Every finding on record at Reagan County Care Center

Based on record review and interview, the facility failed to conduct and document a comprehensive facility-wide assessment to determine what resources were necessary to care for its residents competently during day-to-day operations and review and update the assessment at least annually for 5 of 5 years (2021, 2022, 2023, 2024, and 2025) reviewed for facility assessment. The facility failed to conduct a Facility Assessment since 2021. This failure could place residents at risk of their needs going unmet and result in a lack of services provided by the facility to competently care for all residents. Findings included: A facility assessment was requested from the Administrator on 6/30/26 at 10:05 AM. Record Review of the most recent Facility Assessment revealed a completion date of 7/1/26. The previous Facility Assessment was completed on 10/18/21. In an interview on 05/26/24 at 1:47 PM, the Administrator said he had never completed a facility assessment and did not remember the requirement to complete/update it annually, even though he was sure he was trained previously. He said that was a failure on his part. He said he did not feel the failure would result in any negative consequences because the facility scheduled more than enough staff and had plans in place to move staff around during each shift if staff are absent.Record Review of the facility's policy Facility Assessment revealed, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication rooms that had Tuberculosis solution that was not labeled with an open date. The facility failed to ensure one Tuberculosis solution was labeled with the open date. This failure could place residents at risk of adverse medication reactions.Findings included: Observation on 6/30/2026 at 10:30 AM revealed the refrigerator in Medication room [ROOM NUMBER] had the following opened medications with no open date labeled: Aplisol Tuberculin solution Interview on 6/30/2026 at 10:41 AM with ADON, she said once Tuberculosis solution was opened, they need to be labeled with open dates. She stated tuberculosis solutions are good for 28 days after opening. She stated the risk of not having an open date was that they would not be able to know when they expire, and they will not be effective. She stated it was opened on Saturday 6/27/2026 when they had a new admit and only one dose was used. Interview on 6/30/26 at 12:36 PM with the DON revealed the tuberculosis solution when opened should be dated. He stated it was the responsibility of nursing management to check and audit the carts and medication rooms after the nurses. The DON said the nurses were responsible for dating the medication when opened. He stated tuberculosis solution was good for 28 days and should be dated once the vial was opened. He stated the risk of it not being dated is not knowing when it expires and could become ineffective. The DON stated there have been no negative outcomes due to the tuberculosis solution not being dated. Record review of the Recommended Medication Storage policy, undated, reflected the following: Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, interview, and record review, the facility failed to post the daily nurse staffing information in a prominent place readily accessible for visitors, staff, and residents for 1 of 1 facility reviewed on 6/30/2026, 7/1/2026, and 7/2/2026 for nursing services. The facility failed to post the daily nurse staffing information in a readily accessible place for visitors, and residents. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding the numbers of staff caring for the residents each shift and the facility census.The findings included: During an observation on 06/30/2026 at 9:50a.m., the daily staffing posting was behind the nurses' station and not accessible to residents and visitors. During an observation on 7/1/2026 at 11:30a.m., the daily staffing post was behind the nurses' station on the wall and not accessible to residents and visitors. During an observation on 7/02/2026 at 10:15a.m., daily staffing post was behind the nurses' station and not accessible to residents and visitors. During an interview on 7/1/2026 2:05pm with the ADON, she stated the staffing sheet was updated every morning by her or night nurse. The ADON stated the purpose of the daily staffing sheets was so that family and residents were aware of how many staff were available. During an interview on 7/2/2026 at 3:00pm with the DON, he stated that it has been the night nurse's responsibility to update the staff posting. The DON stated he would move the clipboard to where it was visible on the hallway. The DON stated the expectation was that it should be posted daily as required. The DON stated the risk of not posting the daily staffing could be residents and families not being aware of the staff available. During an interview on 07/2/2026, at 3:30pm with the Administrator, he said that the expectation was that daily staffing was posted daily where it was accessible by residents and visitors. He stated they would be moving where it was located so it is visible to residents and visitors. He said the Daily Staffing Sheet should be updated to show everyone (visitors or family) how many staff are available each shift. Record review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, August 2022, indicated, Our facility will post daily for each shift Nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents.Within two hours of the beginning of each shift, the number of licensed nurses and the number of unlicensed nursing personnel directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on interviews, observation, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #1) of 2 residents reviewed for PASRR services. The facility failed to submit a complete an accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASRR services for a better quality of life and could lead to a decline in health.Findings include: Record review of Resident #1's face sheet dated 01/14/2026 revealed a [AGE] year-old male, admitted to the facility on [DATE]. He had the following diagnoses: cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture) depression (a serious mood disorder causing persistent sadness, loss of interest and affecting thoughts) and chronic kidney disease (progressive damage and loss of function in the kidneys). Record review of Resident #1's MDS quarterly assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. He was understood by others and understood others. He used a wheelchair for mobility. Record review of Resident #1's care plan initiated on 5/6/2025 revealed Resident #1 was PASRR positive related to developmental disability, will participate in quarterly care plan meetings with PASRR representative, the coordination of PASRR services, and Individual Service Plan would be developed by the PASRR representative. Record review of Resident #1's PCSP dated 12/19/2025 revealed the quarterly IDT meeting was held on 12/19/2025. Attendees included the PASRR Habilitation Coordinator, MDS Coordinator, and Resident #1. The following NFSS were identified and confirmed: Customized Manual Wheelchair - 6 (indicated pending), Durable Medical Equipment-Gait Trainer-6 (pending), and Orthotic Device-6 (pending). In section A3300, Local Authority Comments stated the CMWC, Orthotics, and gait trainer were still pending. During an observation on 1/14/2026 at 2:00 PM, Resident #1 was wheeling himself down the hall in his wheelchair to go to an activity. He was utilizing the handrails in the hallway to pull himself down the hall instead of pushing the wheels to make the chair go. Resident #1 was able to make it to the destination independently. During an interview on 1/14/2026 at 12:44 PM the PASRR Habilitation Coordinator recommended customized manual wheelchair, gait trainer, and orthotics. Habilitation Coordinator states these have been an ongoing request for almost a year now and it has not been completed. PASSR HC stated there has been no negative outcome but if it is not completed soon Resident #1 could have a decline in mobility. During an Interview on 1/14/2026 at 1:15 PM with Resident #1, he stated he has been waiting for approximately one year for a customized manual wheelchair, gait trainer, and orthotics. Resident #1 stated a guy came out and showed him a chair, got his measurements, and said he would bring the chair back once all the paperwork was completed. Resident #1 stated it was his understanding that the paperwork from the facility had not been approved. Resident #1 stated the Physical Therapist told him the current chair he was in was too big. Resident #1 stated the chair he was using was fine, and he uses it for mobility. Resident #1 denied negative outcomes from not receiving this equipment. During an Interview on 1/14/2026 at 1:30 PM with the DOR (Physical Therapist), she stated Resident #1 was not currently on therapy services. The DOR stated she assisted the DME company with measurements for the wheelchair and gait trainer. DOR stated she does not know where the paperwork is in transition, but she doesn't remember it taking that long in the past. She stated she has not noticed or been reported to about a decline in Resident #1's physical mobility, but she does agree that he needs a better fitting chair. She stated the risk of this not getting completed could be a decline in physical mobility. During an Interview on 1/14/2026 at 2:00 PM with MDS Coordinator, she stated it was her responsibility to enter the NFSS form into the LTC online portal. She stated she has been trying to enter the information into the LTC portal to get funding approval for the wheelchair. She stated she keeps receiving error messages each time she tries to submit the form. MDS Coordinator has reported this to PASRR HC. She stated, she emailed the Lead PASRR specialist at the DME company for help, and the Lead PASRR specialist sent her a brochure. She stated she reached out to Simple LTC online portal, but they provided no assistance. She stated she worked at facility for 7 years and has not received training on PASRR. She stated she would continue to work on it. She stated the risk of not getting this done timely could result in Resident #1's physical decline in mobility and ADLs. MDS Coordinator stated it has not negatively affected Resident #1 at this time. During an interview on 1/14/2026 at 3:30 PM with the Administrator, he stated things kept getting messed up on multiple levels. He stated he was not aware the MDS Coordinator had not received PASRR training. He stated he would look into getting her some training. He stated, for training, they use computer-based software and do in services one on one on an as needed basis. He stated he met with the Habilitation Coordinator and knew they had some trouble getting paperwork completed, but he assumed things were taken care of. He stated determining the risk of this noncompliance was out of his scope. Administrator stated, he has not noticed a decline in Resident #1's condition. During an interview on 1/14/2026 at 3:43 PM with the DON, he stated he was not aware the process had not been completed. He was not aware of the complications. The DON stated they did not do PASRR training that he is aware of, and he was not aware of the MDS Coordinators' lack of knowledge or training on PASRR. He stated he does not have PASRR training himself. He stated the risk of Resident #1 not having the recommended equipment could be safety, and slower mobilization. During an interview on 1/14/2026 at 4:23 PM with Resident #1's Physician, he stated Resident #1 had not had a decline, but his mobility is expected to decline due to his diagnosis of Cerebral Palsy; not because CMWC and DME's have not been provided. He stated the risk of not having these items is minimal. Surveyor requested facility policy on PASRR but was not provided with a PASRR policy prior to exiting.

Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS (Centers for Medicare & Medicaid Services) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS . The facility failed to submit Payroll Based Journal staffing information to CMS for the fiscal year Quarter 1 2025 (October 1 - December 31). The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. The findings included: Record review of the PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 1 2025 (October 1 - December 31) dated 05/12/2025, revealed the following entry: Failed to Submit Data for the Quarter .Triggered .Triggered=No Data Submitted for the Quarter. Review of the facility's Employee List dated 6/27/23 indicated the following staff quantities: 1 Administrator 3 RNs (included DON) 5 LVNs. 14 CNAs 3 Maintenance Personnel 9 Housekeeping Personnel 1 Human Resources 10 Dietary Personnel 1 Activity Director. Record review of the facility CMS form 672 (Resident Census and Conditions of Residents) dated 05/13/2025 provided by the DON indicated a total of 27 residents in the facility. During an interview on 05/13/2025 at 10:45 AM Chief Financial Officer (CFO), stated that Quarter 1 was the first time she had submitted the data on her own and assumes she did it wrong. CFO stated she had submitted the information, but it apparently did not go through. CFO stated she did not know she was supposed to receive an email, so she did not follow up with it. CFO stated since it was past the deadline it would not let her submit any data. CFO stated that she has all the data to submit and was submitting early, so she had a few days to follow up and correct anything if needed.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #2) reviewed for incontinent care. The facility failed insure CNA A changed her contaminated gloves and clean Resident #2's penis area during incontinent care. These failures could place resident's risk for cross contamination and the spread of infection. Finding included: 1. Record review of Resident #2's electronic admission record dated 05/14/2025 indicated he was admitted to the facility on [DATE] with diagnoses of Alzheimer ' s disease and aphasia (difficult talking). He was [AGE] years of age. Record review of Resident #2's care plan revised 11/22/23 indicated in part: Focus: Resident has frequent bladder and bowel incontinence. Is at risk for skin breakdown and infection. GOAL: Resident will have minimal to no signs/symptoms of skin breakdown or infection due to incontinence and brief use. Interventions: Clean peri-area with each incontinence episode. Record review of Resident #2 ' s quarterly MDS dated [DATE] indicated in part: BIMS = 5 indicating the resident had severe impairment. Bladder and bowel: Urinary continence = Occasionally incontinent. Bowel continence = Occasionally incontinent. During an observation on 05/13/25 at 11:22 AM CNA A and CNA B performed incontinent care for Resident #2. Both staff members entered the resident's room, sanitized their hands, and put some gloves on. CNA A then undid the resident's brief, took some wet wipes, and cleansed the resident's scrotum but did not perform peri-care to the resident's penis. Both CNAs then turned the resident on his side and without changing gloves CNA A wiped the residents ' buttocks with some wipes and then took some barrier cream and applied it to the residents ' buttocks. While still wearing the same gloves first put on by CNA A, CNA A took the new brief and fastened it to Resident #2, pulled up the resident's pants, placed the mechanical lift sling under the resident and handled the mechanical lift machine remote to transfer the resident to the Geri- chair. After they were done the CNA ' s sanitized their hands and exited the room. During an interview on 05/15/25 at 3:07 PM the DON was made aware of the observation of the incontinent care performed by CNA A. The DON said it was expected for the CNAs to change gloves once they became contaminated to prevent cross contamination. The DON said it was also expected for CNAs to perform peri-care to the resident penis. The DON said that the ADON and himself were responsible to monitor that staff was using infection control procedures. The DON said they did that by rounds being conducted and in-services on proper incontinent care. The DON said the CNA not providing proper incontinent care and not changing her gloves could lead to cross contamination and possibility of UTIs. During an interview on 05/15/25 at 3:20 PM the Administrator was made aware of the observation of the incontinent care performed by CNA A. The Administrator said it was expected for the CNA to change their gloves once they became contaminated to prevent cross contamination. The Administrator said the CNA should have performed incontinent care to the resident ' s penis. The Administrator said he believed the failure occurred because CNA A got nervous and forgot the steps. The Administrator said the CNA ' s received in-services and training of proper incontinent care and glove use. Record review of the facility's policy titled Perineal Care dated 02/2018 indicated in part: Purpose - The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident ' s skin condition. Preparation - review the resident ' s care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed. For a male resident - wet washcloth and apply soap or skin cleansing agent. Wash perineal area starting with urethra and working outward. Retract foreskin of the uncircumcised male. Wash and rinse urethral area using a circular motion. Continue to wash the perineal area including the penis, scrotum, and inner thighs. Thoroughly rinse perineal area in same order, using fresh water and clean washcloth. Reposition foreskin of uncircumcised male. Ask the resident to turn on his side with is upper leg slightly bent, if able. Rinse washcloth and apply soap or skin cleansing agent. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. Dry area thoroughly. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. Record review of the facility's policy titled Handwashing/Hand hygiene dated 2001 indicated in part: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for hand hygiene - Hand hygiene is indicated after contact with blood, body fluids or contaminated surfaces; after touching a resident; Before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. Use an alcohol-based hand rub containing 60% alcohol for most clinical situations: Single-use disposable gloves should be used; before aseptic procedures; when anticipating contact with blood or body fluids; The use of gloves does not replace handwashing/hand hygiene. 48593 51011

Based on observation, interview, and record review, the facility failed to review and revise the care plans for 1 of 4 residents (Resident #21) whose care plans were reviewed in that: The facility failed to ensure Resident #21's care plan was revised to accurately reflect current indwelling urinary foley catheter status that was removed on 02/12/2025. These failures could place residents at risk of receiving inadequate individualized care and services. Findings included: Record review of Resident #21's electronic admission record dated 05/13/2025 indicated he was admitted to the facility on [DATE] with diagnoses of overactive bladder and Parkinson's disease. He was [AGE] years of age. Record review of Resident #21's care plan revised 12/18/24 indicated in part: Focus: Resident has foley catheter due to Benign prostatic hyperplasia with urinary retention. Will refer him to Urologist (doctor who focuses on the diagnosis and treatment of conditions related to the urinary [NAME]). GOAL: Resident will be/remain free from catheter-related trauma through review date. Interventions: Check tubing for kinks each shift. Monitor/document for pain/discomfort due to catheter. Record review of Resident #21's quarterly MDS assessment dated [DATE] indicated in part: BIMS = 7 indicating had severe impairment. Section H Bladder and bowel indicated none for indwelling catheter. Record review of Resident #21's order summary report for May 2025 documented in part: Discontinue Catheter today. May replace catheter if unable to void within 6-8 hours after removing catheter. Order start date: 01/16/2025. During an interview and observation on 05/14/25 at 10:52 AM Resident #21 was sitting up in his recliner in his room awake and alert. There was no observation of an indwelling urinary catheter being used by the resident. Resident #21 said he used to have a catheter some months ago but no longer had one and that it had been removed. The resident said he now used a urinal to pee whenever he had to go. During an interview on 05/14/25 at 11:55 AM CNAs A and B said Resident #21 no longer had an indwelling urinary catheter but did have one several months ago. During an interview on 05/14/25 at 2:35 PM charge nurse RN E said she was Resident #21's charge nurse. RN E said the resident did not have an indwelling catheter anymore at this time. RN E said she had removed that urinary catheter back in January 2025 but had restarted it back on 02/04/2025 then another nurse discontinued it again on 02/12/25. Record review of Resident #21's nurses note indicated 2/12/2025 04:42 am, Foley catheter. Discontinued per order, resident tolerated procedure well, urine yellow in color without sediment. Completed LVN F. During an interview on 05/14/25 at 2:45 PM the MDS coordinator said she updated the care plans as needed or quarterly or annual as triggered on the MDS. The coordinator said if for example a resident went off an indwelling urinary catheter then it should have come off the care plan. The coordinator said she must have missed that because she had not removed the indwelling urinary catheter from Resident #21's care plan and that she would update it. During a phone interview on 05/14/25 at 4:00 LVN F stated she had discontinued Resident #21's indwelling catheter on 02/12/2025 and as far as she knew the resident did not have another one reinserted. During an interview on 05/15/25 at 3:10 PM the DON stated that the MDS coordinator was the person in charge of updating the care plans whenever there was a change and that he would sign off on them. The DON said after Resident #21 had his urinary indwelling catheter discontinued back in February 2025 then it should have been removed from his care plan, but it was missed. During an interview on 05/15/25 at 3:24 PM the Administrator said it was expected for the resident's care plans to be kept up to date. The Administrator said that the indwelling urinary catheter care should have been removed from the care plan, but it was missed. The Administrator said the care plan had already been updated to reflect what?. Record Review of the facility's policy titled Care Plans dated 2001 indicated in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan includes: measurable objectives and time frames; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical. Mental and psychosocial well-being. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The interdisciplinary team reviews and updates the care plan: at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety for 1 of 1 kitchen and 1 of 2 Maintenance personnel (Ground Maintenance D) reviewed for kitchen sanitation in that: The facility failed to ensure Ground Maintenance D was wearing a moustache guard or a beard guard when he was in the kitchen and while staff was preparing uncovered food. These deficient practices could place residents who consumed meals and/or snacks from the kitchen at risk for food borne illness. The findings included: During an observation on 05/13/25 at 10:05 AM the facility Ground Maintenance Man D was observed in the kitchen while food was being prepared by the kitchen staff. Ground maintenance man D was observed to have a moustache and beard which was not covered. On the kitchen entrance door was a posted sign that indicated Notice hairnets and beard must be covered beyond this point. During an interview on 05/14/25 at 3:45 PM Ground Maintenance Man D said that he normally wore a face mask when he entered the kitchen. He said yesterday when he had entered the kitchen, he had gone in to repair the food disposal and forgot to wear his mask. During an interview on 05/15/25 at 9:52 AM the Dietary Supervisor said that staff were expected to wear a hair or beard restraint whenever they entered the kitchen to prevent hair from landing on the food. The Dietary Supervisor said Ground Maintenance Man D had entered the kitchen to unstick (unclog) the food disposal but that he should have covered his beard and moustache. During an interview on 05/15/25 at 3:36 PM the Administrator said it was expected for staff to put on a hair net and beard restraint when entering the kitchen. The Administrator was made aware of the observation of Ground Maintenance D seen in the kitchen without a beard restraint while there was food in the open. The Administrator said the maintenance man should have put a beard restraint on as not wearing one could lead hair landing on the food. The Administrator said he believed the failure occurred because the maintenance man forgot to put on a beard restraint. Record review of the facility's policy titled Preventing foodborne illness-employee hygiene and sanitary practices and dated May 2021 indicated in part: Hairnets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 1 of 1 back patio reviewed for environment. The facility failed to keep a landscaped area on the back patio free of cat feces. This failure could lead to unsanitary conditions for residents and staff and possible parasitic infection. The findings included: Observation on 04/03/24 at 12:40 PM of back patio area/smoking area revealed approximately fifteen feet straight out from the door, was a large circle (approximately 10 feet in diameter) of rocks with a tree planted in the center. There was visible cat feces in several spots as well as multiple areas of dirt that had been dug out by an animal with claw marks visible in the dirt. The places that had been dug out were surrounding the base of the tree and all rocks had been removed from the area. There was a slight fecal odor noted to the area. In an interview on 04/03/24 at 01:09 PM the Maintenance Director stated that he had his guys go out 2-3 times a week to clean out cat poop in the front and back of the facility. He stated there had been no discussion of using litter boxes because the cats were wild animals, and they probably would not have used them. He stated that the smell did become an issue when it was hot outside, but he and his crew tried to stay on top of it. In an interview on 04/04/24 at 10:45 AM the Administrator stated that the cats did use the area under the tree as a makeshift litterbox and he agreed that was an issue. He stated that he believed putting litterboxes out and digging up the dirt and rocks surrounding the tree to remove the scent and re-landscaping that area would help deter the cats from using the tree as a bathroom. He stated that the maintenance is responsible for keeping the area clean. He stated there is no facility policy regarding the cats or the care of the cats, but he is currently working on making one. Review of www.CDC.gov Toxoplasmosis Epidemiology & Risk Factors Page last reviewed: September 4, 2018 Content source: Global Health, Division of Parasitic Diseases and Malaria revealed, in part: Toxoplasmosis is caused by the protozoan parasite Toxoplasma gondii. In the United States it is estimated that 11% of the population 6 years and older have been infected with Toxoplasma. In various places throughout the world, it has been shown that more than 60% of some populations have been infected with Toxoplasma. Infection is often highest in areas of the world that have hot, humid climates and lower altitudes, because the oocysts survive better in these types of environments. Animal-to-human (zoonotic) transmission: Cats play an important role in the spread of toxoplasmosis. They become infected by eating infected rodents, birds, or other small animals. The parasite is then passed in the cat's feces in an oocyst form, which is microscopic. Kittens and cats can shed millions of oocysts in their feces for as long as 3 weeks after infection. Mature cats are less likely to shed Toxoplasma if they have been previously infected. A Toxoplasma-infected cat that is shedding the parasite in its feces contaminates the litter box. If the cat is allowed outside, it can contaminate the soil or water in the environment as well. People can be infected by: Accidental ingestion of oocysts after cleaning a cat's litter box when the cat has shed Toxoplasma in its feces. Accidental ingestion of oocysts after touching or ingesting anything that has come into contact with a cat's feces that contain Toxoplasma. Accidental ingestion of oocysts in contaminated soil (e.g., not washing hands after gardening or eating unwashed fruits or vegetables from a garden) Drinking water contaminated with the Toxoplasma parasite.

Based on interview and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change of condition for 1 (Resident #11) of 28 residents reviewed for assessments, in that: The facility failed to complete a Significant Change MDS for Resident #11 within 14 days after the resident was admitted to hospice services. This failure could affect any resident who experienced a significant change in their condition requiring an MDS assessment and placed them at risk of not receiving needed services. Findings Included: Record Review of Resident #11's face sheet revealed an [AGE] year-old female with an admitted [DATE]. Resident #11 was admitted with diagnoses including atherosclerotic heart disease (thickening of arteries), dementia (progressive loss of intellectual functions), anxiety disorder (excessive worry), major depressive disorder (persistent depressed mood). Record Review of Resident #11's Quarterly MDS assessment dated [DATE] revealed a BIMs score of 11 out of 15 indicating cognition was moderately impaired. There was no Significant Change MDS found in resident's records. Record Review of Resident #11's care plan dated 01/05/24 reflected it had not been updated with being admitted to hospice. Record Review of Resident #11's physician orders revealed an order on 03/12/24 stating admit to nursing facility under Hospice for routine care with a diagnosis of hypertensive heart disease with heart failure. Interview on 04/03/24 at 02:15 PM with MDS consultant stated she took over as MDS consultant for this facility on March 1, 2024. MDS consultant stated she was in the facility on 3/13/24 and thought Resident #11 was an ongoing hospice resident. MDS consultant stated she was not kept up to date by the facility on the status of this resident, therefore a significant change MDS was not completed. She stated that she will do one now. Interview on 04/03/24 at 02:33 PM with ADON stated that MDS consultant was responsible for completing MDS and she was in the building on 3/13/24 and was made aware of Resident #11's status by ADON. Interview on 04/03/24 at 02:40 PM with Administrator stated that MDS consultant was contracted to complete all MDS assessments. Administrator stated that the facility and the consultant have a contract in place, however the MDS consultant works out of another city and rarely comes into the facility. Administrator stated that he is aware that the ultimate responsibility falls on the facility to ensure a change of status MDS is completed. Record Review of facility policy titled Change in a Resident's Condition or Status revised February 2021 read in part: A significant change of condition is a major decline or improvement in the resident's status that requires interdisciplinary review and/or revision to the care plan. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI instruction manual.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #5, #6 and #26) of 5 residents reviewed for infection control. Staff failed to place Resident #5's and #26's SVN (a machine that mixes medicine and converts it into a mist.) masks in a bag when not in use. CNA A failed to wash or sanitize her hands after removing her gloves and putting on a clean pair of gloves while assisting Resident #6 with incontinent care. This failure could place residents at risk for cross contamination and the spread of infection. Finding include: RESIDENT #5 Record review of Resident #5's admission record dated 04/03/2024 indicated she was admitted to the facility on [DATE] with diagnoses of dementia and chronic obstructive pulmonary disease (a chronic condition in which a patient's lungs are susceptible to infections and moreover, the infections show exaggerated symptoms in the patients). She was [AGE] years of age. Record review of Resident #5's physician orders dated 04/03/2024 indicated in part: Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% Albuterol Sulfate (Albuterol belongs to a class of drugs known as bronchodilators. It works by relaxing the muscles around the airways so that they open up and you can breathe more easily) one vial inhale orally via nebulizer one time a day related to COPD. Start date 12/05/2023. Record review of Resident #5's care plan dated 11/22/23 indicated in part: Focus: Resident requires continuous oxygen therapy r/t ineffective gas exchange secondary to COPD. Goal: Resident will have minimal to no s/s of poor oxygen absorption through the review date. Interventions: Give medications as ordered by physician. Monitor/document side effects and effectiveness. Record review of Resident #5's MDS dated [DATE] indicated in part: Section C - BIMS = 11 indicated resident was moderately impaired Section O - Special Treatments, Procedures, and Programs: Respiratory Treatments. During an observation and interview on 04/02/24 at 11:06 AM Resident #5's SVN machine was seen on her couch and the SVN mask was laying on top of the couch and not stored in a bag. Resident #5 said staff usually stored the SVN mask in a bag but there was not one to put it in at this time. RESIDENT #26 Record review of Resident #26's admission record dated 04/03/2024 indicated she was admitted to the facility on [DATE] with diagnoses of stroke and chronic obstructive pulmonary disease (a chronic condition in which a patient's lungs are susceptible to infections and moreover, the infections show exaggerated symptoms in the patients). She was [AGE] years of age. Record review of Resident #26's physician orders dated 04/03/2024 indicated in part: Xopenex Nebulization Solution 0.63 MG/3ML (Levalbuterol HCl) - (Bronchodilator, It can treat or prevent bronchospasm) 3 milliliter inhale orally via nebulizer every 6 hours related to COPD. Start date 02/10/2024. Record review of Resident #26's care plan dated 04/04/24 indicated in part: Focus: Resident has potential for impaired gas exchange and impaired airway clearance secondary to COPD. At risk for further decline in pulmonary function and at risk for respiratory infections. Goal: Resident Will Remain Free of Secondary Complications through the review date. will have minimal to no s/s of respiratory infections through the review date. Resident will display optimal breathing patterns daily. Interventions: Monitor for difficulty breathing (Dyspnea) on exertion. Remind the resident not to push beyond endurance. Monitor for s/s of acute respiratory insufficiency, Anxiety, Confusion, Restlessness, SOB at rest. Record review of Resident #26's MDS dated [DATE] indicated in part: Section C - BIMS = 08 indicated resident was moderately impaired Section O - Special Treatments, Procedures, and Programs: Respiratory Treatments. During an observation on 04/02/24 at 2:36 PM Resident #26's SVN mask was laying on top of the bedside dresser and not stored in a bag. Resident #26 said she would use the breathing machine at times but did not know anything about a bag. During an interview on 04/03/24 at 3:22 PM RN B said the SVN masks were supposed to be stored when they were not in use. RN B said if the SVN masks were not stored in a bag it could lead to infections. RN B said that perhaps the residents took the masks off at times and they placed them just anywhere. RN B said it was their responsibility to make sure the masks were kept stored in a bag. RESIDENT #6 Record review of Resident #6's admission record dated 04/03/2024 indicated she was admitted to the facility on [DATE] with diagnoses of mild intellectual disabilities and generalized anxiety disorder. She was [AGE] years of age. Record review of Resident #6's care plan dated 03/28/24 indicated in part: Focus: Resident has frequent bladder and bowel incontinence. Goal: Resident will remain free from skin breakdown due to incontinence and brief/pull up use through the review date. Interventions: Clean peri-area with each incontinence episode. Record review of Resident #6's MDS assessment dated [DATE] indicated in part: BIMS = 12 indicating resident was moderately cognitively impaired. Urinary continence = Always incontinent (no episodes of continent voiding). Bowel continence = Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement). During an observation on 04/02/24 at 2:42 PM CNA A performed incontinent care for Resident #6. CNA A entered the resident's room, washed her hands and put on some gloves. CNA A undid the Resident #6's brief and with some wet wipes she wiped the resident's vaginal area from front to back then turned the resident on her side and again wiped from front to back with the wet wipes. CNA A's gloves came in contact with the resident's vaginal and rectal area during the wiping. The resident had voided as her brief was noted to be wet. CNA A then pulled the brief off and threw it in the trash and then removed her gloves. Without washing her hands or sanitizing her hands the CNA put on a new pair of gloves and then applied the new brief to Resident #6 and then covered her back up. During an interview on 04/03/24 at 2:38 PM CNA A said she should have washed her hands or sanitized prior to putting on the clean pair of gloves. CNA A said she had been trained on that but just forgot. CNA A said if she did not sanitize or wash her hands in between glove changes that could lead to cross contamination. Record review of the facility's policy titled Respiratory therapy - prevention of infection dated 11/2011 indicated in part: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators among residents and staff. Infection control considerations related to medication nebulizers/continuous aerosol: 1. Obtain equipment (i.e. administration set up plastic bag, gauze sponges). 2. wash hands. 3. After completion of therapy. a. remove the nebulizer container. b. rinse the container. c. dry on a clean paper towel or gauze sponge. 4. Reconnect to the administration set up when air dried. 5. Take care not to contaminate internal nebulizer tubes. 6. Wipe the mouthpiece with damp paper towel or gauze sponge. 7. store the circuit in plastic bag marked with date and resident name, between uses. 8. Wash hands. 9, Discard the administration set up every seven (7) days. During an interview on 04/04/24 at 12:36 PM the ADON said it was her expectation for staff to wash or sanitize their hands prior to putting gloves on or after they removed them. The ADON said staff were expected for the SVN masks to be stored in a bag when not in use. The ADON said if staff did not wash or sanitize their hands at the appropriate times it could lead to cross contamination. The ADON said if staff did not place the SVN masks in a bag then that could lead to germs getting into the mask and residents breathing them. During an interview on 04/04/24 at 01:26 PM the Administrator said it was expected for staff to wash or sanitize their hands prior to putting gloves on or after they removed them. The Administrator said if the staff did not sanitize their hands it could lead to cross contamination. The Administrator said the SVN masks were expected to be stored in a bag to prevent cross contamination. The Administrator said the staff would forget to place the items in the bags or to wash or sanitize their hands as they would get nervous at times. Record review of the facility's policy titled Standard precautions dated 09/2022 indicated in part: Standard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions and excretions (except sweat) non-intact skin and mucous membranes may contain transmissible infectious agents. Standard precautions include the following practices: Hand Hygiene - hand hygiene refers to handwashing with soap or the use of alcohol-based hand rub which does not require access to water - after removing gloves. Gloves are changes as necessary during the care of a resident to prevent cross contamination from one body site to another (when moving from dirty site to a clean site). Record review of the facility's policy titled Handwashing/hand hygiene dated 08/2019 indicated in part: This facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol or alternatively soap and water for the following situations. Before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin/ after contact with blood or bodily fluids; after removing gloves. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace handwashing/hand hygiene.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 28 residents (Residents #11) reviewed for care plans in that: The facility failed to ensure Resident #11's Care Plan addressed her hospice status. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Record Review of Resident #11's face sheet revealed an [AGE] year-old female with an admitted [DATE]. Resident #11 was admitted with diagnoses including atherosclerotic heart disease (thickening of arteries), dementia (progressive loss of intellectual functions), anxiety disorder (excessive worry), major depressive disorder (persistent depressed mood). Record Review of Resident #11's Quarterly MDS assessment dated [DATE] revealed a BIMs score of 11 out of 15 indicating cognition was moderately impaired. Record Review of Resident #11's care plan dated 01/05/24 reflected it had not been updated with being admitted to hospice. Record Review of Resident #11's physician orders revealed an order on 03/12/24 stating admit to nursing facility under Hospice for routine care with a diagnosis of hypertensive heart disease with heart failure. Interview on 04/03/24 at 02:15 PM with MDS consultant stated she took over as MDS consultant for this facility on March 1, 2024. MDS consultant stated she was in facility on 3/13/24 and thought Resident #11 was an ongoing hospice resident. MDS consultant stated she was not kept up to date by the facility on the status of this resident. She stated she is not in charge of creating care plans and she is unsure who is. Interview on 04/03/24 at 02:33 PM with ADON stated that MDS consultant was in the building on 3/13/24 and was made aware of Resident #11's status by ADON. ADON stated that MDS consultant is responsible for creating care plans. Interview on 04/03/24 at 02:40 PM with Administrator stated that MDS consultant was contracted to complete all care plans. Administrator stated that the facility and the consultant have a contract in place, however the MDS consultant works out of another city and rarely comes into the facility. Administrator stated that he is aware that the ultimate responsibility falls on the facility to ensure care plans are completed. Review of facility policy Care Plans dated March 2022 revealed in part: A care plan includes instructions needed to provide effective, person-centered care plan of the resident that meet professional standards of quality care. A comprehensive care plan is developed within 7 days of completing the resident assessment.

Based on observation and interview the facility failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 1 of 1 medication storage compartments (DON's office) reviewed for labeling/storage of drugs and biologicals. The facility failed to ensure stored discontinued controlled medications and biologicals were separately locked and in a permanently affixed compartment kept in the DON's office. This failure could place residents at risk of drug diversion and unauthorized access to medications. The findings included: During observation and interview on 4/4/24 at 1:25 PM with the ADON of the discontinued controlled medication cabinet in the DON's office it was noted that the cabinet only had one functioning lock. The medications were stored in the bottom drawer of a two-drawer filing cabinet that was bolted to the wall. The bottom drawer had an external pad lock on the left side of the bottom drawer and the built-in lock on the top right side to lock both drawers. The ADON stated that the built in lock was a functioning lock, but the key had been lost when the facility had moved furniture around and the cabinet was not being used to store the discontinued medications. The ADON stated that initially there was a second padlock on the right side of the bottom drawer, but it had to be removed because the drawer was getting stuck when it was opened. The ADON confirmed that meant there was only one drawer lock and the office door lock. She stated the DON, herself, the Administrator and possibly the housekeeping staff had keys to the DON's office, but she would have to confirm that with the housekeeping supervisor. In an interview on 4/4/24 at 1:45 PM the Housekeeping Supervisor stated that she had a master key to the DON's office but none of her staff had access to the office and only went into that office when the DON or ADON were present. She stated that she knew the Maintenance Director and his staff all had master keys as well. In an interview on 4/4/24 at 2:00 PM the Maintenance Director stated that he and all of his staff were required to have master keys to all offices in the facility for safety reasons such as fire. He stated that including himself there were four maintenance staff bringing the total of people with keys to the DON's office to seven. He stated there was no way to put an additional lock on the office door because the maintenance department would still need to have access, but he would be able to put an additional lock on the cabinet until a different solution could be worked out by the ADON and the Administrator. In an interview on 4/4/24 at 2:40 PM the Administrator stated that he had been made aware of the issue with the need for double locks on the discontinued controlled medication storage cabinet in the DON's office. He stated that during a previous survey the facility was told that having one lock on the cabinet and the lock on the office door was sufficient. After the findings were fully explained to him, he agreed that seven people having access to the office without a double locked cabinet was a high risk for a drug diversion and he would start looking at alternative storage options. At the time of exit the facility had not provided a policy on medication storage for review on 4/4/24.

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 all drugs and biologicals) to meet the needs of residents, 1 of 2 Medication Carts and 1 of 1 Medication Storage Rooms reviewed for pharmacy services. - The facility failed to ensure Medication Cart #1 did not include an expired box of Hyoscyamine SL tablets, Ondansetron tablets, and AZO Bladder Control tablets. - The facility failed to ensure the Medication Storage Room did not contain an expired box of Thick and Easy Food and Beverage Thickener, and Promethazine HCL suppositories. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and worsening of symptoms of diseases. Findings Included: Medication Cart #1 In an observation 02/22/23 at 3:50PM, inventory of Medication Cart #1 with LVN A revealed: - a box of Hyoscyamine SL tablets 0.125mg, expired 11/05/22 - a box of Ondansetron tablets 4mg, expired 08/12/22 - a bottle of AZO Bladder Control tablets, expired 01/23 Medication Storage Room In an observation on 02/22/23 at 1:45PM, inventory of the Medication Room with LVN A revealed: - one box of Thick and Easy Food and Beverage Thickener, expired 05/10/22 - eight individually packed Promethazine HCL 25mg suppositories, expired 09/22 In an interview on 02/22/23 at 4:00 PM, LVN A stated that she had only been employed at the facility for 5 days, but the DON would be available the next day for questions. In an interview on 02/23/23 at 10:30 AM the DON stated that she audits medication carts and the medication room thoroughly on a quarterly basis. The DON stated the last check was probably November 2022, there is no documentation of audit. The DON stated that she relies on her staff to check their carts, and the charge nurses are supposed to check for expired meds daily. The DON stated that it is important for expired medications to be disposed because expired medications will have decreased efficacy and will not work the way they should. Record review of the facility policy titled Storage of Medications undated reads in part: Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on interview and record review, the facility failed to ensure dialysis service was provided consistently with professional standards of practice for 1 of 2 residents (Resident #25) reviewed for dialysis services. The facility failed to keep ongoing communication with the dialysis facility for Resident #25. The facility failed to have a contract with Resident #25's providing dialysis center prior to 02/23/23. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Review of Resident #25's Admission Record, dated 2/21/23, revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] with diagnosis including Stage 5 Kidney Disease and Dependence on Renal Dialysis. Review of Resident #25's Significant Change MDS, dated [DATE], revealed: He had a cognitive status exam score of 12 of 15 (indicating he was moderately cognitively impaired). He needed one person assistance for activities of daily living. Special treatments included dialysis. Review of Resident #25's Care Plan, initiated 11/8/22, revealed Issue: Resident #25 needed hemodialysis related to renal failure. Identified goals included: Resident #25 will have immediate intervention should any signs or symptoms from dialysis occur through the review date. Identified interventions included: encourage him to go to dialysis appointments. Resident #25 receives dialysis M-W-F at [provider]. (Communicating with the provider was not an identified intervention.) Review of Resident #25's Order Summary Report, dated 2/21/23, revealed orders dated 12/15/22 for Dialysis at [Provider] Monday/ Wednesday/ Friday. Review of Resident #25's Nurse's Notes between 11/9/22 through 2/22/23 revealed the only communication with the dialysis provider was: 11/9/2022 at 05:07 a.m. a call was placed to the provider for resident's scheduling for dialysis and was not able to speak with an actual person; after selecting a few different prompts, the recording said for all other questions to call back during regular business hours, 7:30 to 5:30. The DON was notified. Review of Resident #25's Nurse's Notes between 11/9/22 and 2/22/23 revealed complications the dialysis provider should have been communicated and coordinated with include: 2/17/2023 at 2:58 p.m.: Received report from LVN from Hospital stating resident is ready to be discharged back to building. Will have new medications for the blood thinner Apixaban 2.5mg twice a day for two weeks. Administrative assistant notified so Dialysis will be notified of return to previous dialysis schedule Monday. 2/15/2023 at 3:27 p.m. Resident admitted to Hospital due to blocked shunt. 2/15/2023 at 3:24 p.m. Late Entry: Resident had two areas on shunt to left arm bleeding RN re-dressed dressing on site. Notified oncoming nurse. 12/21/2022 at 2:11 a.m.: Noted on Physician appointment form from 12/20/22 with doctor. Resident #25 had appointment with doctor to evaluate arteriovenous (into the vein) access for dialysis. Physician notes: Patient with End Stage Renal Disease on dialysis; needs arteriovenous access; arteriovenous graft placement on 1/5/23. 12/29/2022 at 3:29 p.m.: Resident returned from Hospital via facility van accompanied by staff. Resident came into facility walking with cane feeling short of breath. Resident lying in bed at this time resting. Will notify oncoming nurse. Interview on 02/21/23 at 10:34 AM Resident #25 stated he was on dialysis three times a week in a neighboring city. Interview on 2/22/23 at 4:33 PM the DON confirmed Resident #25 was on dialysis. She said she did not have a good answer for how information was communicated between the facility and the dialysis company. She said a lot of time a phone call between the facility and the doctor occurred. The DON stated she had spoken with the dialysis group, and they asked for his weight and once they informed the driver that Resident #25 had to go to the emergency room because he had a blocked shunt . She said the facility did not have a form that went with the resident to dialysis. She said care that needed to be provided to the center would be thrill and bruit (the feel and sound of blood flow through the dialysis shunt). She said the facility did weekly weights on the resident and medications. The DON said other information that needed to be communicated would be a decrease in urine output or weight gain. The DON said the nurses called the dialysis center if there were abnormal vital signs. The DON said vital signs should be documented in the resident's record. The DON stated Resident #25 had two hospitalization s that could or were complications from dialysis. She said monitoring dropped off the documentation after Resident #25's first hospitalization and when she did a chart audit on his return from the second hospitalization , she corrected the error. The DON stated in other facilities she worked at there was a form, but at this facility most of the communication was done over the phone . The DON stated the dialysis provider had been very hesitant to share information about Resident #25's condition after dialysis including fluids removed. The DON stated complications for this included a lack of continuity of care back and forth and that Resident #25's shunt could get blocked off. She said the shunt did get blocked off recently and he was in the hospital for a couple of days. Interview on 2/22/23 at 4:45 PM the Administrator stated he provided the contract from the other dialysis company used but was not sure he provided the contract from Resident #25's provider. Interview on 2/23/23 at 10:33 AM the DON stated Resident #25's shunt was placed on 1/5/23 but he had a catheter prior to that. She stated the care provided would be similar, but the shunt collapsed the first time dialysis used it. The DON stated she went through previous paperwork for communication methods. She agreed there was not a monitoring process for Resident #25's dialysis shunt prior to 2/18/23. She agreed there was not ongoing consistent communication between the nursing facility and the dialysis facility. The DON said the facility should be communicating with the dialysis company . The DON stated she did not have information as to why the dialysis provider did not give information on Resident #25 upon him leaving. The DON said she had not talked to the Dialysis provider about it. The DON said when Resident #25 was first admitted the facility had a lot of problems with his blood pressure, but he had just started dialysis. The DON stated the doctor adjusted his medications. She stated communication was primarily with hospitals. The DON said information the facility would need was his pre-dialysis weight, how much fluid was removed, and his post dialysis weight, vital signs while he was there and if there were any problems. She said she needed her nurses to check the shunt and make sure it was ok. The DON stated the facility did not have a lot of dialysis residents so not monitoring it was an oversight. The DON said the nurses were not documenting Residents #25's condition upon return and were not documenting any ongoing communication. She explained when dialysis sent Resident #25 to the hospital for the collapsed shunt the transportation team was who called the facility nurses and the facility nurses were the ones who called the hospital to give report. Interview on 2/23/23 at 2:19 PM the DON said she had no addition information on Resident #25. Review of the Nursing Home Dialysis Transfer Agreement on 2/23/23 with Resident #25's provider, dated 2/23/23 revealed: Written protocol: Center will develop a written protocol governing specific responsibilities, policies and procedures to be used in rendering dialysis services to Designated Resident at Center, including, but not limited to, the development and implementation of a Designated Resident's care plan relative to the provision of dialysis service. to Designated Resident's care plan relative to the provision of dialysis services. Facility will provide for the interchange of information useful or necessary for the care of the Designated Resident and provision of dialysis resident by Center to the Designated Residents of Facility. Notwithstanding anything herein to the contrary, Company and Center reserve the right to discontinue the provision of dialysis services to any Designated Residents of Facility who, in the sole discretion of the Company and Center, does not observe the establish responsibilities, policies and procedures of Center. (The Contract was dated after survey beginning) Review of the facility's policy and procedure on Hemodialysis, dated February 2023, revealed, The facility will assure that each resident receives care and services for the provisions of hemodialysis and/or peritoneal dialysis consistent with standards of practice, comprehensive person-centered care plan and the resident's goals and preferences to meet the special medical, nursing, mental and psychosocial needs of residents receiving hemodialysis. The facility will ensure that each residents receives care and services for dialysis consistent with practice standards, which will include: 1. Ongoing assessment of resident's conditions and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. 2. Ongoing assessment and oversight of the resident, before, during, and after dialysis treatments, including monitoring of the resident's condition, implication of appropriate interventions and using appropriate infection control practices. 3, Ongoing communication and collaboration with the Dialysis Facility regarding Dialysis, regarding Dialysis. Implementation The facility will coordinate and collaborate with the dialysis facility assure that: the provision of the dialysis treatments and care of the resident meets current standards of practice for the safe administration of the dialysis treatments. Documentation requirements are met to assure that treatments are provided as ordered by the nephrologist, attending physician and dialysis team. There is ongoing communication and collaboration for the development and implementation of the dialysis care plan by the nursing home and dialysis staff.

Based on interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of four residents reviewed for accidents and supervision. The facility failed to provide adequate supervision to Resident #1. As a result, she eloped from the facility and was located approximately 1 hour and 40 minutes later in 39° Fahrenheit weather on the opposite side of the hospital complex. Resident #1 had had an apparent fall which resulted in a hematoma to the right orbital eye area and 1 cm x 1 cm abrasion to right eyebrow. It was determined a past non-compliance Immediate Jeopardy existed from 01/17/22 to 01/25/22. The Immediate Jeopardy was determined to have been removed on 01/25/22 due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation on 02/17/22. This failure could place residents at risk for elopement, accidents, falls and injury and death. Findings included: Review of Resident #1's Admission Record dated 03/01/22 indicated she [AGE] years and was admitted to the facility on [DATE]. Diagnoses included unspecified convulsions, Alzheimer's Disease, [CONDITION(S)], mood, and anxiety disorders. Review of Resident #1's MDS assessment dated [DATE] indicated she had a BIMS score of 4 meaning she had severe cognitive impairment. No problematic behaviors were listed. She required supervision or limited assistance for ADLs. She used a walker for mobility. Review of Resident #1's comprehensive care plan dated 12/27/21 included: Focus (Resident) is an elopement risk/wanderer r/t diagnosis of Alzheimer's Disease. (Resident) has wander guard in place. She has had past hx of wandering away from the facility. Revision on: 06/16/21 Goal (Resident's) safety will be maintained through the review date. (Resident) will not leave facility unattended through the review date. Interventions * Distract (Resident) from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. * Ensure wander guard in place Q shift every shift * Provide structured activities: toileting, walking inside and outside, reorientation strategies including conversation with her. Focus (Resident) has a behavior problem r/t resident going out the back door with no one to accompany her and refusing to come back inside. Revision on: 09/15/2020 Goal (Resident) will have fewer episodes of going outside without someone to accompany her through the next review date. Date Initiated: 09/15/2020 Interventions * Anticipate and meet her needs. * If reasonable, discuss her behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to her. * Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Focus (Resident) has history of actual falls. She is forgetful and does not remember to use ambulation assistance devices. She has poor balance. Revision on: 06/16/2021 Goal (Resident) will have fall risk minimized through the next review date. Interventions * Anticipate and meet her needs. * Be sure her call light is within reach and encourage her to use it for assistance as needed. She needs prompt response to all requests for assistance. * (Resident) needs activities that minimize the potential for falls while providing diversion and distraction (group exercise, bingo, socials). * PT evaluate and treat as ordered or PRN. * The resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls, personal items within reach. Record Review of Resident 1's Elopement Risk Assessments dated 07/05/21 and 10/05/21 indicated she was a moderate elopement risk. Review of the Elopement Risk assessment dated [DATE] indicated she was a high elopement risk. Record Review of Nurses Note dated 1/17/2022 revealed Resident #1 was admitted to the COVID unit. Record Review of Nurses Note dated 1/22/2022 at 02:05 AM by LVN A included: Notified by (CNA B) - Covid Unit that resident was not in room. Began search of facility. Began search outside. Resident found by (hospital) ER bay drive sitting on sidewalk. Assisted resident back inside building to COVID unit/room via wheel chair. Resident able to walk with assistance. Contusion noted to right side of face et cheek, small abrasion noted near mouth-right side and bruise to right hand. Resident hypothermic. V/S 167/65, 96.6, 106, 20, SPO2 96% RA. Notified FNP. Resident transferred to (hospital) ER for evaluation. Notified DON. Attempted to notify POA, left voicemail. According to wunderground.com (accessed on 03/01/22), the temerature in San [NAME], Texas on 01/22/22 at 1:51 a.m. was 32 degrees Fahrenheit. Record Review of the ER records dated 01/22/22 indicated Resident #1 was admitted to the ER at 2:45 AM with a hematoma to the right orbital eye area and 1 cm x 1 cm abrasion to right eyebrow. Following negative CT scans the resident was returned to the care center at 3:50 AM. Upon return to facility no new orders were received from ER and neuro checks were performed per facility policy. Record Review of Nurses Note dated 01/23/22 at 2:03 AM indicated Resident #1 attempted to exit the back door again and was redirected by staff. Record Review of the Provider Investigation Report dated 01/25/22 included: Investigation Summary On 01/22/22, (Resident #1) was concluding her quarantine period in the facility COVID Hot Zone (A Hall) after her mild symptoms had resolved. In reviewing security footage, it was found that resident exited Hall A emergency exit door on 01/22/22 at 12:24 a.m. At 01:53 a.m., staff are seen exiting the same door, starting to look around outside for the resident. At 02:05 a.m., staff members are shown ambulating the resident back inside the building through the same door. Resident was ambulating with assistance. Staff stated resident was found around the building sitting on the curb/landscaping rocks just outside the (hospital pharmacy) It appeared she had fallen, as she had scrapes and blood about her head. Resident was assessed by (LVN A), in the Care Center, and due to the apparent fall and observed abrasions about her head, the nurse contacted the ER and was instructed to bring the resident to the ER at (hospital) on the other side of the building for evaluation. Care Center notes included with this report. Findings 1. Facility staff failed to ensure the safety of the resident by unlocking emergency exit door. 2. Facility staff failed to immediately notify the Administrator and Director of Nursing of resident elopement. Provider Response On 01/25/22 upon finding out Hall A emergency exit door was unlocked, Administrator directed staff to lock it and leave it locked at all times. Alarm will sound when panic bar is pressed, door will open in 15 seconds, and alarm can be silenced by touching fob to panel on exterior of building adjacent to the door. Administrator initiated in servicing staff on 01/25/22 on what is considered elopement, elopement notification to the Administrator and Director to Nursing, and resident safety. Provider Action Taken Post-Investigation 1. Administrator observes all 4 emergency exits upon entering the facility, upon exiting the facility, and multiple times daily while in the building. 2. Nursing to start checking the 4 emergency exits each shift to ensure doors are locked and properly secured. Investigator observed nurses performing door checks and proper documentation was being done. 3. (Hospital District) is getting quotes to increase the number of wander guard systems to cover all exits from the Care Center. 4. In servicing of Care Center staff will be ongoing regarding all aspects of resident safety. Record Review of the written statement by CNA E dated 02/01/22 included the following, in part: Resident W (Resident #1's roommate) turned on her call light .Went in and noticed (Resident #1) was gone. The last time I had been in there she was asleep. So, I yelled at the other CNAs and nurse down the hall to see if she had walked that way, but they said no, so I looked through all the rooms and the COVID side .and she was nowhere. I walked outside to the east side of the building and saw no one. So, I went back inside .and the nurse (LVN A) went outside to look for her but didn't find her. I decided to walk all around the hospital .and (CNA C) walked outside with me. We walked to the west side of the hospital, by the pharmacy, and she was on the ground yelling for someone to help her. We got her up and walked her back inside . In an interview on 02/17/22 at 1:30 PM the Administrator stated he was not aware of Resident #1's elopement until late afternoon on 1/25/22 when he overheard staff talking about her falling outside the facility. He immediately questioned the staff and learned Resident #1 had eloped from the facility on the night of 01/22/22 through the emergency exit door on the A Hall COVID unit. When she was noted to be missing from her room, the staff on duty that night began searching and found her approximately 10 - 15 minutes later. He said it was unclear from the interviews exactly where Resident #1 was found: the area near the ER entrance, (in front of the complex between the hospital and the care center entrances) or near the pharmacy drive -thru (at the side of the building opposite the care center). He said outside security cameras showed she was found near the pharmacy drive-thru. Upon learning that the A Hall emergency door was unlocked, he stated staff were instructed to lock the door and keep it locked. Stated that when the door is locked the alarm will sound 15 seconds after the panic bar is pressed and then the door will open. Stated that the emergency exit doors are not equipped with the wander guard system. Stated he began in servicing staff on 01/25/22 on elopement and immediate notification to Administrator and DON. Investigator checked the emergency doors with alarm system in place and functional. In-service documentation was reviewed and current. In an interview on 02/18/22 at 11:30 AM DON stated that staff found Resident #1 10 - 15 minutes after she was discovered missing (on 01/22/22). Stated that the resident was found near the pharmacy area, not at the ER bay. Stated that she doesn't know why staff didn't report it to supervisor at time of incident. DON stated that she was only told by LVN A that Resident #1 fell and was going for evaluation at the ER, LVN A did not report that Resident #1 had eloped. DON stated (LVN A) didn't notify me but documented that she did. DON stated on 1/25/2022 the day nurse (agency) called to give report on all the residents with agency nurse stating Resident #1 had a second fall post elopement (first fall was at time of elopement). DON stated that when she spoke with LVN A she stated, Administrator knows of Resident #1's elopement and is taking care of it. DON stated that three elopement drills were conducted this week and will continue, and in services are being done with all facility staff. Stated that the key to the emergency door alarm which was kept on the nurses' key ring (which unlocked and unalarmed emergency door) was removed and is now kept only on the Maintenance Director's key ring to prevent emergency exit doors being unlocked. Nurse's facility key's were checked and key to emergency exit doors not located on key ring. DON stated that the EOP (Emergency Operations Plan) was not included in initial employee orientation or agency staff orientation but has now been added to required training and that the EOP book has been updated and is kept at the nurses' station. Record Review of the EOP Book located at the nurses' station included the policy/procedure , Emergency Procedure - Missing Resident, revised August 2018, included the following, in part: 1. Announce CODE SILVER with the resident's room/unit number. 2. Note the time the resident was discovered missing. 3. Report to the nursing station to see if the resident was signed out. 4. Notify the administrator, director of maintenance, and director of nursing if not on premises. 6. Report to the resident's unit for briefing and instruction. 7. Initiate a thorough search .If the resident is not located, proceed with the following: a. Instruct staff to search the entire facility, grounds, and neighboring streets. b. Assign each staff member a section to search in order to minimize overlapping of or overlooking an area. c. When conducting a search, it is important to look under beds .Being thorough is extremely important. d. Instruct staff to report to the administrator/Incident commander when finished searching a section. 8. If the search is unsuccessful after a period of ten minutes, call the police to report the resident missing. In an interview with CNA H on 02/18/22 at 1:30 PM she said she hasn't had an elopement drill yet, but she heard that the other rotation did. (Staff works 7 days on 7 days off) She said she has been in-serviced on what to do if a resident is missing; notify the charge nurse and thoroughly search her assigned area. In an interview on 02/18/22 at 1:40 PM, CNA I stated that the supervisory staff held an in-service regarding elopement and performed an elopement drill on 02/16/22. CNA I stated that if she isn't able to find a resident, she is to report missing resident to the charge nurse immediately and then follow nurse's instructions. Investigator reviewed in-service training documentations and is current. In an interview on 02/22/22 at 2:20 PM LVN A stated that she was the charge nurse the night Resident # 1 eloped. Stated that an agency CNA (CNA E) was working on the COVID unit (Hall A) with 8 residents, including Resident #1. Stated that CNA E called her a little after 2:00 AM and said she couldn't find Resident #1. LVN A stated that the outside exit door on Hall A was left unlocked for Resident 2's daughter to go in and out of COVID unit (via emergency door) due to Resident #2 was deemed end of life. LVN A stated that Resident #2's daughter would enter/exit through the emergency door at all hours. Stated that the last time Hall A was set up as the COVID unit the emergency exit door was kept locked. LVN A stated that when CNA E was tending to other residents, Resident #1's roommate turned on the call light. CNA E went to answer the call light and noted that Resident #1 was not in the room. Stated that CNAN E notified that Resident #1 was not in her room and two CNAs went outside to look for Resident #1 who was found sitting on the curb. LVN A stated that it was believed that Resident #1 had fallen due to bruises observed on face and arms. LVN A stated that she notified the FNP on call and was instructed to send Resident #1 to the ER for assessment. LVN A stated that she contacted DON immediately after notifying FNP even though The DON said I didn't notify her of the elopement. I talked to her right after talking to (FNP). I called and woke her up. In an interview on 02/22/22 at 3:13 PM, DON stated Hall A's emergency exit door was not supposed to be unlocked. DON stated that staff were going in and out Hall A's emergency exit door. DON stated that the key to Hall A emergency exit door was located on the facility nurses' key ring but should not have been. DON stated, Maybe staff were leaving Hall A's emergency door unlocked because it was more convenient than waiting the 15 seconds for the door to open but is not aware who left door unlocked or why the key to Hall A's emergency door was located on nurse's key ring. In an interview on 02/22/22 at 3:35 PM, RN B stated that the COVID unit was initiated, with first positive COVID resident test, on 01/15/22. RN B stated the DON informed her that the door (Hall A emergency door) was left unlocked in order for Resident #2's daughter to visit as she wanted due to Resident #2 deemed end of life. RN B stated that on 01/20/22 she observed Resident #1 following Resident #2's daughter out Hall A's emergency exit door (when daughter was exiting building) and went immediately to redirect Resident #1 back into the building. In an interview on 02/22/22 at 5:15 PM, DON stated that Resident #2's daughter did come to visit with her mother often at different times throughout the day, but that wasn't the reason the door was unlocked. DON stated the daughter was screened at the front door and went around to the back (Hall A door) to protect other residents since she had just recovered from COVID herself. Investigator attempted to contact Resident #1's daughter but was not able to contact. In an interview on 02/28/22 at 12:15 PM, Administrator stated that all residents have been reassessed for elopement risk. Stated that there are 2 other residents at risk for elopement. Administrator stated that one elopement risk resident is currently in the hospital and the other elopement risk resident does not wear a wander guard bracelet due to family refusing use of a wander guard. Administrator stated that when the resident, without the wander guard bracelet, is in her electric wheelchair staff have been in-serviced to heighten observation during these times. Administrator stated that the facility has conducted in-services and elopement drills, and these will continue. Stated that he has consulted with the facility contracted alarm company and requested that the alarm tone be increased for the emergency exit doors. Stated that he spoke with the facility contracted wander guard agency and they are getting parts together to install the wander guard system on doors not currently equipped. In an interview on 02/28/22 at 1:55 PM, CNA C stated that she was working on Hall B the night Resident #1 eloped. Stated she responded when CNA E radioed that Resident #1 was missing. Stated that CNA E and herself searched Halls A and B. Stated that she got a flashlight and CNA E and herself went outside through the main entrance and searched around the facility grounds. Stated that Resident #1 was found sitting on the curb at the far end of the building past the dumpsters. Stated that Resident #1 was wearing a very light weight gown and shoes. Stated that when Resident #1 was located she appeared cold due to noted shivering and stated she took her hoodie off and placed it on resident. Stated that Resident #1 was assisted back to A Hall A back door and into the COVID unit, without the use of key or staff allowing them back into building. Stated that the nurse's assessed Resident #1 and applied blankets during their assessment. CNA C stated that she asked the following day why the door did not alarm with other facility staff stating that the DON allowed Hall A emergency back door unlocked/unalarmed to allow Resident #2's daughter to enter and exit through this door since Resident #2 was deemed end of life. CNA C stated that the facility has held elopement drills and in-services . She was able to describe the procedures to take if a resident is missing. In an interview on 02/28/22 at 3:55 PM, CNA D stated that she has been in-serviced on elopement policies and drills. CNA D was able to describe the process to follow when a resident is missing during interview. In an interview on 02/28/22 at 6:20 PM, LVN F stated that as charge nurse it is her job to assign staff to areas to search when an elopement occurs and is to notify the administrator and DON immediately. Stated that she is to initiate Code Silver over the intercom and if resident not found within 10 minutes to call police. These were covered in the elopement inservice and drills. In an interview on 02/28/22 at 6:35 PM CNA G stated that if a resident is missing staff are to report it to the charge nurse and follow instructions given from nurse. If a Code Silver alert is called staff are to report to the nurses' station for instructions. In an interview on 03/01/22, Administrator stated that the facility are continuing elopement in-services and drills. Review of the Incident/Accident log did not list any further elopements since 01/22/22. Review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised April 2021, included the following, in part: 1. If resident abuse, Neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. the administrator or the individual making the allegation immediately reports his or her suspicions suspicion to the following persons or agencies: a. The state licensing / certification agency responsible for surveying/ licensing the facility; b. the local board slash state ombudsman; c. the residence representative; e. law enforcement officials; f. the resident's attending physician; and g. the facility medical director. 3. Immediately is defined as: a. Within two hours of allegation involving abuse or result in serious bodily injury; or b. Within 24 hours of an allegation that does not involve abuse or serious bodily injury. The administrator and DON were notified of the Past Non-Compliance IJ existing from 01/17 - 01/25 22 regarding Neglect and Accidents/Supervision. The 3-Strike Letter was explained and signed by the administrator.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 of 2 medication carts inspected for medication reconciliation and failed to ensure medications were discarded when expired and dated when opened for 1 of 1 medication rooms inspected for medication storage. LVN A did not document the administration of a controlled medication on the individual controlled medication records after administering it to Resident #10 on [DATE]. The medication room had expired vial of [MEDICATION(S)] (TB) medication in the refrigerator. This failure could place residents at risk of under dose, overdose and drug diversion and could place residents at risk of receiving medications that were expired and not produce the desired effect. The findings were: Record review of Resident #10's admission record dated [DATE] indicated he was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], dysphagia (difficulty swallowing), anxiety and [CONDITION(S)]. He was [AGE] years of age. Record review of Resident 10's [DATE] physician orders indicated in part: [MEDICATION(S)] Tablet ,d+[DATE] MG ([MEDICATION(S)]-Acetaminophen ) Give 1 tablet via PEG-Tube every 8 hours for pain related to [CONDITION(S)]. Start date [DATE]. During an observation and record review on [DATE] at 10:30 AM the medication cart was inspected with the DON present. The controlled medication count was incorrect for Resident #10. Resident #10's blister pack of [MEDICATION(S)] APAP ,d+[DATE]MG contained 13 pills and the corresponding medication sheet indicated there were 14 pills left. During an interview on [DATE] at 10:32 AM the DON said the nurse would normally sign out the medication when given but that sometimes the nurse would get called out to do something else. During an interview on [DATE] at 04:24 PM the Administrator was made aware of the controlled medication record was not correct when reconciled with the corresponding blister pack. The Administrator acknowledged it was an issue . During an interview and observation on [DATE] at 10:06 AM the medication room was inspected with the DON present. Inside the small refrigerator was a 0.1 ML [MEDICATION(S)] (used to check resident and staff annually and at time of hire/admission for [CONDITION(S)]) vial that indicated Discard After 28 days with expiration date of ,d+[DATE] written on it. The DON said it appeared the date was [DATE]th, 2021, she said the vial was expired and should have been removed. The DON said she usually checked the refrigerator every 30 days but that it got missed. The DON said if the TB was expired and then used to test someone it could possibly cause a false reading or a bad reaction. During an interview on [DATE] at 04:24 PM the Administrator was made aware of the expired TB vial in the medication room. The Administrator acknowledged it was an issue. Record review of policy titled control substances and dated [DATE] indicated in part: The facility complies with all laws regulations and other requirements related to handling storage disposal and documentation of control medications. Control substances are reconciled upon receipt administration disposition and at the end of his shift. Upon administration the nurse administering the medication is responsible for recording time of administration, quantity of the medication remaining and signature of nurse administering medication. Record review of the [MEDICATION(S)] Purified Protein Derivative [MEDICATION(S)] manufacture undated package insert indicated in part: A vial of [MEDICATION(S)] which has been entered and in use for 30 days should be discarded. Do not use after expiration date. Record review of policy titled storage of medications and dated [DATE] indicated in part: The facility stores all drugs and biologicals in a safe secure and orderly manner. Discontinued outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 3 of 12 (Residents #4, #10, and #11,) reviewed for infection control. The facility failed to ensure: Residents #4, #10, #11, oxygen nasal cannulas and SVN masks were bagged when not in use. LVN A and the DON performed hand hygiene when indicated prior to providing care to Resident #10 (Medication administration and wound care). LVN A prevented cross contamination between a dirty site and a clean site during Resident #10's wound care. (Resident #10 and Resident #4). This failure placed residents at risk for infection. Findings included: RESIDENT #10 Record review of Resident #10's admission record dated 12/15/2021 indicated he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was [AGE] years of age. Review of Resident #10's Annual MDS assessment dated [DATE] indicated: He had long- and short-term memory impairment with severely impaired cognitive decision-making abilities. He showed no signs of depression and revealed no behaviors. He was dependent on two or more staff for all ADL care He had upper and lower range of motion impairment on both sides and used a wheelchair. He was incontinent of bowel and bladder. He showed no indicators of pain. He weighed 131 pounds and was dependent on a feeding tube for 51% or more of his nutrition. Triggering medications included: an antipsychotic for 7 of 7 days; an anti-anxiety for 7 of 7 days; an antidepressant for 7 of 7 days; and an opiate medication for 7 of 7 days. Record review of Resident 10's December 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Lorazepam Tablet 2 MG Give 1 tablet via PEG-Tube every 6 hours related to anxiety disorder. Start date 04/22/2021. [MEDICATION(S)] Tablet 1 MG Give 1 tablet via PEG-Tube three times a day. Start date 10/07/2019. Acetaminophen Liquid 160 MG/5ML Give 10 ml via PEG-Tube three times a day for Pain. Start date 11/28/2017. NPO. Start date 08/01/2015. Oxygen 2 liters to keep saturations equal to or greater than 92%. active 2/11/19 May provide PEG site/PEG Stoma care as needed to maintain skin integrity as needed. Start date:3/4/19 Record review of Resident #10's care plan initiated 9/13/21indicated in part: - Focus: Resident #10 has an ADL self-care performance deficit r/t [CONDITION(S)] Chorea. Interventions/tasks: Resident is totally dependent on pump infusion for feeding. Observation during initial rounds revealed on 12/13/21 at 10:14 AM revealed Resident #10 in bed with the head of bed up. The oxygen nasal cannula and SVN mask was beside him on nightstand not bagged and left opened to air. Observation and interview on 12/14/21 at 12:29 PM revealed LVN A had gloves on when surveyor walked into the room. She repositioned Resident #10's with the DON's assistance. LVN A checked Resident #10's Peg-tube site and explained he pulled it out last week and there's been leakage. The DON took off the bandage and beige (feeding formula) colored fluid did come out of Resident #10's belly button in spurts. LVN A sprayed the site with wound cleaner; patted it dry (touched the wound); and changed the bandage surrounding the site. LVN A put two dressings around tube, went around the curtain to Resident #4's side and got tape from his supplies. LVN A taped down the dressing and took off her gloves. The DON was present and held Resident #10's hands to keep him from pulling on the tube. Resident #10's nasal cannula and SVN mask were on the night stand open to air. LVN A washed her hands with soap and turned off the faucet with her bare hands and left the room to provide care to the next resident. During an observation on 12/14/21 at 12:42 PM LVN A prepared Resident #10's medication. The LVN poured 1 pill of Lorazepam, 1 pill of [MEDICATION(S)] and 10ml of acetaminophen in another cup. LVN A entered the resident's room. LVN A entered the restroom and opened the faucet and got some water in some cups. LVN A then went to Resident #10's bed side and placed the medication and cups down on the bed side table. Without using hand sanitizer or washing her hands LVN A donned a pair of gloves and administered the medications via the resident's PEG tube. During an interview on 12/14/21 at 12:54 PM LVN A said she became nervous and forgot to wash her hands before donning gloves. LVN A said she would be more careful and wash her hands or use hand sanitizer from now on. During an interview on 12/14/21 at 1:12 PM the DON was made aware of the observation regarding LVN A. The DON said if staff did not wash their hands then cross contamination could occur with the resident being contaminated. Interview on 12/14/21 at 3:12 PM the DON said she remembered she entered Resident #10's room and donned gloves and they checked Resident #10's Peg site for leaking. The DON stated the site was leaking feeding formula and she reminded LVN A there was an as-needed order to change the dressing. The DON said she pulled the dressing off (contaminating her gloves) while LVN A got supplies from the bed side table. The DON said LVN A sprayed the wound with a 4x4 gauze pad (contaminating LVN A's gloves). LVN A took 2 dressings and placed it around the Peg-tube, when she realized there was no tape to secure the dressing she left Resident #10's area and went into Resident #4's half of the room and returned with tape. The DON said LVN A then pulled down Resident #10's shirt and placed a sheet loosely over his abdomen to prevent him from pulling on the Peg-site and then removed her gloves. The DON said she did not remember LVN A switching gloves. The DON said she did not wash her hands prior to donning gloves and assisting with Resident #10. The DON said LVN did not wash her hands correctly. She said she trained staff on handwashing and had been doing random checks. The DON said LVN A was an agency nurse so had not had a facility competency on handwashing. During an interview on 12/15/21 at 04:24 PM the Administrator was made aware of the staff not washing their hands and then providing patient care. The Administrator said acknowledged it was an issue. RESIDENT #11 Record review of Resident #11's admission record dated 12/15/2021 indicated she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was [AGE] years of age. Record review of Resident 11's December 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Oxygen per NC at 2 liters per minute continuous. Every shift related to shortness of breath. Order date 03/12/2019. Change O2 tubing and humidifier and clean filter weekly every night shift every Wednesday. Order dated 1/7/21. Record review of Resident #11's care plan dated 10/3/21 indicated in part: - Focus: Resident #11 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She requires continuous 02. Interventions/tasks: Oxygen per NC at 2L per minute continuous. Observation on 12/13/21 at 10:38 AM revealed Resident #11 away from her oxygen concentrator in the shower. The oxygen nasal cannula was wrapped around the humidifier not bagged. During an observation on 12/15/21 at 9:48 AM Resident #11's oxygen concentrator was in the living room area. The concentrator was not in use and had the nasal cannula wrapped around the handle. During an interview on 12/15/21 at 10:09 AM the Administrator was made aware of the oxygen concentrator located in the living area with the oxygen tubing wrapped around the handle. The Administrator said he did not know whom the concentrator belonged to and would find out. The Administrator said the oxygen tubing was not supposed to be stored in that way and should have been in a bag. During an interview on 12/15/21 at 10:50 AM the DON said the oxygen tubing was supposed to be kept in a bag. The DON said the nasal cannula could become contaminated and the residents could inhale the contaminates if left wrapped around the handle instead of stored in a bag. During an interview on 12/15/21 at 3:52 PM the DON said the only policy they had for storage of nasal cannulas and SVN masks was the one she provided. Record review of the facility's policy dated 10/2010 and titled Oxygen Administration did not indicate had to store nasal cannulas or SVN masks. Record review of the facility's policy titled handwashing/hand dated 08/2019 indicated in part: This facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol or alternatively soap and water for the following situations. Before and after direct contact with residence. After contact with objects (example- medical equipment) in the immediate vicinity of the resident. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. Perform hand hygiene before applying non- sterile gloves. Review of the facility's undated Nurse Aide Competency Checklist on Hand Hygiene (Hand Washing) indicated: Uses clean, dry paper towel/towels to turn off faucet before throwing in waste container or uses knee/foot controls to turn off faucet.

Based on observations, interviews and record reviews the facility failed to ensure that residents were free from physical restraints imposed for purposes of convenience, and not required to treat the resident's medical symptoms for 2 residents of 4 residents (#11 and #23) who were reviewed for physical restraints in that: Resident #11 and #23 had mattress pad bed alarms (a pressure alarm that lies across the bed, when turned on it will sound with there is no pressure on it) without a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] This deficient practice could affect residents at the facility with a bed alarm by contributing to restricted movement, a decline in ADLs function, and psychological distress. The findings were: Review of Resident #11's Admission Record dated 12/15/21 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's quarterly MDS assessment dated [DATE] revealed: She scored a 6 of 15 on her mental status exam (indicating sever cognitive impairment) and showed no signs of [CONDITION(S)]. She indicated she had 5 of 30 indicators of depression (indicating possible depression) with no behaviors or [CONDITION(S)]. She needed extensive assistance of one or two staff for all ADL's. She had no range of motion impairments and used a wheelchair. She was frequently incontinent of bladder and usually continent of bowel. She had received as needed pain medications but did not rate any pain. She had one fall with no injury in the previous look back timeframe. Triggering medications included: an antipsychotic for 4 of 7 days, an anti-anxiety medication for 7 of 7 days, and opiate medication for 2 of 7 days and an anti-depressant for 6 of 7 days. The MDS indicated no bed alarms or other alarms were used. Review of Resident #11's care plan, revised on 9/21/21 revealed Resident #11 was at risk for falls due to weakness, confusion, and [CONDITION(S)] medication use; the care plan revealed Resident #11 had actual falls on 5/28/21 (no injury); 9/5/21 (unwitnessed); and 9/21/21 (unwitnessed). The identified goal was Resident #11 would have her fall risk minimized through the next review date. The use of a pad alarm on the bed was not an identified intervention and was not care planned. There was no care plan addressing the use of the pad mattress alarm as a goal or an intervention. Review of Resident #11's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's incident accident reports documented Resident #11's last fall was 9/25/21. Observation on 12/13/21 at 10:38 AM revealed a mattress pad alarm was attached to Resident #11's bed. Observation and interview on 12/15/21 at 10:30 AM, the DON checked Resident #11's bed and stated there was a mattress pad alarm. The DON stated the pad alarm absolutely was for staff convenience because Resident #11 did not get up anymore. The DON did not answer why the pad alarm was present. Review of Resident #23's Admission Record dated 12/15/21 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's quarterly MDS assessment dated [DATE] revealed: She scored a 2 of 15 on her mental status exam (indicting severe cognitive impairment) but showed no signs of [CONDITION(S)]. She had 1 of 30 indicators of depression with no behaviors documented. She needed extensive assistance of one or two staff for all ADL's. She had no range of motion impairments and used a wheelchair. She was frequently incontinent of both bowel and bladder. She had received as needed pain medications and reported experiencing no pain. She had 2 or more falls with no injury and one with injury in the look back period. Triggering medications were an antidepressant for 7 of 7 days and an opiate medication for 6 of 7 days. The MDS did not document the use of any restraints or alarms in use. Review of Resident #23's Care Plan revised 8/31/21 revealed she was a moderate risk for falls related to confusion and gait/balance problems. Resident #23 had falls on 8/3/21 (unwitnessed fall); 8/20/21 (unwitnessed fall); and 8/ 30/21 (unwitnessed fall). The use of a pad alarm on the bed was not an identified intervention, nor was it care planned. The care plan did not address the use of the pad mattress alarm as either an issue or intervention. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's Incidents revealed her last fall was 10/27/21. Observation and interview on 12/15/21 at 10:23 a.m. the DON and surveyor entered Resident #23's room and there was a pad alarm on Resident #23's bed. She stated the pad alarm was probably for staff convenience. The DON stated she did not know why Resident #23 had the pad alarm because she had removed them the week prior. The DON stated she did random room audits checking for alarms and other fall precautions. Review of the facility's policy and procedure on Managing Falls and Fall Risk revised March 2018 revealed: based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident - Centered Approaches to Managing Falls and Fall Risk: Position -change alarms will not be used ass the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.

Based on observation, interview and record review the facility failed to attempt to use alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation and on an ongoing basis, review the risks and benefits of bed rails with the resident or resident's representative and obtain informed consent prior to installation of full bed rails for 2 of 2 residents (Resident #4 and Resident #10) reviewed for full side rails. The Facility: 1. failed to assess for entrapment risks and attempt less restrictive measures prior to installing bed rails; 2. failed to provide education regarding the risks and benefits and obtain consents from the resident or the responsible party for the bed rails; 3. failed to provide ongoing assessment for the continued need of the side rails. This deficient practice could affect residents who utilized full bed rails in the facility and could put the residents at risk for potential injuries including skin tears and bruising or impair skin integrity. The findings were: Review of Resident #4's Admission Record dated 12/14/21 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's quarterly MDS assessment revealed: He had long- and short-term memory impairment and exhibited no signs of [CONDITION(S)]. He showed no indicators of depression and had no behaviors. He was total assistance of two staff for all ADLs. He had upper and lower range of motion impairment on one side and used a wheelchair. He was incontinent of bowel and bladder. He showed signs of pain one or two days a week. He had a feeding tube for 51% or more for nutrition. He weighed 171 pounds with no weight loss indicated. Triggering medications included insulin injections for 7 of 7; an antipsychotic for 7 of 7 days; and an anticoagulant for 7 of 7 days. He used a bedrail daily. Review of Resident #4's care plan initiated 2/27/19 revealed: Resident #4 had an ADL self-care performance deficit due to immobility related to stroke. The identified goal was Resident #4 would maintain current level of function. Identified interventions included: bed mobility: Resident #4 required extensive to total assistance of two staff members for bed mobility. Side rails: full side rails up x4 as per doctor's order and at family request for safety during care provision, to assist with bed mobility and positioning. Observe for injury or entrapment related to side rail use. Reposition as needed. (Initiated 6/5/19). Review of Resident #4's Order Summary Report dated 12/14/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Every shift for safety, positioning during care period dated 6/5/19. Review of Resident #4's electronic chart revealed no education related to the benefits and risks or consent for Resident #4's full side rails. Review of Resident #4's electronic record revealed the last assessment for the side rail use was 6/23/21. Interview on 12/14/21 at 5:00 PM the DON stated the last assessment for Resident #4's siderail was 6/23/21. She stated the facility had an order from the physician for a family request for the side rails but she did not find a consent in the electronic record. She stated to her knowledge Resident #4 had not fallen since 2019. She revealed the medical justification for the siderail was periods of agitation and he had attempted to crawl out of bed before, but she did not know when. The DON said she did not talk to the family about the side rails or attempts of reduction and did not know if anyone else had. Interview on 12/15/21 at 9:59 AM the DON revealed she was still going through progress notes for the residents about when the side rails were initiated but as far as she had been able to determine Resident #4 did not turn himself. She stated she had not seen him turn himself when he was agitated. She revealed when he was agitated, he would bear down and the peg tube would have backflow. She stated the siderail did not suit him for grabbing. Review of Resident #10's Admission Record dated 12/14/21 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's Annual MDS assessment dated [DATE] documented: He had long- and short-term memory impairment with severely impaired cognitive decision-making abilities. He showed no signs of depression and revealed no behaviors. He was dependent on two or more staff for all ADL care He had upper and lower range of motion impairment on both sides and used a wheelchair. He was incontinent of bowel and bladder. He showed no indicators of pain. He weighed 131 pounds and was dependent on a feeding tube for 51% or more of his nutrition. Triggering medications included: an antipsychotic for 7 of 7 days; an anti-anxiety for 7 of 7 days; an antidepressant for 7 of 7 days; and an opiate medication for 7 of 7 days. He was on Hospice. He used a siderail daily. Review of Resident #10's Care Plan initiated 7/5/17 documented: Resident #10 had an ADL self-care performance deficit related to [CONDITION(S)] disease. The identified goal was Resident #10 would maintain current level of function. Interventions included side rails: full side rails up as per doctor's order for safety and to assist with care and with bed mobility. Observe for injury or entrapment related to side rail use. Initiated on 6/26/19. Review of Resident #10's care plan initiated 11/26/18 documented: Resident #10 used full side rails up on bed for safety and positioning and pillows for padding/ positioning. The goal identified was Resident #10 would remain free of complications related to the use of side rails and pillows. Interventions identified included discuss and record with Resident #10/family/caregivers the risks and benefits of using the side rails and pillows for resident. Initiated on 11/26/18. Review of Resident #10's care plan initiated 6/30/18 documented: Resident #10 had potential impairment to skin integrity of extremities, coccyx and back due to bed immobility, being bed bound, involuntary spasms, peg tube, and incontinence related to [CONDITION(S)] disease. The goal was Resident #10 would be free from any significant skin injuries through the next review date. Identified interventions included: bumper pads wrapped around bed rails to prevent Resident #10 from rubbing up against them. Initiated 12/10/20. Review of Resident #10's Order Summary Report dated 12/14/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's Incident/Accident log for the six months prior to the survey (6/12/21 through 11/30/21) revealed Resident #10 had 4 incidents of skin issues (6/25/21, 9/2/21, 10/12/21, and 11/14/21). Observation on 12/13/21 at 10:14 AM revealed Resident #4 and Resident #10 shared a room. Resident #4 was in his bed with the upper and lower half rails up surrounding the mattress. Resident #10 was also in bed with a bolster cushion surrounding him on both sides and half side rails upper and lower sides engaged. Observation on 12/14/21 at 12:28 PM revealed Resident #4 in bed with the upper and lower side rails up surrounding the bed. Resident #10 was also in bed with the upper and lower half rails up along with the bolster cushions. Interview on 12/14/21 at 4:47 PM the DON was asked to find consent, family education, and attempts at alternatives or reductions for Resident #4 and Resident #10's side rails. Observation and interview on 12/15/21 at 10:06 AM with the DON revealed Resident #4's side rails were all engaged and approximately 8 to 12 inches from the top edge of Resident #4's mattress. Resident #10 had bolster cushions immediately against the siderails that were the same height as the side rails which were also up. The DON stated the bolsters served the same purpose as the side rails for Resident #10. Interview on 12/15/21 at 2:34 PM the DON stated Resident #4's order for siderails was from the medical director on admission and she had not been able to find any consent or education related to his side rails. The DON stated there was no reason to have Resident #10's side rails with the bolster mattress in place. She acknowledged all of Resident #10's skin issues were because he would hit his foot against the side rail and rub an open little spot on the outside of his feet and since he had gotten the bolster mattress that had reduced. The DON stated she put in the documentation related to reducing the side rails. She revealed she talked to Resident #10's doctor who would reassess next week, but his responsible party was agreeable to reducing the side rail. The DON stated the doctor agreed there was no clinical justification for Resident #10's side rail. Review of the facility's policy and procedure for Proper Use of Side Rails revised December 2016 documented: the purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat resident medical symptoms. Definition of physical restraints were defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the residence body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. (The definition of restraint is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint.) General guidelines side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his or her bed). Side rails are only permissible if they are used to treat a resident medical symptom or to assist with mobility and transfer of resident. An assessment will be made to determine the resident symptoms, risk of entrapment and reason for using the side rails. When used for mobility or transfer, an assessment will include a review of the residents bed mobility; Ability to change position, transfer to and from better chair, risk of entrapment from the use of side rails; and that the bed's dimensions are appropriate for the resident size and weight. The use of side rails as an assistive device will be addressed in the resident's care plan. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. Less restrictive interventions that will be incorporated in care planning include providing restorative care; placing the bed lower to the floor and surrounding the bed with a soft mat; Documentation will indicate if less restrictive approaches are not successful prior to considering the use of side rails. The risks and benefits of side rails will be considered for each resident. Side rails with padding may be used to prevent resident injury in situations of uncontrollable movement disorders but are still restraints if they meet the definition of a restraint. Facility staff, in conjunction with the attending physician, will assess and document the residents' risk for injury due to neurological disorders and other medical conditions