on 06/03/2025 at 12:02 PM, the holding temperatures were taken on the HC Arbor unit. The following was noted: chicken strips 121 degrees; French fries 116 degrees; One foil covered plate was uncovered and the temperatures were: pureed chicken and dumplings 122 degrees, pureed spinach 113 degrees, pureed vegetable soup 113 degrees, and DA D did not take any food temperatures of the remaining 3 foil covered plates. During an observation and interview on 06/03/2025 on the HC Woodlands unit kitchen at 12:10 PM, DA D put on gloves to start service and wore them throughout the service picking up French fries, onion rings, and chicken strips with her gloved hands after touching serving utensils, plates, meal tickets, and cabinet doors. DA D said the soup and chicken and dumplings should have been 180 degrees and the chicken strips and French fries should have been 165 degrees. She said those food items were not at the proper serving temperatures but she served them anyway. She said she should have called the FSM with the improper temperatures. She said people could get sick if they ate food that was not held at the proper temperatures. She said she could use her gloved hands to touch food items as long as she had the gloves on. She said she did not have to change them. During an interview on 06/02/2025 at 1:25 PM the FSM said dietary staff should use utensils to serve any food item. He said gloved hands were not to be used to serve rolls, French fries, chicken strips, etc. He said every food item should be tested for a holding temperature before service to the residents; not just the main food items. Review of the Dishmachine Temperature Record (High Temperature Machine) dated June 2025 indicated Wash Temp of 165 degrees and Final Rinse temperature of 160 degrees was done by DW A on 06/01/2025. There were no temperatures entered for lunch or dinner on 06/01/2025. There were no temperatures entered for breakfast on 06/02/2025. Review of the facility policy Dishmachine Temperatures, revised date 01/2024, indicated .High Temperature Machine: . Single-tank, stationary-rack, dual-temperature machine Wash temperature 150 degrees and Final rinse temperature 180 degree-194 degrees.Procedures: Supervisor/Food and Nutrition Associate as assigned High Temperature Dishmachine-record on Dishmachine Temperature Record Form.Supervisor: If documentation of the temperature and test strips/max temps results has been assigned to a Food and Nutrition Associate confirms that it is completed at each meal period. Review of the facility policy Meal Quality and Temperature, revised date 01/2024, indicated .Dining Room and Pantry: When bulk food is transported to a dining serving location, temperatures are taken and recorded in the kitchen before transport as well as at the final serving location.Records temperatures no more than 30 minutes prior to meal service. If hot food is below standard, it must be reheated up to 165 degrees for a minimum of 15 seconds.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's main kitchen observed for kitchen sanitation. The soda drink dispenser had undated (date when opened) and expired soda syrup concentrates connected and available to be served. The freezer had open to air, improperly labeled and expired foods. This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness. The findings included: During an observation and interview on [DATE] at 09:20 am of the drink dispenser, 6 containers of concentrated soda syrup connected to dispenser had no opened date documented. Container of concentrated lemon soda expired [DATE], container of concentrated root beer expired [DATE], and a container of diet coke expired [DATE]. All three containers were connected to the dispenser and available to serve. The Dining Director said he had worked at the facility for two months and he was responsible for ensuring all expired items were discarded. The Dining Director said he would remove the expired soda concentrate and replace with new ones . During an observation on [DATE] at 09:30 am of the freezer revealed a clear zip lock bag of frozen chicken dated [DATE] with no use by date. The frozen chicken was not sealed and was open to air. A frozen clear zip lock bag of beef stock dated [DATE] use by date [DATE]. A zip lock bag of frozen fish unlabeled for contents dated [DATE] with no year, no use by date. The Dining Director said he was responsible for training the dietary staff and at for ensuring items were dated as required. He said he would discard the undated items. During an interview on [DATE] at 10:00 am the Dining Director said serving expired sodas could cause gastric distress or diarrhea. The Dining Director said the expired frozen items should have been removed from the freezer and could cause an illness if served. He said all frozen Items should be labeled with contents in the container, the date it was packaged and a serve by date. He said they had training today for the dietary staff regarding labeling and removing expired items. During an interview on [DATE]at 10:10 am the Dietary Director said serving expired foods could cause illness. He said they had begun an in-service for the dietary staff regarding labeling and removing expired items. The Dietary Director said it was the responsibility of all team members to make sure the items were labeled and removed when expired. During an interview on [DATE] at 08:00 am the Administrator said her expectation was for all foods to be labeled when opened and thrown away when expired. She said it was the responsibility of the Dietary Director to make sure all expired food was removed from the kitchen. The Administrator said, the potential negative outcome for residents consuming expired foods could be food borne illnesses. Record review of an undated Compass Group Food Safety and Quality Assurance Standards Manual Food Expiration and Rotation policy indicated . Foods that have expired must be discarded and not used or served. This includes both manufacturer and unit-labeled food expiration dates on dry, refrigerated and frozen foods . discard any foods that are past expiration, those that do not have a date, or have an illegible date.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 3 of 28 dietary staff (Dietary Staff D, E and F) reviewed for reviewed for food and nutrition services. The facility did not ensure Dietary Staff D, E and F had a current food handlers' certificate while working in the facility's kitchen on 04/29/24 to 05/01/2024. This failure could place all residents who consumed food prepared from the kitchen at risk of food-borne illness. Findings included: Record review of 28 Dietary Staff food handlers' certificates indicated Dietary Staff D hire date 06/09/2022, Dietary Staff E hire date 10/29/2021 and Dietary Staff F hire date 10/01/2020 did not have a food handler's certificate. During an interview on 05/01/24 at 08:40 am, the Dining Director said that the three dietary employees did not have a current certificate. He said he had spoken with all three employees on 05/01/24, and they had informed him that they had no current food handler's certification . He said it was his responsibility to ensure all kitchen staff had a current food handler certification and will develop a system to track them. He said that the three employees will complete the certifications by Friday 05/03/2024 or will be taken off the schedule until completed. The Dining Director said the residents could be at risk for food borne illness if the staff did complete training on proper food handling requirements as required by regulations. During an interview on 05/01/24 at 09:00 am the Administrator said she expects the dietary staff to have updated food handler certificates and for all staff to receive training to prevent food borne illness. She said the Dining Director is responsible for overseeing all staff's certifications. Review of reference obtained from the TAC chapter 228 .Certified Food Protection Manager and Food Handler Requirements. (e) The food establishment shall maintain on premises a certificate of completion of the food handler training course for each food employee. The requirement to complete a food handler training course . Review of an undated Facility policy titled Licensure, Certification, and Registration of Personnel. Policy Statement . Employees who require a license, certification, or registration to perform their duties must present such verification with their application for employment. Policy Interpretation and Implementation 1. Personnel who require a license, certification, or registration to perform their duties must present verification of such license/certification/registration to the Human Resources Director/designee prior to or upon employment. 2. A copy of the current license, certification, or registration number must be filed in the employee's personnel record. 3. A copy of recertifications (e.g., annual, bi-annual, etc., as applicable) must be presented to the Human Resources Director/designee upon receipt of such recertifications and prior to the expiration of current licensure, certification, and/or registration. A copy of the recertification must be filed in the employee's personnel record .

Based on interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 1 of 6 residents (Residents #6) reviewed for MDS assessment accuracy. The facility incorrectly coded Resident #6 as having restraints on her MDS assessment. 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: Record review of an Admission Record dated 4/29/2024 for Resident #6 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses s of dementia (a group of thinking and social symptoms that affect activities of daily life), anemia (low red blood cells that carry oxygen in the body), and hypertension (high blood pressure). Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated she had severe impairment in thinking with a BIMS score of 00. She required substantial/maximal assistance to partial/moderate assistance with ADL's. She was always incontinent of bowel/bladder. Physical restraints used in bed-(other) that was used less than daily. During an interview on 4/29/2024 a 4:14 PM, the DON said there were not any residents in the facility that had restraints and they were a restraint free facility. She said she was not aware of Resident #6 having restraints but would talk to the MDS Coordinator. During an interview on 4/30/2024 at 10:30 AM, the MDS Coordinator said she was responsible for completion of the MDS assessments. She said she usually went through all of the assessments and checked restraints not used on all of the residents in the facility. She said on Resident #6 she accidentally checked that she had restraints on the MDS dated [DATE]. She said the facility was restraint free. She said she completed a modification of the MDS assessment dated [DATE] for Resident #6 on yesterday 4/29/2024. She said the facility did have some residents that used assist bars but not any restraints such as bed or chair alarms. She said by completing the MDS Assessments she was stating that they were accurate and correct to the best of her ability. She said she was not aware that Resident #6 had a MDS assessment that indicated she had restraints until the DON mentioned it to her on 4/29/2024. She said there could be a risk of the facility not getting paid correctly and could affect the care of the residents if assessments were not coded correctly. She said going forward she would be slowing down while completing the assessments and would be checking everything from now own. During an interview on 4/30/2024 at 3:00 PM, the Regional MDS Coordinator said she visited the facility every 2 months or about once a quarter. She said she conducted audits for documentation of the MDS assessments. She said she looked at things that could affect reimbursement such as ADL's, BIMS and PH9 (instrument for screening, diagnosing, monitoring, and measuring the severity of depression) in the assessments. She said she would expect the MDS Coordinator to catch the restraints that was incorrectly coded on the MDS assessment because the facility was restraint free. She said restraints was not something that would be caught during an audit, but the MDS Coordinator should be monitoring the facility matrix that would indicate if a resident had restraints. She said going forward she would send training and education to the MDS Coordinator. She said there was a risk of the assessments affecting quality measures if they were not coded accurately. Record review of the Resident Matrix dated 4/29/2024 indicated Resident #6 had physical restraints. During an interview on 5/1/2024 at 10:25 AM, the Administrator said the IDT team members had portions of the MDS they were responsible for and there was a Regional MDS Coordinator that assisted as needed. She said the Regional MDS Coordinator conducted audits and reviewed the MDS assessments randomly. She said the facility was restraint free and Resident #6 did not have any restraints. She said the MDS Coordinator did a modification of the MDS Assessment that reflected Resident #6 did not have a restraint. She said going forward she would look at an audit system with the Regional MDS Coordinator to see what would be best for accuracy. Record review of a facility polity titled Certifying Accuracy of the Resident Assessment revised November 2019 indicated, .Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sing and certify the accuracy of that portion of the assessment. 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 3. The Resident Assessment Coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each resident is coordinated and certified as complete by the Resident Assessment Coordinator, who is a registered nurse .

Based on interviews, and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 12 residents (Resident #196) reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission on Resident #196 and provide a care plan summary to the resident or representative. This failure could place residents at risk of not receiving correct and/or necessary care/treatment. Findings: Record review of a facility face sheet dated 4/30/2024 indicated Resident # 196 was a [AGE] year old male and admitted on [DATE] with a diagnosis of aftercare for femur fracture (broken upper leg). Record review of a baseline care plan indicated Resident # 196 was admitted on [DATE] and the baseline care plan was not completed until 4/18/2024 and the family was not provided a summary of the baseline care plan. Record review of an admission MDS assessment dated [DATE] indicated Resident # 196 had a BIMS of 13 indicating intact cognition. During an interview on 04/29/2024 at 2:43 PM LVN C stated she was responsible for completing the baseline care plans on new admissions and making sure the resident or family received a copy of the summary . She said the admitting nurse initiated the baseline care plan, but she reviewed and completed them. She said they should be completed within 48 hours of admission but sometimes she got behind. She said if the baseline care plan was not completed it could cause care delivery issues. During an interview on 04/30/2024 at 2:49 PM the MDS Coordinator said the admitting nurse was responsible for completing the baseline care plan within 48 hours of admission and if the admission occurred after hours or on the weekend the charge nurse or weekend supervisor was responsible for completing the baseline care plan. She said if the baseline care plan was not done it could delay resident care. She said the family or resident should receive a summary of care and if they were not provided a summary they would not be involved in their care goals. During an interview on 05/01/2024 at 11:12 AM the DON said the baseline care plans were to be completed by the admission nurse and should be completed within 48 hours of admission. She said the resident or family should receive a copy of the summary. She said previously the social worker was completing them but recently it was changed to LVN C. She said on the weekend the charge nurse was responsible for completing the baseline care plan and then LVN C audits for accuracy. She said if baseline care plans were not completed it could affect resident receiving needed services. During an interview on 05/01/24 at 11:50 AM the Administrator said that the admission nurse was responsible for completing the baseline care plan and the DON/ADON were responsible for reviewing for compliance. She said the resident and family should receive a copy of the summary. She said previously there was a different system in place, but they found that the baseline care plans were not being completed per the regulation. She said if the baseline care plans were not completed within 48 hours of admission it could cause care delivery issues. She said she expected that all baseline care plans were completed per the regulation and would review the current process and make changes as needed. Record review of a facility policy titled Care Plans - Baseline dated December 2016 indicated, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission, 4. the resident and their representative will be provided a summary of the baseline care plan .

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 4 residents reviewed for accidents. (Resident #37) On 4/04/2024 CNA G failed to ensure a safe transfer by leaving Resident #37 standing in the sit to stand lift unattended and left the room to retrieve supplies and Resident #37 fell . This failure could place residents who required supervision at risk of injury or accidents and hospitalization . Findings included: 1.Record review of Resident #37's face sheet dated 4/29/2024 indicated she was an [AGE] year-old female that admitted to the facility on [DATE] with diagnoses that included: urinary tract infection, history of falling, muscle weakness, and dementia (impaired ability to remember, think, or make decisions). Record review of the significant change MDS dated [DATE] indicated Resident #37 had clear speech and makes self-understood. Resident #37's BIMS was 03 indicating severe cognitive impairment. Resident #37 required substantial/maximal assistance with transfers. Record review of Resident #37's care plan dated 3/07/2024 indicated Resident #37 needed assistance with activities of daily living with an intervention: Elder is a two person transfer or sit to stand transfer and Increase assistance as needed to ensure elder safety. Resident #37 had a history of falls with interventions that included: For no apparent acute injury, determine and address causative factors of the fall. Record review of facility post fall evaluation dated 4/04/2024 indicated Resident #37 had an unwitnessed fall from the mechanical sit to stand lift at 1:45 pm on 4/04/2024, with no injuries. Record review of an incident statement dated 4/04/2024 given by CNA G indicated: While taking Resident #37 to her room from the dining room, CNA noticed that resident was wet, and CNA used the stand up lift to provide care. CNA removed resident's brief, and realized resident had a bowel movement. CNA stated she did not see any wipes in the room, so she left the room while the resident was in the stand up lift to obtain wipes. CNA went to the room across the hall to look for wipes and a nurse was in the room. CNA let the nurse know she was looking for wipes to attend to resident. CNA stated that there were no wipes in that room either on the A or B side. CNA then went back into the resident's room to check on her and let her know that she will be back. CNA stated she recalled earlier in the day that the housekeeper advised her that there were wipes at the nurses station. CNA then went to the nurses station and found the wipes. CNA reports that she believes that it took less than 5 minutes to retrieve the wipes and return to resident's room. When CNA returned, she noted resident on the floor. CNA retrieved the nurse, LVN H and reported that resident fell . Brief was placed on resident. CNA and nurse were able to return resident to the bed. Nurse assessed resident for injury, and care was then provided to resident in bed. During care, the resident did not indicate pain. After care was provided, resident was transferred from the bed to the recliner. The nurse assessed resident for injury. During an interview on 4/29/2024 at 10:04 AM Resident #37 said she did not remember having a fall. Surveyor attempted an interview with CNA G via phone on 4/29/2024 at 10:33 AM, CNA G did not answer phone or call back. During an interview on 04/30/24 at 11:01 AM LVN H said staff were supposed to use 1-2-person assistance with the sit to stand lift. She said with the old lifts they were always a 2 person assist. She said the new lifts were bought about 6 months ago and only require 1-2 person assist . She said on 4/4/24 the CNA G went to her and told her that Resident #37 was on the floor. She said CNA G told her she left Resident #37 in the sit to stand lift to go and retrieve wipes and when she returned Resident #37 was on the floor. She said she went and assessed Resident #37 for injuries with none found. She said CNA G was suspended on 4/4/24 and terminated. She said after the fall staff was in-serviced on lifts and physical therapy demonstrated how to appropriately use lifts. During an observation on 04/30/24 11:12 AM, Observed CNA I and CNA J as they performed a sit to stand transfer via a sit to stand lift. Observed CNA J place the sling around Resident #37's torso and chest area, she then tightened the straps and latched the buckles. CNA J had Resident #37 sit straight up in her wheelchair and attached the lift sling to the lift and had Resident #37 grab on to the handlebars. CNA I ensured Resident #37's feet were on the lift platform and attached the leg safety strap behind Resident #37's lower legs. CNA J then lifted Resident #37 to a standing position. CNA J and CNA I then rolled Resident #37 into the bathroom and lowered her onto the commode. During an interview on 04/30/24 at 11:21 AM, CNA I said when she transfers Resident #37 she always had 2 staff members in the room. She said she gets how each resident transfers from therapy. She said she could always see how any resident transfers by looking on the Kardex in the computer. During an interview on 04/30/24 at 11:29 AM, the PTA said she had been at the facility for about 2 years. She said that all mechanical lifts in her opinion should be 2 person assist. She said Resident #37 was a 1-2 person assist with transfers depending on the day and what is going on with Resident #37. The PTA said Resident #37's cognition and strength varied from day to day and some days she would be appropriate for a sit to stand lift and some days she was not appropriate for the sit to stand lift. During an interview on 04/30/24 at 11:38 AM CNA K said she had worked at the facility for about 1 week. She said that when using any kind of mechanical lift there should always be 2 staff assistance. She said you can find what level of assistance a resident needs by looking at the point of care system in the computer. During an interview on 04/30/24 at 11:43 AM CNA L said she had worked at the facility for about 6 months. She said for any transfers requiring a lift there should always be 2 staff assistance. She said when she first started at the facility she was trained on the mechanical lifts by therapy. During an interview on 05/01/24 at 08:02 AM, The DON- Said CNA G took Resident #37 to her room to do incontinent care and had put Resident #37 in a sit to stand lift. She said CNA G left the room to get wipes and when she returned the resident was on the floor. She said she is not sure if the sling was snug enough to hold the resident because she had slid out of the sling and onto the floor. The DON said Resident #37 was on the floor in the sitting position. The DON said after Resident #37's fall they had increased their training with the sit to stand and the mechanical lifts. She said they had in-serviced on fitting the sling properly around residents. She said they had also done some gait belt training with staff. She said she and the ADON had been randomly monitoring transfers weekly. She said therapy had monitored transfers to ensure the proper transfer techniques are used. The DON said they talk about residents that has had a change in functional status in their daily huddle meeting. The DON said she expected staff to follow the proper policies and procedures to ensure the resident's safety during transfers. During an interview on 05/01/24 at 09:08 AM, The ADON said on 4/04/2024 she was in a meeting and LVN H called and let her know that Resident #37 was on the floor. She said by the time she got to the room the staff already had the resident back in her wheelchair and at the nurse's station. The ADON said she inspected the lift while it was still in the resident's room. She said they determined that the sling may not have been secure on Resident #37. She said CNA G was suspended pending investigation and ultimately terminated. The ADON said the restorative aide trains all CNAs on the lifts. She said after Resident #37's incident there was an in-service regarding all lifts . During an interview on 05/01/24 at 10:13 AM, The Admin said CNA G was transferring Resident #37 and was in the sit to stand lift. She said CNA G left the room to get supplies for less than 2 minutes and when she returned Resident #37 was on the floor. She said Resident #37 slid through the sling and resident was sitting on the floor in front of the lift. The Admin said LVN H assessed Resident #37 for injury with none found. She said mobile x-rays were done to rule out injury and were negative. She said Resident #37's daughter did not want disciplinary actions taken against CNA G. She said CNA G was suspended immediately, and once her investigation was complete, she decided to terminate CNA G. She said the expectation for her staff was to never leave any resident unattended in a mechanical lift. She said the potential negative outcome was a resident could fall with or without injury. Record review of right wrist x-ray dated 4/04/2024 indicated: Impression: 1. The study is within normal limits. Record review of bilateral hip with pelvis x-ray dated 4/04/2024 indicated: no acute pelvic or hip joint pathology. Record review of CNA orientation and Annual Review Checklist dated 3/11/2024 indicated: CNA G L. Practices safety measures 2. Gait belt for assisted transfers 3. Full body mechanical lift/2-person transfer 4. Sit to stand lift. Record review of Understanding Job Expectations dated 4/09/2024 indicated CNA G was terminated via phone on 4/10/2024. Record review of in-service titled Lifts and Safe Transfers, Gait Belts, Safety, Sit to Stand, Hoyer Lift dated 4/05/2024 indicated staff had been trained on transferring residents safely. Record review of facility policy titled Lifting Machine, Using a Mechanical. General guidelines: 1. Utilize manufacturers recommendations for number of staff needed to safely move a resident with a mechanical lift. Steps in the Procedure: 1. Before using a lifting device, assess the resident's current condition, including: a. Physical b. Cognitive/Emotional. 8. Double check the sling and machines weight limits against the resident's weight. 9. Place the sling under the resident. Visually check the size to ensure it is not too large or too small. 12. Lift the resident 2 inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution. Record review of manufacturers guide of mechanical lift [NAME] Flex undated indicated: Designed to make everyday transfer and care tasks easier, [NAME] Flex from Arjo equips a single caregiver with the ability to position a patient from a seated to a safe, secure and comfortable standing position, in one ergonomic movement.

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 10 residents (Resident #6) and 1 of 8 staff (CNA A) reviewed for infection control. CNA A did not sanitize/wash hands between glove changes when providing incontinent care on 4/29/2024. This failure could place residents at risk for exposure to and transmission of diseases and infections. Findings included: Record review of an Admission Record dated 4/29/2024 for Resident #6 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (a group of thinking and social symptoms that affect activities of daily life), anemia (low red blood cells that carry oxygen in the body), and hypertension (high blood pressure). Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated she had severe impairment in thinking with a BIMS score of 00. She required substantial/maximal assistance to partial/moderate assistance with ADL's. She was always incontinent of bowel/bladder. Record review of a care plan dated 12/2/2021, revised 10/11/2023 for Resident #6 indicated she had bladder incontinence related to impaired mobility and cognition with interventions to clean peri-area with each incontinence episode. During an observation on 4/29/2024 at 4:25 PM, CNA A and CNA B were in the room of Resident #6 to provide incontinent care. CNA A donned (put on) gloves and pulled down the brief between Resident #6's thighs. CNA B was in the room and had gloves on both hands. CNA A opened a package of disposable wipes and pulled out one wipe and wiped across her lower abdomen and placed the wipe in the trash. CNA A pulled out another wipe from the package and wiped down on the resident's right inner thigh and placed the wipe in the trash. CNA A removed another wipe and wiped down the resident's left inner thigh and then used another wipe and wiped from the front down the middle of the resident's peri area and placed the wipes in the trash. CNA B rolled the resident to her right side and CNA A rolled the brief underneath the resident's buttocks. CNA A removed his gloves and placed them in the trash and applied clean gloves without washing or sanitizing his hands. CNA A removed wipes and wiped the rectal area multiple times from front to back using three wipes. CNA A removed the brief and placed in in the trash and removed his gloves. CNA B rolled the resident onto her back and secured the brief. CNA A and CNA B both pulled up the resident's pants. CNA A went into the restroom and washed his hands. CNA B removed her gloves and washed her hands. During an interview on 4/29/2024 at 4:46 PM, CNA A said he had been employed at the facility since August 2023 and worked prn . He said during the incontinent care provided to Resident #6 he should have sanitized or washed his hands when he removed his gloves. He said he had training in the past on skills and was taught to change gloves when going from the front to the back and use one wipe per swipe. He said he was in a rush during the care provided and should have taken his time. He said residents could be at risk for UTI's and infections if staff did not properly sanitize or wash their hands. During an interview on 5/1/2024 at 9:07 AM, the ADON said she had been employed at the facility for 3 years. She said every department head conducted annual skills and she was responsible for overseeing the skills check offs. She said new hires were observed by trainer CNA's. She said she conducted random audits for infection control and monthly checks on handwashing. She said all staff should sanitize or wash their hands between glove changes. She said going forward she would continue to audit for hand hygiene and the facility identified a problem last month regarding infection control. She said residents could be at risk for infections and spreading infections to others if staff did not wash or sanitize their hands between glove changes. During an interview on 5/1/2024 at 10:25 AM, the Administrator said she expected all staff to follow infection control protocols. She said the ADON conducted audits on pericare at times and the ADON was going to do an audit with CNA A and submit it to QA. She said there was a risk of spreading infections to the residents if staff did not wash or sanitize their hands when changing gloves. Record review of a CNA Orientation and Annual Review Checklist dated 8/4/2023 for CNA A indicated he demonstrated infection control with hand washing. Record review of a Handwashing/PPE Monthly Audit Sheet dated 12/2023 indicated that CNA A was observed for handwashing by the ADON. Record review of a facility policy titled Hand Washing/Hand Hygiene revised August 2019 indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the hand washing/hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or; alternatively, soap and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; m. After removing gloves

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 2 resident personal refrigerators reviewed for food safety (Resident #9). The facility failed to ensure the refrigerator for Resident #9 did not contain expired cheese sticks, prune juice, or nutritional shakes. This failure could place resident at risk for food borne illnesses. Findings include: Record review of Resident #9's face sheet dated [DATE] revealed that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: scoliosis (a sideways curve of the spine), chronic pain, and anemia (low red blood cells). Record review of Resident #9's quarterly MDS dated [DATE] indicated Resident #9's BIMS was 15 indicating no cognitive impairment. Record review of Resident #9's care plan dated [DATE] indicated: Elder chooses to have a refrigerator in his room and is able to monitor the temperature and cleanliness daily with intervention of: Remind elder to check and record temperature daily and remove any expired items. During an observation and interview on [DATE] at 10:40 AM, Resident #9 said he tried to keep up with taking the temperatures on his personal refrigerator. Resident #9 said his family member brought him food from Walmart at times. He said he tries to keep his refrigerator clean and throw out expired items. Resident #9 said he got food out of his refrigerator to eat himself. Resident #9 said staff would come periodically to check the temperature log and make sure all food in the refrigerator was labeled and dated. Resident #9's refrigerator contained 8 individual cheese sticks with the expiration date [DATE], a half empty opened bottle of prune juice 64 fluid ounces with the expiration date of [DATE], nutritional shake 8 fluid ounces with the expiration date of [DATE], and a nutritional shake 8 fluid ounces with the expiration date of [DATE]. During an interview on [DATE] at 09:40 AM LVN H said that administration normally checks the personal refrigerators, she said she checks Resident #9's to make sure it is done but she does not check the refrigerator for expired foods. During an interview and observation on [DATE] at 09:42 AM CNA L said she checked the residents' personal refrigerators ,d+[DATE] times a week. She said she checked for expired foods and for smells. She said she had checked Resident #9's refrigerator on [DATE] and did not find any expired foods. On [DATE] at 9:42 AM CNA L entered Resident #9's room and she checked the refrigerator and removed 8 individual cheese sticks with the expiration date [DATE], a half empty opened bottle of prune juice 64 fluid ounces with the expiration date of [DATE], nutritional shake 8 fluid ounces with the expiration date of [DATE], and a nutritional shake 8 fluid ounces with the expiration date of [DATE]. CNA L said she on [DATE] she had only checked to make sure the temperature log had been completed but did not check for expired foods. She said the risk for residents consuming expired foods is residents could get sick. During an interview on [DATE] at 09:51 AM LVN M said she checked the personal refrigerators to make sure food is not expired and their temperature logs were being done. She said all resident personal refrigerators are checked daily. She said that normally the personal refrigerators were checked at night on the ,d+[DATE] shift. She said the temperature logs are pulled at the end of the month and are uploaded into the computer system. During an interview on [DATE] at 09:57 AM CNA I said she checked residents' personal refrigerators ,d+[DATE] times a month. She said the last time she checked Resident #9's was ,d+[DATE] months ago. She said one time she checked, and he had some expired prune juice. She said the risk to the resident for consuming expired food was residents could get sick. During an interview on [DATE] at 10:02 AM LVN O said they only have a community refrigerator on the rehab hall and the night shift checked it periodically. She said the risk to the resident for consuming expired food was residents could get gastritis or allergies. During an interview on [DATE] at 09:08 AM The ADON said the residents checked temperatures, make sure all food is dated, and cleaned their personal refrigerators . She said nurses also checked the personal refrigerators to ensure expired foods are removed. She said the ADON and DON make rounds to ensure that it was being done. During an interview on [DATE] at 10:07 AM, The Admin said residents are responsible for the care of personal refrigerators. She said that nursing checked for compliance, and they checked the temperature logs and for expired foods. She said Resident #9 is pretty on top of keeping up with his refrigerator. She said her expectation was there should never be expired foods in the residents' personal refrigerators. She said the potential negative outcome was the resident could get sick. Record review of the facility policy titled Resident Room Refrigerators for Personal Use undated indicated: A. Resident and or family responsibilities: 3. All items that are opened or dated must be discarded three days from the date. B. The food protection measures that are to be inspected by facility staff are: 7. If items are outdated or not dated, items must be discarded.

Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 5 of 5 months (February 2022, May 2022, August 2022, November 2022, January 2023) reviewed for pharmacy services. The facility failed to have a licensed pharmacist and witnesses initial the attached pages of medication destruction inventory sheets. This failure could place residents at risk for misappropriation and drug diversion. Findings: During a record review of facility medication destruction log for the last 12 months indicated the facility had 5 medication destructions in the last year (02/23/2022, 05/26/2022, 08/24/2022, 11/18/2022, and 01/25/2023) and the pharmacist and 2 witnesses did not initial the attached sheets of the medication destruction inventory sheets. During an interview on 02/22/2023 at 1:20 pm the ADON stated the pharmacy consultant, herself and either the DON or another nurse performed the medication destruction. She stated they check each medicine off before placing them in the destruction box. She stated she was not aware that attached forms had to be initialed. She stated she didn't see any risk to the resident because she knows they were destroyed. She stated it could cause a drug diversion. During an interview on 02/22/2023 at 1:40 pm the DON stated that she was responsible for oversight of medication destruction along with the pharmacist and ADON. She stated she was not aware of the rule that attached pages of the drug destruction had to be initialed and just did it the way the pharmacist told her. She stated the risk could be a drug diversion. The DON stated she would contact the pharmacist and correct their process. During an interview on 02/22/2023 at 3:00 pm the pharmacist consultant stated she had been at the facility for 2 years and was not aware the rule required the initials of the pharmacist and 2 witnesses on each additional page attached for drug destruction. She stated she would see that the failure was corrected. She stated the risk could be a drug diversion. During an interview on 02/23/2023 at 8:10 am the Administrator stated the DON and pharmacist consultant were responsible for medication destructions. She stated she was not aware of the need for initials on each attached page but expected that the regulation was followed. She stated they had already updated their forms and training had been done to correct the failure. She stated she did not see a risk to the patient or facility. Record review of facility policy dated April 2019, titled, Discarding and Destroying Medications indicated, .2.Non-controlled and Schedule V controlled substances will be disposed of in accordance with state regulations and federal guidelines. 3. Schedule II, III, and IV controlled substances will be disposed of in accordance with state regulations and federal guidelines . Record review of 22 TAC S303.1 Destruction of Dispensed Drugs accessed online 02/22/2023 at https://texreg.sos.state.tx.us/ indicated; (a) Drugs dispensed to patients in health care facilities or institutions. (1) Destruction by the consultant pharmacist. The consultant pharmacist, if in good standing with the Texas State Board of Pharmacy, is authorized to destroy dangerous drugs dispensed to patients in health care facilities or institutions. A consultant pharmacist may destroy controlled substances as allowed to do so by federal laws or rules of the Drug Enforcement Administration. Dangerous drugs may be destroyed provided the following conditions are met. (A) A written agreement exists between the facility and the consultant pharmacist. (B) The drugs are inventoried, and such inventory is verified by the consultant pharmacist. The following information shall be included on this inventory: (i) name and address of the facility or institution. (ii) name and pharmacist license number of the consultant pharmacist. (iii) date of drug destruction. (iv) date the prescription was dispensed; (v) unique identification number assigned to the prescription by the pharmacy; (vi) name of dispensing pharmacy; (vii) name, strength, and quantity of drug; (viii) signature of consultant pharmacist destroying drugs; (ix) signature of the witness(es); and (x) method of destruction. C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet, provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are initialed by the consultant pharmacist and witness(es). v) any two individuals working in the following capacities at the facility: (I) facility administrator; (II) director of nursing; (III) acting director of nursing; or (IV) licensed nurse.

Based on interview and record review, the facility failed to maintain clinical records that were accurate for 1 of 15 residents (Resident #21) reviewed for advanced directives. Resident #21 did not have clear advance directive orders. This failure could place residents at risk for inappropriate interventions by staff when reading information in the clinical record, (that is inaccurate or incomplete) which could incur unwanted treatment or delay emergency treatment. Findings included: Review of Resident #21's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for Full Code had a start date of 10/30/20 with no end date. The order for DNR had a start date of 03/02/21 with no end date. Resident was a [AGE] year-old female admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's undated Care Plan indicated the 'Resident has chosen DNR code status. Date Initiated: 03/02/21.' Review of Resident #21's Electronic Medical Record (EMR) revealed appropriate and valid DNR documentation. During an interview on 11/30/21 01:10 PM LVN C said if a resident tells her he/she wants to be changed from Full Code to DNR, she starts the process by notifying the Social Worker. The Social Worker talks to the resident and family. The physician is notified. Documentation is completed and notarized as needed. Once everything is complete, the physician would give the order for the DNR which nursing would enter into PCC. The order has to be entered in 2 parts in PCC. The Full Code status has to be deleted first then the DNR can be entered. She said Resident #21 was a DNR and there should only be that specific advance directive order in the EMR. During an interview on 11/30/21 at 03:04 PM the DON said, in the case of Resident #21, there should not be 2 active advance directive orders. She said the DNR order was the correct one. The order for the DNR was not entered into PCC correctly by the nurse using the appropriate order group. She said if a resident or resident representative decides to pursue a DNR order, the Social Worker discusses this with all relevant parties and the physician is notified of the request. Once all documents were signed and notarized and provided the physician agrees and gives the order for the DNR, the nurse receiving the order is responsible for entering it into PCC (Point Click Care/EMR). The DNR will not be active in the PCC system until the Full Code order was discontinued and the new order was entered into the correct order group. This serves to prevent any confusion about the Resident's wishes. Record review of the policy entitled Advance Directives (revised December 2016) indicated under #19. and #20. the following: 19. Changes or revocation of a directive must be submitted in writing to the Social Worker. The Charge Nurse and the Interdisciplinary Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident chart, assessment (MDS) and care plan. 20. Once notification of Advance Directive, the Charge Nurse will notify the Attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care.

Based on interview and record review the facility failed to ensure that each resident who experiences a significant change in status is comprehensively assessed using the CMS-specified Resident Assessment Instrument (RAI) process for 1 of 2 resident's (Resident # 4) on hospice. A significant change MDS was not completed for Resident #4 within 14 days of the resident experiencing a significant change in condition when admitted to hospice services on 11/2/2021. This failure could contribute to providing an inaccurate assessment of resident's most current medical condition. Findings included: Record review of Resident # 4's Admission Record dated 12/1/2021 indicated she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's MDS indicated a Quarterly MDS assessment was completed on 9/7/2021. Further review revealed no significant change MDS was completed to indicate hospice services within 14 days after 11/2/2021 when she was admitted to hospice services. During an observation and interview on 11/29/2021 in Resident #4's room, CNA E was present brushing Resident #4's hair said she worked for hospice and provided care to the resident 5 days a week. During an interview on 12/01/2021 at 8:40 AM, MDS nurse said she had been responsible for completing the MDS assessments since July 2020. She said she was not aware that Resident #4 was admitted to hospice services. She said that usually the floor nurses would tell her when a resident had been admitted to hospice. She said they also notify her of new antibiotic orders, falls, different events such as skin conditions that need to be care planned. She said she was responsible for updating the care plans with changes. She said she would create a significant change assessment for Resident # 4 and she was admitted to hospice services as of 11/2/2021. During an interview on 12/1/2021 at 10:00 AM, DON said every morning they had a meeting to discuss clinicals that included the Administrator, DON, MDS, Social Worker and the Rehab Director. She said during the clinical meeting they would discuss new or changes that included significant changes of the residents and Resident #4 was admitted to hospice services as of 11/2/2021. She said the nurses or social worker would usually notify the MDS coordinator of changes and was not sure why she was not aware that Resident #4 was on hospice services. She said a significant change assessment should have been completed for Resident #4 within 14 days of the change. During an interview on 12/1/2021 at 10:05 AM, Administrator said her expectations were for significant change assessments to be completed when a resident admits to hospice or any other changes that would indicate a significant change. She said staff would be in-serviced immediately and the DON and herself would be conducting frequent audits of the resident charts to ensure the MDS assessments are completed timely and accurately. Record review of a facility titled, Resident Assessments with a revision date of November 2019 indicated, .3. A Significant Change in Status Assessment (SCSA) is completed within 14 days of the interdisciplinary team determining that the resident meets the guideline for major improvement or decline. 5. A SCSA is required when a resident: a. enrolls in a hospice program, changes hospice providers and remains in the facility; discontinues hospice services.

Based on interview and record review, the facility failed to transmit a resident assessment within the required time frame for 1 of 1 resident (Resident #1) reviewed for data transmission in that: Resident #1 discharge MDS with a discharge date of [DATE] was not transmitted within 14 days of discharge. The discharge assessment was not completed and transmitted until 11-29-21 (Over 120 days). This failure could place residents at risk of not having their assessments transmitted timely and delay in reimbursement for services received. Findings Include: Record review of clinical record for Resident #1's admission face sheet revealed she was [AGE] years old admitted to the facility on ,d+[DATE] and discharged on [DATE]. Record review of clinical record for Resident #1's discharge summary and MDS assessment for discharge date d 8/12/21 revealed she was assessed to be discharged into the community, the discharge was planned and completed. The MDS assessment was not completed, locked and transmitted until 11/29/2021 after discovered by this surveyor. During an interview on 12/1/2021 at 10:00 AM, DON said every morning they had a meeting to discuss clinicals that included the Administrator, DON, MDS, Social Worker and the Rehab Director. She said the admission/discharge coordinator was also included in the meeting but would leave the meeting when clinicals were being discussed. She said during the clinical meeting they would discuss new or changes that included significant changes of the residents. She said the nurses or social worker would usually notify the MDS coordinator of changes. The facility has no formal tracking system for completion and transmittal of discharge MDS. During an interview on 12/01/21 at 10:10 a.m. with MDS nurse said that she was the one that submitted the Discharge MDS on 11/29/21. When asked the required timeline to submit a discharge MDS, she stated, 14 days after the resident was discharged . She said they used the RAI (Resident Assessment Instrument) manual to assess the residents. MDS-nurse said she missed completing and transmitting the assessment. Record review of a facility policy titled Resident Assessment with a revision date of 2019 indicated: . (5) Obra required assessments, discharge assessment, conduct when a resident is discharged from the facility. Record review of the RAI Manual Obra Assessment Summary page 2-16 revealed that the MDS completion date is to be no later than the discharge date plus 14 calendar days. N1364 Refer to CMS 2567 F640 dated 12/01/2021 for evidence of licensure violation.

Based on interview and record review, the facility failed to ensure a person-centered plan of care was implemented and physician orders [REDACTED]. (Resident #130) This failure could place residents at risk for more than minimal harm. *Resident #130's daily weights were not completed as ordered by the physician. Findings included: A consolidated physician order [REDACTED].#130 was an [AGE] year-old female born on 11/18/39. She was initially admitted to this facility on 09/19/18 and readmitted on [DATE] with [DIAGNOSES REDACTED]. An individual physician order [REDACTED].#130 was to have daily weights every morning related to unspecified [MEDICAL CONDITION]. A weight report of Resident #130's weights for May, June, July and August 2020 indicated that on: 05/09/20 Resident #130's ordered daily weight was not done. 05/10/20 Resident #130's ordered daily weight was not done. 05/16/20 Resident #130's ordered daily weight was not done. 05/17/20 Resident #130's ordered daily weight was not done. 07/18/20 Resident #130's ordered daily weight was not done. 07/19/20 Resident #130's ordered daily weight was not done. 07/24/20 Resident #130's ordered daily weight was not done. 07/25/20 Resident #130's ordered daily weight was not done. 07/26/20 Resident #130's ordered daily weight was not done. 07/27/20 Resident #130's ordered daily weight was not done. 08/03/20 Resident #130's ordered daily weight was not done. 08/04/20 Resident #130's ordered daily weight was not done. A quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #130 had an active [DIAGNOSES REDACTED]. An undated care plan indicated Resident #130 .has [MEDICAL CONDITION] and is receiving [MEDICATION NAME]. She is at risk for fluid overload. During an interview on 09/14/20 at 09:35AM RN A said Resident #130 had recently returned from the hospital where she was treated for [REDACTED]. During an interview on 09/15/20 at 02:20PM LVN B said Resident #130 had an order for [REDACTED]. During an interview on 09/16/20 at 10:35AM the MDS/RN said she was the ADON until recently. She said Resident #130 had been hospitalized from [DATE]-05/04/20 which was why no weights were recorded. She said the restorative aid does the weights but is sometimes not working on weekends and this appears to be when most of the missing weights occurred. She said it is the nurses' responsibility to make sure the doctor's orders are carried out. She said no weights were done or documented for 7/24, 7/27, 8/3, 8/4, 8/14, 8/19, 8/20, 8/21 of 2020. She said the DON was putting the order on the TAR so it would no longer be overlooked. During an interview on 09/16/20 at 11:21AM the DON said some of Resident #130's daily weights had not been performed or recorded. He said the weights were done by the restorative aid, but the ultimate responsibility for ensuring physician orders [REDACTED]. He noted the weights had frequently been missed on weekends and this would coincide with the restorative aid being off. He said he changed the order to make it pop up in the nurse TAR as a reminder that the weight must be done and documented.

Based on interview and record review, the facility failed to ensure a discharge summary was completed for 1 of 2 residents reviewed for discharge summaries. (Resident #30) Resident #30's closed record did not include a discharge summary. This failure could result in incorrect, incomplete or misleading information being recorded regarding discharged residents. Findings included: physician's orders [REDACTED].#30 was an 88 -year-old female who admitted to the facility on [DATE] and expired [DATE]. The record did not include a discharge summary. During an interview on [DATE] at 02:39 pm, the administrator said a discharge summary had not been completed for Resident #30.

Based on interview and record review, the facility failed to ensure all irregularities identified by the licensed pharmacist were acted upon in order to minimize or prevent adverse consequences to the extent possible for 2 of 2 residents reviewed for drug regimen review. (Resident #s 14 and 10) The facility did not follow up on pharmacy consultant's findings with the physician for Resident #s 14 and 10 for 3 months. This failure could place residents being at risk for medication errors, unnecessary medications and incorrect administration. Findings included: 1. Physician order [REDACTED].#14 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #14's cognition was intact. A Pharmacy Consultant Medication Regimen Review for Resident #14 dated 06/24/20 noted she received [MEDICATION NAME] as needed. The pharmacy consultant noted Resident #14 requested [MEDICATION NAME] daily and sometimes twice a day. The pharmacy consultant recommended adding Tylenol 325 milligrams 2 tablets twice a day. The recommendation had not been addressed. During an interview 09/16/20 at 10:40 a.m., the MDS Coordinator said the recommendation had not been addressed by the physician. 2. Physician order [REDACTED].#10 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. His orders included [MEDICATION NAME] 1.5 (237 milliliters) bolus five times a day. The most recent MDS dated [DATE] indicated Resident #10's cognition was severely impaired. A gastrostomy tube care plan revised on 04/13/20 for Resident #10 indicated the resident would remain free of any side effects or complication related to his enteral feeding. A Pharmacy Consultant Medication Regimen Review for Resident #10 noted his April lab indicated an elevated potassium level of 5.5. The review indicated Resident #10 received [MEDICATION NAME] (enteral feeding) which was high in potassium with a daily dose of 66.5 milliequivalent. The pharmacy consultant recommended repeating the basic metabolic panel lab test. The recommendation had not been addressed. During an interview on 09/16/20 at 1:22 p.m., the MDS Coordinator, said the lab was not done. During an interview on 09/16/20 at 2:25 p.m., DON said he expected the pharmacy recommendations sent to the physician and back within one week. A Medication Regimen Review policy revised May 2019 noted, .The goal of the MRR (Medication Regimen Review) is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication .