Every finding on record at Ridgecrest Healthcare and Rehabilitation Center

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, 2 of 10 (Residents #1 and #2) reviewed for abuse. The facility did not ensure the Abuse Coordinator implemented their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 11/09/25 between Resident #1 and Resident #2. This deficient practice could place residents at risk of unreported abuse, neglect, and a decreased quality of life. Findings include: Record review of the facility policy for Abuse Prohibition Policy, revised 02/26/26 reflected.each resident has the right to be free from abuse. Investigation: (2) The Abuse Coordinator will report such allegations to the state agency in accordance with state law.within two hours of the allegation.Resident #1 Record review of Resident #1's face sheet, dated 05/14/26, reflected Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included cerebrovascular disease (a group of conditions that affect the blood flow and the blood vessels in the brain). Record review of Resident #1's quarterly MDS assessment, dated 04/30/26, reflected Resident #1 made himself understood and understood others. Resident #1's BIMS score was a 15, which reflected his cognition was intact. Resident #1 had no behaviors or refusal of care during the look-back period.Record review of Resident #1's comprehensive care plan revised on 11/24/25 reflected Resident #1 had a potential to be physically aggressive related to anger. The care plan interventions included on 11/09/25 the victim was removed from the aggressor, incident called into state, psych eval conducted as allowed and 1:1 supervision placed on resident. Resident #2Record review of Resident #2's face sheet, dated 05/14/26, reflected Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included sepsis (condition in which the body responds improperly to an infection). Record review of Resident #2's admission MDS assessment, dated 11/06/25, reflected Resident #2 sometimes made himself understood and sometimes understood others. Resident #2's BIMS score was 0, which reflected his cognition was severely impaired. Resident #2 had no behaviors or refusal of care during the look-back period.Record review of Resident #2's comprehensive care plan, revised 11/21/25 reflected verbal aggression received and Resident #2 was removed from the aggressor and placed in another room. Record review of the PIR dated 11/13/25 reflected an allegation of resident-to-resident incident on Resident #1 and #2 that occurred on 11/09/25. The PIR reflected Resident #1 was witnessed by staff speaking in a loud tone toward Resident #2. Resident #1 stated he was frustrated and irritable due to difficulty sleeping since Resident #2 arrival, citing Resident #2 snoring and vocalization at night as contributed factor. The incident was reported to the state agency on 11/09/25 at 5:23 p.m.Record review of the verbal aggression incident report dated 11/09/25 at 9:00 a.m. reflected LVN A was in the resident's room administering Resident #2 a breathing treatment when a loud verbal altercation was heard from the hallway. Resident #1 was observed rolling inside the room with MA B walking behind him when Resident #1 appeared visibly agitated and shouting as he was rolling in the room. Resident #1 stopped by the foot of Resident #2 bed and stated, I am going to punch him while raising his fist. The DON was notified 9:25 a.m. and the Administrator was notified at 9:30 a.m. of the incident. During an interview on 05/13/26 at 9:04 a.m., Assistant Administrator C stated she learned of the incident 11/09/25 at 3:55 p.m. by the Administrator. Assistant Administrator C stated after she was notified, she initiated the self-report and submitted the information to the state of Texas by 5:23 PM. Assistant Administrator C stated during the investigation she started pulling progress notes and the incidents report, she noticed the incident occurred approximately 9:00 a.m. on 11/09/25. Assistant Administrator C stated she was told by the Administrator he was not sure if it was reportable or not, that was why she was not notified that morning. Assistant Administrator C stated when she initially reported the incident, she was taking the directions of the Administrator who was the abuse coordinator. Assistant Administrator C stated she was not sure if the incident needed to be reported or not because there were no lasting psychological effects. Assistant Administrator C stated abuse should be reported within two hours to HHSC either by her or the Administrator. Assistant Administrator C stated she monitored by daily management clinical rounds by speaking to the residents/family, any of their concerns or grievances were followed up immediately and reviewed the grievances during morning meeting and address any concerns. Assistant Administrator C stated it was important to report an allegation of abuse and neglect for safety and protection of the residents and try to prevent other incidents of abuse.During an interview on 05/14/26 at 3:00 p.m., the DON stated she was notified by the RN weekend supervisor the morning of the incident on 11/09/25. The DON stated she immediately notified the Abuse Coordinator, which was the Administrator right after the RN weekend supervisor notified her. During an interview on 05/14/26 at 3:40 p.m., the Administrator stated he was notified by the DON the morning of the incident. The Administrator stated he did not feel the incident was reportable at the time he was notified that morning, and then after later review with his corporate team, he determined it was reportable. The Administrator stated he was notified the resident was upset and yelling at Resident #2 and got close to his face but did not make any physical contact with him. The Administrator stated later he had spoken to the DON, and she felt the incident was a reportable event. The Administrator stated after speaking to the DON he contacted his corporate staff and all agreed that it should be reported to the state. The Administrator stated he notified Assistant Administrator C around 5:00 p.m. to tell her to initiate a reportable event. The Administrator stated this incident was considered verbal abuse. The Administrator stated he was not in a location that permitted him to report at that time, so he contacted Assistant Administrator C and asked her to report. The Administrator stated he monitored abuse by daily rounds and open conversations with residents/staff to ensure comfortability to report concerns to her. The Administrator stated it was important to report allegations of abuse for the safety of the residents to prevent further incidents.

Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 10 (Residents #1 and #2) residents reviewed for reporting. The facility did not report the resident-to-resident altercation between Resident #1 and Resident #2 to the State Survey Agency within 2 hours of been notified on 11/09/25. This failure to report could place the residents at risk for abuse. Findings include:Resident #1 Record review of Resident #1's face sheet, dated 05/14/26, reflected Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included cerebrovascular disease (a group of conditions that affect the blood flow and the blood vessels in the brain). Record review of Resident #1's quarterly MDS assessment, dated 04/30/26, reflected Resident #1 made himself understood and understood others. Resident #1's BIMS score was a 15, which reflected his cognition was intact. Resident #1 had no behaviors or refusal of care during the look-back period.Record review of Resident #1's comprehensive care plan revised on 11/24/25 reflected Resident #1 had a potential to be physically aggressive related to anger. The care plan interventions included on 11/09/25 the victim was removed from the aggressor, incident called into state, psych eval conducted as allowed and 1:1 supervision placed on resident. Resident #2Record review of Resident #2's face sheet, dated 05/14/26, reflected Resident #1 was an [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included sepsis (condition in which the body responds improperly to an infection). Record review of Resident #2's admission MDS assessment, dated 11/06/25, reflected Resident #2 sometimes made himself understood and sometimes understood others. Resident #2's BIMS score was 0, which reflected his cognition was severely impaired. Resident #2 had no behaviors or refusal of care during the look-back period.Record review of Resident #2's comprehensive care plan, revised 11/21/25 reflected verbal aggression received and Resident #2 was removed from the aggressor and placed in another room. Record review of the PIR dated 11/13/25 reflected an allegation of resident-to-resident incident on Resident #1 and #2 that occurred on 11/09/25. The PIR reflected Resident #1 was witnessed by staff speaking in a loud tone toward Resident #2. Resident #1 stated he was frustrated and irritable due to difficulty sleeping since Resident #2 arrival, citing Resident #2 snoring and vocalization at night as contributed factor. The incident was reported to the state agency on 11/09/25 at 5:23 p.m.Record review of the verbal aggression incident report dated 11/09/25 at 9:00 a.m. reflected LVN A was in the resident's room administering Resident #2 a breathing treatment when a loud verbal altercation was heard from the hallway. Resident #1 was observed rolling inside the room with MA B walking behind him when Resident #1 appeared visibly agitated and shouting as he was rolling in the room. Resident #1 stopped by the foot of Resident #2 bed and stated, I am going to punch him while raising his fist. The DON was notified 9:25 a.m. and the Administrator was notified at 9:30 a.m. of the incident. During an interview on 05/13/26 at 9:04 a.m., Assistant Administrator C stated she learned of the incident 11/09/25 at 3:55 p.m. by the Administrator. Assistant Administrator C stated after she was notified, she initiated the self-report and submitted the information to the state of Texas by 5:23 PM. Assistant Administrator C stated during the investigation, when she started pulling progress notes and incidents report she noticed the incident occurred approximately 9:00 a.m. on 11/09/25. Assistant Administrator C stated she was told by the Administrator he was not sure if it was reportable or not, that was why she was not notified that morning. Assistant Administrator stated when she initially reported the incident, she was taken direction of the Administrator who was the abuse coordinator. Assistant Administrator C stated she was not sure if the incident needed to be reported or not because there were no lasting psychological effects. Assistant Administrator C stated abuse should be reported within two hours to HHSC either by her or the Administrator. Assistant Administrator C stated she monitored by daily management clinical rounds by speaking to the residents/family, any of their concerns or grievances were followed up immediately and reviewed the grievances during morning meeting and address any concerns. Assistant Administrator C stated it was important to report an allegation of abuse and neglect for safety and protection of the residents and try to prevent other incidents of abuse.During an interview on 05/14/26 at 3:00 p.m., the DON stated she was notified by the RN weekend supervisor the morning of the incident on 11/09/25. The DON stated she immediately notified the Abuse Coordinator, which was the Administrator right after the RN weekend supervisor notified her. During an interview on 05/14/26 at 3:40 p.m., the Administrator stated he was notified by the DON the morning of the incident. The Administrator stated he did not feel the incident was reportable at the time he was notified that morning, and then after later review with his corporate team, he determined it was reportable. The Administrator stated he was notified the resident was upset and yelling at Resident #2 and got close to his face but did not make any physical contact with him. The Administrator stated later he had spoken to the DON, and she felt the incident was a reportable event. The Administrator stated after speaking to the DON he contacted his corporate staff and all agreed that it should be reported to the state. The Administrator stated he notified Assistant Administrator C around 5:00 p.m. to tell her to initiate a reportable event. The Administrator stated according to facility policy abuse should be reported within two hours of notification. The Administrator stated this incident was considered verbal abuse. The Administrator stated he was not in a location that permitted him to report at that time, so he contacted Assistant Administrator C and asked her to report. The Administrator stated he monitored abuse by daily rounds and open conversations with residents/staff to ensure comfortability to report concerns to her. The Administrator stated it was important to report allegations of abuse for the safety of the residents to prevent further incidents. Record review of the facility policy for Abuse Prohibition Policy, revised 02/26/26 reflected.each resident has the right to be free from abuse. Investigation: (2) The Abuse Coordinator will report such allegations to the state agency in accordance with state law.within two hours of the allegation.

Based on interview and record review, the facility failed to have evidence alleged violations were thoroughly investigated for 1 of 18 (Resident #1) residents reviewed for abuse and neglect. The facility did not provide evidence of immediate corrective actions implemented according to the Provider Investigation Report of a Resident to Resident verbal altercation that occurred on 11/21/25 to include evidence that staff were provided and received the in-service training on abuse and neglect and the facility failed to provide evidence that Resident # 1 was monitored for 1:1 supervision for 1 of 5 (11/23/25) days. This failure could place residents at risk for abuse or neglect in that that facility did not thoroughly investigate the alleged violations and take appropriate corrective action as a result of the investigation findings.Findings included: Record review of Resident #1's face sheet dated 05/13/26 revealed a [AGE] year old male admitted [DATE] and readmitted [DATE] with diagnoses that included cerebrovascular disease (a group of conditions that affect blood flow and blood vessels in the brain), Diabetes Type II (a chronic condition where the body does not use insulin properly or cannot make enough insulin), anxiety (sudden feelings of intense fear or worry that interferes with daily life), and Dysthymic (a chronic form of depression). Record review of Resident #1's quarterly MDS dated [DATE] revealed he had no communication deficits and a BIMS score of 14 which indicated intact cognition. The MDS revealed Resident #1 had upper and lower extremity range of motion impairment, required the use of a wheelchair for mobility, supervision with eating, bed mobility, and moderate assistance in upper and lower body dressing, bathing, toileting, and transfers. Record review of the Provider Investigation Report (PIR) #1052028 dated 11/26/25 identified a Resident-to-Resident verbal altercation between Resident #1 and Resident #3 with immediate actions taken that included placing Resident #1 (aggressor) on 1:1 supervision. Record review of the 1:1 supervision and monitoring sheets revealed Resident #1 was placed 1:1 and monitored every hour on 11/21/25, 11/22/25, 11/24/25, and 11/25/25. The facility failed to provide evidence of 1:1 monitoring for 11/23/25. Record review of the PIR #1052028 dated 11/26/25 identified a Resident-to-Resident verbal altercation on 11/21/25 with immediate actions taken that included an all-staff in- service regarding Resident-to-Resident Abuse. The facility provided a copy of an in-service dated 11/24/25 and titled Resident-to-Resident Abuse but failed to provide evidence that staff received the in-service with an attendance roster or signature or attendance sheet. During an interview on 05/13/26 at 3:49 p.m., Assistant Administrator C stated that she was responsible for giving the in-services to the staff for any self-report allegations pertaining to abuse or neglect. Assistant Administrator C stated that some of the in-services are completed with a training application that is sent to the staff members' phone numbers. The Assistance Administrator C could not provide documentation of staff physical attendance at the Resident-to-Resident in-service or receipt of the in-service through the computer application program. During an interview on 05/13/26 at 10:33 a.m., CNA D stated that she had received multiple in-services on abuse and neglect but could not recall is she received an in-service on Resident-to-Resident Abuse on 11/24/26. CNA D stated if she observed a resident-to-resident altercation, she would separate residents who were arguing and ensure their safety, then tell the charge nurse. CNA D stated she was aware that Resident #1 was placed on 1:1 monitoring because of a verbal altercation, but stated that she was not assigned to complete the monitoring. During an interview on 05/13/26 at 5:08 p.m., the DON stated that the Assistant Administrator is responsible for ensuring the appropriate in-services are completed for staff when allegations of abuse or neglect are identified. The DON stated she does not check to ensure that all the staff have received the in-services. The DON stated that she believed the in-services were provided but did not have any documentation to provide. During an interview on 05/14/26 at 8:15 a.m., the Administrator stated that the Assistant Administrator C was responsible for the completion of the in-services. The Administrator stated that they were unable to locate the additional documentation to verify staff received the in-service on 11/24/25 on Resident-to-Resident Abuse and the 1:1 tracking sheet for 11/23/25 that verified Resident #1 was monitored due to the Resident to Resident verbal altercation that occurred 11/21/25. During an interview on 05/14/26 at 8:50 a.m., the Activity Director stated that she had only been working at the facility for four months and was not familiar with the Resident-to-Resident verbal altercation that occurred on 11/21/25. Stated she did receive training on hire about abuse and how to intervene if residents were arguing. She stated she would separate the residents to keep them safe and then get the nurse for help. The Activity Director stated she would let the Administrator know because he was the Abuse Coordinator. During an interview on 05/14/26 at 9:48 a.m., LVN E stated that she had received multiple in-services on abuse and neglect but could not recall specifically if she received in-services on Resident-to-Resident Abuse on 11/24/26. LVN E stated that 1:1 monitoring is done every 15 minutes or every hour based on the recommendation from the DON or the Abuse Coordinator when the incident occurs. LVN E stated Resident #1 was placed on hourly monitoring because he was the aggressor in the Resident-to-Resident verbal altercation that took place on 11/21/25. LVN E was not able to identify what staff member was responsible for the 1:1 monitoring of Resident #1 for 11/23/25. During an interview on 05/14/26 at 1:21 p.m., the Social Worker stated that she had received multiple in-services on abuse and neglect but could not recall specifically if she received an in-service on Resident-to-Resident abuse on 11/24/26. The Social Worker stated she does not usually participate in the 1:1 monitoring as that task was done by the nursing department. The Social Worker stated that she was aware of the Resident-to-Resident verbal altercation that occurred on 11/21/25 and that Resident #1 was the identified aggressor and that is why he was placed on 1:1 monitoring. During an exit interview on 05/14/26 at 3:00 p.m., the DON stated that she believed the Resident-to-Resident Abuse in-service was completed but did not know where the attendance sheet could be. The DON stated that Resident #1 was the aggressor in the Resident-to-Resident verbal altercation that occurred on 11/21/25 which is why he was placed on 1:1 monitoring. The DON stated that she believed the nursing staff provided 1:1 for Resident #1 on 11/23/25 because the nursing MAR did indicate 1:1 was provided for each shift but acknowledged that it did not reflect the hourly monitoring and location of Resident #1. The DON stated that she expects the nursing staff to complete tracking for 1:1 on the hourly tracking sheets. The DON was unable to recall who was assigned to complete the 1:1 monitoring for 11/23/25. During an exit interview on 05/14/26 at 3:40 p.m., the Administrator stated he reviewed the documentation that was submitted in the Provider Investigation Report for this incident for accuracy and completeness. The Administrator stated that he had suspended the Assistant Administrator C after he learned during this survey that she was not keeping an accurate record of provided in-services. The Administrator stated that he expects nursing staff to complete 1:1 monitoring and tracking sheets if a resident is identified as requiring 1:1 monitoring based on the incident investigation and that he expected these documents to be included in the final investigation report. The Administrator stated he is ultimately responsible for ensuring the PIRs are accurate and complete and that failing to provide appropriate in-services for each allegation could result in harm or injury to the residents because the staff may not know what interventions to use. Record review of the facility policy titled Abuse Prohibition Policy, revised 02/26/26, revealed, in part, Investigation: 1. The facility will thoroughly investigate all alleged violations and take appropriate actions., 5. Investigations will be prompt, comprehensive and responsive to the situation., 6. All documentation of pertinent date to the investigation will be collected, maintained, and safeguarded in the Administrator/DON's office by the facility. Resident-to-Resident Incidents: 7. If the perpetrator is placed on location monitoring, staff will be instructed on the reason for monitoring and target behaviors being monitored.

Based on interviews and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were accurately documented for 1 of 7 residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure a pulse and blood pressure was not recorded for Resident #1 on 3/26/26 when she was discharged to the hospital on 3/25/26 and had not returned to the facility. The facility failed to ensure the ADON charted the correctly dated vital signs on skilled nursing notes for Resident #1 on 3/22/26, 3/23/26, and 3/24/26. The facility failed to ensure the ADON did not chart skilled nursing notes on Resident #1 on 3 days (3/26/26, 3/27/26, and 3/28/26) after she had been admitted to the hospital. These failures could place residents at risk for inaccurate assessments, monitoring, and for not being provided proper care due to inaccurate documentation.Findings included: Record review of the face sheet dated 4/14/26 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Record review of the Diagnoses Report dated 4/14/25 indicated Resident #1 had diagnoses including seizures (temporary, uncontrolled surges of electrical activity in the brain that disrupts normal function), schizoaffective disorder (a chronic mental health condition characterized by a combination of schizophrenia and mood disorder), hypertensive heart disease (refers to heart damage including thickened muscles, coronary artery disease, and heart failure caused by long-term unmanaged high blood pressure), diabetes, and hypertension (elevated blood pressure). Record review of the MDS dated [DATE] indicated Resident #1 understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS score of 03 and severely cognitively impaired. The MDS indicated Resident #1 was dependent on staff for transfers. Record review of the care plan initiated 3/3/26 indicated Resident #1 had an ADL self-care deficit. Record review of the weights and vitals summary dated 4/14/26 indicated Resident #1 had a blood pressure of 103/60 on 3/26/26 and a pulse of 100 on 3/26/26. Record review of daily nursing charting skilled note dated 3/22/26 and completed by the ADON indicated Resident #1 had a blood pressure of 103/60 on 3/26/25, temperature of 98.4 on 3/25/26, pulse of 100 on 3/26/26, a respiration rate of 17 breath per minute on 3/25/26, and an oxygen saturation (the measure of oxygen-carrying hemoglobin (an iron rich protein in red blood cells) in the blood) of 96% on 3/25/26. Record review of daily nursing charting skilled note dated 3/23/26 and completed by the ADON indicated Resident #1 had a blood pressure of 103/60 on 3/26/25, temperature of 98.4 on 3/25/26, pulse of 100 on 3/26/26, a respiration rate of 17 breath per minute on 3/25/26, and an oxygen saturation of 96% on 3/25/26. Record review of daily nursing charting skilled note dated 3/24/26 and completed by the ADON indicated Resident #1 had a blood pressure of 103/60 on 3/26/25, temperature of 98.4 on 3/25/26, pulse of 100 on 3/26/26, a respiration rate of 17 breath per minute on 3/25/26, and an oxygen saturation of 96% on 3/25/26. Record review of the SBAR (situation, background, assessment, and recommendation) report dated 3/25/26 indicated Resident #1 was transferred to the ER due to a change in condition. Record review of daily nursing charting skilled note dated 3/26/26 and completed by the ADON indicated Resident #1 had a blood pressure of 103/60 on 3/26/25, temperature of 98.4 on 3/25/26, pulse of 100 on 3/26/26, a respiration rate of 17 breath per minute on 3/25/26, and an oxygen saturation of 96% on 3/25/26. Record review of daily nursing charting skilled note dated 3/27/26 and completed by the ADON indicated Resident #1 had a blood pressure of 103/60 on 3/26/25, temperature of 98.4 on 3/25/26, pulse of 100 on 3/26/26, a respiration rate of 17 breath per minute on 3/25/26, and an oxygen saturation of 96% on 3/25/26. Record review of daily nursing charting skilled note dated 3/28/26 and completed by the ADON indicated Resident #1 had a blood pressure of 103/60 on 3/26/25, temperature of 98.4 on 3/25/26, pulse of 100 on 3/26/26, a respiration rate of 17 breath per minute on 3/25/26, and an oxygen saturation of 96% on 3/25/26. During an interview on 4/14/26 at 1:09 p.m. the ADON said she was familiar with Resident #1. The ADON said she did not know why there were skilled nurse's notes for 3 days after Resident #1 was admitted to the hospital. The ADON said she did assist the nurses with their skilled nurse charting on residents. The ADON said if skilled nurse notes were completed for 3 days after Resident #1 was sent to the hospital that it was an error. The ADON said vital signs on skilled nursing notes should be dated the same date as the nursing note. The ADON said if the vital signs were not the same as the date of the skilled nursing note it was an error. The ADON said vital sign recordings for Resident #1 dated after 3/25/26 were an error. The ADON said the importance of accurate documentation and dates was to have the information on a resident in real time. During an interview on 4/14/26 at 2:29 p.m. the DON said she expected charting to be done in real time with a short narrative in addition to check boxes on templates. The DON said the ADON was responsible for ensuring charting was accurate. The DON said it was her responsibility to ensure the ADON was checking resident charts for accuracy. The DON said she only had one ADON as the other one had been termed and it had caused them to get behind on things. The DON said she had failed to check the ADON's work due to working through her medication audits. The DON said the importance of accurate charting was provide proof of what had been done for a resident and when. Record review of the facility's Nursing Documentation Guideline dated 1/15/19 indicated, To ensure nursing document is accurate, timely, and reflective of the resident's clinical condition, while supporting efficient and appropriate documentation practices.Nursing documentation reflects the resident's clinical status and any significant findings or interventions, rather than duplicating information already captured elsewhere in the record.Documentation is completed as close to the time of care as practicable. Entries are accurate, objective, and resident specific. Duplicate of unnecessary documentation is avoided.

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 3 meals (lunch meal) reviewed for palatability, attractiveness, and appetizing. The dietary staff failed to provide food that was palatable and appetizing temperature for the lunch meal on 7/29/25.The facility failed to follow puree recipe for carrots served on 7/29/25 (lunch meal). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: 1. Record review of the menu indicated the lunch meal items on 7/29/25 included roasted turkey, carrots, scalloped potatoes, roll and cheesecake. During an interview on 7/28/25 at 11:03 a.m., Resident #67 stated she did not like the food, and the food was nasty tasting. During an interview on 07/28/2025 at 11:26 a.m., Resident #111 stated the food was not okay. During an interview on 7/28/25 at 11:56 a.m., Resident #55 stated the food was an issue around here; Resident #55 stated they do not know how to cook it; Resident #55 stated the food was bad. During observation and sample test tray of lunch meal on 7/29/25 at 12:45 p.m., the Dietary Manager stated the roasted turkey tasted good, carrots was hard and undercooked, scaled potatoes was warm and good, roll was not tasted, and cheesecake was good. The Surveyors stated roasted turkey tasted good, carrots were hard and needed to be hotter, scaled potatoes was good, roll was not tasted, and cheesecake was good. During an interview on 7/30/25 at 10:45 a.m., the Dietary Manager stated the Administrator oversaw him at the facility. The Dietary Manager stated he always tasted the foods every day at every meal. The Dietary Manager stated he did not taste the carrots served for lunch on 7/29/25. The Dietary Manager stated he handled food complaints by talking directly to the resident and seeing what the food complaint was then changing what the resident did not like. The Dietary Managers stated it was important to ensure the food was palatable, attractive and appetizing to the resident so the residents would eat the foods. The Dietary Manager stated people eat with their eyes first and if the food look good the residents would eat the foods. During an interview on 7/30/25 at 11:03 a.m., the Administrator stated he had been the Administrator since October of 2023. The Administrator stated he oversaw the dietary staff. The Administrator stated he ordered test trays from the kitchen once a week or as needed. The Administrator stated he was not aware of any recent food complaints from the residents. The Administrator stated he handled food complaints by talking to the residents and identifying the concerns then covering the concerns accordingly and lastly conducting in-services with the cook. The Administrator stated it was important to ensure the food was palatable, attractive and appetizing to the residents because it was part of what staff did and for the wellbeing and health for the residents. 2. Record review of the facility week 1 menu received on 7/29/25, indicated the lunch meal items included roasted turkey, carrots, scaled potatoes, roll and cheesecake. margarine, salt/pepper packets, choice of beverage, and water. Record review of the recipe for the carrot slice parslied for 10 or less residents on puree indicated to 2/3 cups of milk or appropriate liquid and 1 1/4 quarts of carrot sliced parslied. During observation of puree meal prep on 7/29/25 at 11:16 a.m., [NAME] A blended (1) cup of water and (3-4) Cups of carrot slice parslied. During an interview on 7/29/25 at 11:25 a.m , [NAME] A stated he had been a cook at the facility for 3 weeks. [NAME] A stated he completed in-services on following the recipe upon hire. [NAME] A stated the reason why he used water instead of following the recipe for the puree carrots because it slipped his mind. [NAME] A stated the facility had 8 residents on a puree diet. [NAME] A stated it was important to ensure he was following the recipe for nutritional value for the residents. During an interview on 7/29/25 at 2:51 p.m., the Dietician stated she had been the dietician since the 1st of February 2025. The Dietician stated she was not aware of the dietary staff was using water to puree meals, she said staff was not to use water to puree meals and she expected the dietary staff to follow the puree recipes. The Dietician stated she had limited oversight over the dietary staff, she said she oversaw meal checks and sanitation in the kitchen. The Dietician stated she had a short inspection and a long inspection once a month. The Dietician stated staff had not completed any in-services on following the recipes. The Dietician stated it was important to make sure the dietary staff was following the recipe for consistency of food products, consistency of puree foods, less of weight loss and wound healing. During an interview on 7/30/25 at 10:34 a.m., the Dietary Manager stated he had been the Dietary Manager since March of 2025, and he oversaw the dietary staff. The Dietary Manager stated he hired the cook and trained the cook to not to use water when pureeing foods. The Dietary Manager stated he expected staff to follow the recipe book. The Dietary Manager stated he completed an in-service with the cook on yesterday (7/29/25) for [NAME] A. The Dietary Manager stated it was important to ensure the dietary staff were following the recipe book for correct nourishment for the residents. During an interview on 7/30/25 at 11:00 a.m., the Administrator stated he had been the Administrator since October of 2023. The Administrator stated he was not made aware the dietary staff was not following the recipes and using water to puree foods, he said he expected staff to follow the recipe book The Administrator stated he oversaw the Dietary Manager. The Administrator stated he inspected the kitchen 3 times a week. The Administrator stated he did not have an accurate date of when staff last completed an in-service on following the recipe. The Administrator stated it was important to ensure the dietary staff were following the recipe book because it was in his policy for staff to follow the recipe book. The Administrator stated he would see if the facility had a policy on staff following the recipe. Policy on following the recipe book was requested from the Administrator on 7/30/25 at 11:00 a.m., was not received prior to exit on 7/31/25.Policy on following the recipe book was requested from the Dietary Manager on 7/30/25 at 10:45 am and was not received prior to exit on 7/31/25

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services, in that: 1) The Dietary staff failed to label and date all food items. 2) Dietary staff failed to effectively reseal, label and date frozen and refrigerated food items. These failures could place residents at risk for food contamination and foodborne illness. The findings included:During observations with Dietary Manager on 07/28/25 beginning at 10:11 a.m., the following observations were made in the kitchen Refrigerator (1 of 2):-(1) Gallon of premade orange juice was not label, had no expiration date and was prepared on 7/27/25.During observations with Dietary Manager on 07/28/25 beginning at 10:13 a.m., the following observations were made in the kitchen Refrigerator (2 of 2):-(1) sliced cheese bag unsealed, had an open date of 7/26/25 and no expiration date.-(1) cream cheese had a open date of 7/16/25 and no expiration date.-(1) Gallon of honey mustard had an open date of 6/12/25 and no expiration date. -(1) Gallon of honey mustard had a receive date of 11/20/24, open date of 4/16/25 and no expiration date. -(1) Gallon of salad dressing had a receive date of 11/6/24, open date of 7/26/25 and no expiration date.(1) container of spiced apples had an open date of 7/22/25 and no expiration date(1) container of sliced oranges had an open date of 7/24/25 and no expiration date. During observations with Dietary Manager on 07/28/25 beginning at 10:21 a.m., the following observations were made in the kitchen walk-in freezer (1 of 1):(1) hamburger Pattie not placed in a zip lock bag and bag was left unsealed.(1) Garlic biscuits had an open date of 5/27/25 and no expiration date.(1) bag of frozen turkey meat opened 7/11/25 had no expiration date. (1) bag of frozen chicken thighs had an open date of 7/25/25 and no expiration date. (1) box of dinner rolls bad was not sealed closed. (1) precooked hamburger patties bag was not sealed closed.(1) zip lock bag of pepperoni was not labeled or dated.(1) zip lock bag of fish Pattie was opened 2/11/25 and had no expiration date. During an interview on 7/30/25 at 10:50 a.m., the Dietary Manager stated he had been the Dietary Manager since March of 2025. The Dietary Manager stated the Administrator oversaw him at the facility. The Dietary Manager stated all food items found in the refrigerator and freezer were to be labeled, dated with receive date, open date and expiration date. The Dietary Manager stated staff completed in-services on labeling and dating on 7/29/25. The Dietary Manager stated staff last completed in-services on resealing refrigerated and frozen food items back in March of 2025. The Dietary Manager stated he conducted walk throughs in the kitchen every morning. The Dietary Manager stated the Administrator conducted walk throughs in the kitchen 3 times a week. The Dietary Manager stated if was important to ensure staff were labeling and dating refrigerator and frozen food items to ensure staff could tell how long they could use the foods for. During an interview on 7/30/25 at 11:05 a.m., the Administrator stated he had been the Administrator at the facility since October of 2023. The Administrator stated he oversaw the dietary staff at the facility. The Administrator stated all food items found in the refrigerator and freezer were to be labeled, dated with receive date, open date and expiration date. The Administrator stated he was not sure when the dietary staff last completed in-services on labeling and dating in the kitchen. The Administrator stated he was not sure if staff completed in-services on resealing refrigerated and frozen food items in the kitchen. The Administrator stated he conducted walk throughs in the kitchen 3 times a week. The Administrator stated it was important to ensure staff were labeling, dating and resealing refrigerated and frozen food items because he did not want to give the resident something that was expired. Record Review of food receiving a storage policy revised dated on 6/23/25 indicated (8) All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).Record Review of refrigerator and freezer policy reviewed on 6/25/25 indicated Policy statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation, and will observe food expiration guidelines; (7) All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. (8) Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufactures when expiration dates are in question or to decipher codes.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, for 1 of 8 residents (Resident #9) reviewed for abuse and neglect reporting. The facility failed to report to HHSC within 2 hours when Resident #9 alleged Resident #57 hit her on 06/17/2025. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #9's face sheet dated 07/31/2025 indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included rhabdomyolysis (muscle breaks down rapidly and releases breakdown into the blood), dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), anxiety disorder. Record review of Resident #9's Quarterly MDS assessment dated [DATE] indicated she was usually understood by others, and she understood others. The MDS assessment indicated Resident #9 had a BIMS score of 13, which indicated she was cognitively intact. The MDS assessment indicated Resident #9 required partial/moderate assistance with personal hygiene and toileting hygiene and substantial/maximal assistance with showering/bathing. Record review of Resident #9's care plan with date initiated 07/08/2025 indicated she received physical aggression on 06/17/2025. Record review of Resident #9's Progress Notes dated 06/17/2025 indicated, The resident has informed the RN at this time she was hit on the arms by another resident. The resident states that she was hit by another individual while eating breakfast on her bilateral arms. The resident states she is not in pain and is fine. She also states she could not understand why the other resident hit her and couldn't understand her as she was speaking gibberish. Head to toe assessment conducted, ROM to extremities intact, no bruising noted at the time of assessment. Resident has denied pain. The victim and aggressor have been separated. The DON, ADMIN, RP, MD are aware and have been notified. Signed by MDS Coordinator B. 2. Record review of Resident #57's face sheet indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), recurrent major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and anxiety disorder. Record review of Resident #57's Comprehensive MDS assessment dated [DATE] indicated she was sometimes understood by others, and she sometimes understood others. The MDS assessment indicated Resident #57 was unable to participate in the BIMS because she was rarely/never understood. The Staff Assessment for Mental Status indicated she had a short and long-term memory problem. The MDS assessment indicated Resident #57 had behavioral symptoms which could put others at significant risk of physical injury. Record review of Resident #57's care plan revised 07/07/2025 indicated she had a behavior problem related to increased agitation, episodes of hitting, and episodes of crying and asking for help. Resident #57's care plan indicated she had a potential to be physically aggressive related to dementia and poor impulse control with physical aggression initiated 06/17/2025. Record review of Resident #57's Progress Note dated 06/17/2025 indicated, The RN has been informed by another resident that this resident hit her on her arms. The resident is unable to recall the incident, these resident states, I don't know when asked about her description. The resident was removed away from the victim and placed on Q15 minute monitoring. The DON, ADMIN, RP, MD are aware and have been notified. Signed by MDS Coordinator B. During an interview on 07/30/2025 at 11:40 AM, MDS Coordinator B said Resident #9 reported to her another resident hit her on the arms while she was in the dining room. MDS Coordinator B said the resident who hit Resident #9 was Resident #57. MDS Coordinator B said when Resident #9 reported the incident to her she was still in the dining room, but the aggressor was not in the area so Resident #9 was safe. MDS Coordinator B said she assessed Resident #9, and she did not have any bruising or pain. MDS Coordinator B said she notified the DON, Administrator, RP, and doctor. MDS Coordinator B said she could not remember if it was witnessed or not. MDS Coordinator B said Resident #9 had reported it to her and she reported it to the above authorities. MDS Coordinator B said she reported the incident because it could be considered abuse. During an interview on 07/30/2025 at 11:51 AM, the Administrator said he was notified by MDS Coordinator B of the incident in the dining room between Resident #57 and Resident #9 on 06/17/2025. The Administrator said he did not report the incident because Resident #57 had a history of touching people, and her dementia is really bad. The Administrator said when Resident #57 was close to the other residents she had a tendency to touch the other residents. The Administrator said Resident #57 was not able to articulate things. The Administrator said he talked to Resident #9, and Resident #9 told him Resident #57 hit her and she could not understand why she did it. The Administrator said Resident #9 was confused about Resident #57 hitting her, so he did not report it. During an interview on 07/30/2025 at 12:05 PM, Resident #9 said about 6-8 weeks ago another resident had hit her on her arms in the dining room. Resident #9 said she was not able to understand what the other resident was saying, but the other resident got mad and hit her. Resident #9 said the other resident took her arm back and hit me, it didn't hurt me, but it hurt. Resident #9 said there were 2-3 staff members around, but she did not know their names. Resident #9 said she yelled for help and the staff took her away. Resident #9 said the staff told her she does that to everybody. During an interview on 07/31/2025 at 4:21 PM, the DON said Resident #9 reported Resident #57 hit her in the dining room. The DON said she did not think Resident #57 hit Resident #9 on purpose. The DON said Resident #57 was a touchy feely person, and she thought she reached out and Resident #9 took it as she hit her. The DON said they did an investigation, but they did not report it because Resident #57's BIMS score was too low. Record review of the facility's Abuse Prohibition Policy revised 11/07/2023, indicated, The Abuse Coordinator will report such allegations to the state agency in accordance with state law. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation.

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 28 residents (Resident #11) reviewed for MDS assessment accuracy. The facility failed to accurately document Resident #11's tobacco use. This failure could place residents at risk for not receiving care and services to meet their needs.Findings included: Record review of Resident #11's face sheet dated 07/31/2025 indicated he was a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #11 was able to make himself understood and usually understood others. The MDS assessment indicated Resident #11 had a BIMS score of 12, which indicated his cognition was moderately impaired. The MDS assessment did not indicate Resident #11 used tobacco. Record review of Resident #11's care plan revised 06/30/2025 indicated Resident #11 was a smoker. Record review of Resident #11's progress note dated 06/10/2025 indicated Resident #11 was a current smoker. During an interview on 07/30/2025 at 11:40 AM, MDS Coordinator B said she completed Resident #11's Comprehensive MDS assessment with an ARD of 06/14/2025. MDS Coordinator B said Resident #11 should have been coded for the use of tobacco because he smoked. MDS Coordinator B said when she completed the MDS assessments she went through the smoking list and reviewed it. MDS Coordinator B said it was her mistake and she may have overlooked it. MDS Coordinator B said when an MDS was not coded accurately it was an error and could affect the billing, and she did not think it could affect the resident directly. During an interview on 07/31/2025 at 4:43 PM, the Administrator said he expected for the MDS assessments to be coded correctly, according to the policies. The Administrator said the MDS Coordinators were responsible for ensuring this happened. The Administrator said if the MDS was not coded according to the resident's plan the interventions in place would not be beneficial to the patient. Record review of the facility's policy titled, MDS Coding Policy, reviewed 06/02/2025, indicated, .affiliated facilities utilize the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment was completed for 1 of 4 residents (Resident #7) reviewed for PASRR Level I screenings. The facility failed to complete the PASRR level 1 screening for Resident #7 who was admitted on [DATE] and had a diagnosis of Schizophrenia on admission. This failure could place residents who had a mental illness at risk of not receiving a needed assessment PE (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #7's face sheet, dated 07/31/25, indicated he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included schizophrenia (a chronic brain disorder characterized by symptoms like hallucinations, delusions, and disorganized thinking), anxiety (a feeling of unease, worry, or fear, often experienced as a normal reaction to stress), and depression (a common mental health condition characterized by persistent sadness and a loss of interest in activities, significantly impacting daily life). Record review of Resident #7's quarterly MDS assessment, dated 07/19/25, indicated he was severely cognitive impaired on decision making. He was able to make himself understood and he was able to understand others. He received an antipsychotic and an antianxiety medication routinely. Record review of Resident #7's electronic medical records did not indicate a PASRR level 1 screening was done, after he admitted on [DATE]. During an interview and observation on 07/31/25 at 10:33 a.m., the MDS Coordinator F said she had been the MDS Coordinator since November 2024. She said she was responsible to ensure a PL1 was completed on any resident when they admitted to the facility. She said Resident #7 was a previous resident but discharged December of 2024 and re-admitted [DATE]. She said since Resident #7 had been discharged for over 30 days then a new PL1 should have been completed. She said she did Resident #7's PL1 yesterday (07/30/25) after been questioned by the state surveyor, and realizing she had not done Resident #7's PL1. She said since Resident #7's PL1 was not completed then LIDDA was not alerted to do a PE. She said it was important for PL1's to be done to see if a resident would meet the criteria to receive services. During an interview on 07/31/25 at 11:43 a.m., the DON said the MDS Coordinator F was responsible to ensure the PL1 was filled when Resident #7 admitted to the facility. She said if Resident #7 admitted with a diagnosis of Schizophrenia, then a PL1 should have been done so a PE could have been done to determine if he would be able to receive services. During an interview on 07/31/2025 at 12:12 p.m., the Administrator said the MDS Coordinator was responsible to ensure the PL1 was done on admission. He said the risk was that the resident could have had PASRR services since they were admitted with the MI diagnosis. During an interview on 07/31/25 at 12:18 p.m., the Regional Compliance Nurse said they did not have a facility policy for PASRR and used the guidelines from the RAI manual. Record review of the RAI manual section A1500: Preadmission Screening and Resident Review (PASRR): All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions (please contact your local State Medicaid Agency for details regarding PASRR requirements and exemptions). Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. A resident with MI or ID/DD must have a Resident Review (RR) conducted when there a significant change in the resident's physical or mental condition. Therefore, when an significant change in status assessment (SCSA) is completed for a resident with MI or ID/DD, the nursing home is required to notify the State mental health authority, intellectual disability or developmental disability authority (depending on which operates in their State) in order to notify them of the resident's change in status. Section 1919(e)(7)(B)(iii) of the Social Security Act requires the notification or referral for a significant change.1 Each State Medicaid Agency might have specific processes and guidelines for referral, and which types of significant changes should be referred. Therefore, facilities should become acquainted with their own State requirements.Preadmission Screening and Resident Review:Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that Medicaid-certified nursing facilities:Evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID). Offered all applicants the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings). Provide all applicants the services they need in those settings.PASRR is an important tool for states to use in rebalancing services. under the Americans with Disabilities Act. PASRR can also advance person-centered care planning by assuring that psychological, psychiatric, and functional needs are considered along with personal goals and preferences in planning long-term care.In brief, the PASRR process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have SMI or ID. This is called a Level I screen. Those individuals who test positive at Level I are then evaluated in depth, called Level II PASRR. The results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care.

Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident within 48 hours of admission that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 (Resident #123 and Resident #127) of 22 residents reviewed for baseline care plans. The facility failed to address Resident #123's vascular dementia diagnosis on her baseline care plan. The facility failed to ensure Resident #127's baseline care plan was completed within 48 hours of admission. These deficient practices could affect residents who are admitted to the facility with specialized needs and result in missed care.Record review of Resident #123’s face sheet dated 7/31/25 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses diabetes mellitus (disease in which results in too much sugar in the blood stream), high blood pressure, cerebrovascular disease (group of conditions that impact the brain’s blood flow), normal pressure hydrocephalus (where excessive spinal fluid builds up in the ventricles), and history of falling. The face sheet did not indicate Resident #123 had a diagnosis of vascular dementia. Record review of Resident #123’s admission MDS dated [DATE] indicated she could understand others and could make herself understood. The MDS also indicated she had a BIMS score of 11 which meant she had moderately impaired cognition. The MDS also indicated she required substantial/maximal assistance from staff for toileting, bathing, moderate assistance with transfers and setup for eating but did not include the diagnosis for non-Alzheimer’s dementia in section I4800. Record review of Resident #123’s base line care plan dated 07/17/25 and unsigned by a nurse indicated she was a diabetic and alert. The baseline care plan did not indicate Resident #123 had vascular dementia or any cognitive loss. During an interview on 07/28/2025 at 3:27 PM Resident #123’s family member said she feels felt as though the staff does did not know that she has had dementia. During an interview on 07/31/2025 at 4:21 PM, ADON F said Resident #123’s baseline care plan should have been completed within 48 hours of admission date 07/17/25. She said vascular dementia was an important diagnosis to be included in the baseline care plan. ADON F said the failure of not ensuring the baseline care plans were complete and accurate placed a risk for Resident #123’s needs not being met. During an interview on 07/31/2025 at 5:02 PM the DON said she expected the baseline care plan to include the dementia and the cognition as well. She said the charge nurses were responsible and then the ADON should have reviewed and discussed in the morning meetings. During an interview on 07/31/2025 at 5:12 PM the Administrator said the charge nurses were responsible for completing the baseline care plans. He said the dementia diagnosis was important to be included in the baseline care plan. The Administrator said the failure of not completing the baseline care plan and including the dementia diagnosis placed a risk for nurses not being aware of what to treat Resident #123 for and could potentially cause harm to the resident. 2. Record review of Resident #127’s face sheet dated 07/31/25, indicated a [AGE] year-old male who admitted to the facility on [DATE]. Resident #127’s diagnoses included heart failure (heart muscle does not pump blood as well as it should), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and acute respiratory failure with hypoxia (lungs cannot adequately oxygenate the blood, leading to low blood oxygen levels). Record review of Resident #127’s EMR on 07/31/25 indicated the admission MDS assessment had not been completed. Record review of Resident #127’s baseline care plan indicated it was completed on 07/29/25 by LVN R. This indicated the baseline care plan was completed 2 days late. During an interview on 07/31/25 at 12:41 PM, ADON F said the baseline care plan was completed within 48 hours of admission and the admit nurse was responsible for completing it. The ADON said if the admit nurse was not able to complete the baseline care plan, then the oncoming nurse was responsible for completing it. ADON F said the baseline care plan gave the staff a baseline for the care needed to take care of the resident. The ADON said if the baseline care plan was not completed timely then they would not know if the resident’s needs were being met. During an interview on 07/31/25 at 12:44 PM LVN R said she did not complete Resident #127’s baseline care plan when he admitted on [DATE] because he admitted late to the facility and did not have time. She said the oncoming nurse should have completed it. LVN R said they usually relayed what was not completed on the admission checklist to the oncoming nurse during report. LVN R said the nurses were responsible to complete the baseline care plans within 24 hours. She said by not completing the baseline care plan timely, the staff would not know how to care for the resident. During an interview on 07/31/25 at 12:25 PM, the DON said the baseline care plans were completed within 24 hours by the admission nurse. The DON said the ADONs were responsible for checking the resident’s chart the next day to ensure all assessments were completed. The DON said failure to complete the baseline care plans timely placed the resident at risk for the staff not knowing the care the resident required. During an interview on 07/31/25 at 12:51 PM, the Administrator said the baseline care plans were to be completed within 48 hours of admission because they allowed the staff to be aware of the specific needs of the resident. He said the IDT was responsible for ensuring the baseline care plans were completed timely. He said by not completing the baseline care plan the staff would not be able to meet the resident’s needs. Record review of the facility policy “Care Plans-Baseline revised October 2023 indicated: Policy Statement A baseline plan of care to meet the resident’s immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident…”

Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 28 residents (Residents #5 and Resident #112) reviewed for care plans. 1. The facility failed to ensure Resident #5's care plan included her fall on 07/19/25 and the use of the non-strip strips and cervical collar (a collar used around the neck to support the neck and spinal cord after an injury) that should always remain in place. 2.The facility failed to update Resident #112's care plans for nectar thick liquids on 06/27/25. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.1.Record review of Resident #5’s face sheet dated 07/31/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses Multiple fractures of Ribs, lack of coordination, high blood pressure, diabetes mellitus (disease in which too much sugar is in the blood stream), and polyneuropathy (general term for peripheral nervous system disorders that impact nerve function in multiple areas of the body). Record review of Resident #5’s admission MDS dated [DATE] indicated she was able to understand others and able to make herself understood. The MDS also indicated she had a BIMS score of 15 which meant she was cognitively intact. The MDS also indicated she had falls in the last month, she had falls in the last six months that resulted in fractures, and she had a fall since admission to the facility. Record review of Resident #5’s care plan revised 05/29/25 indicated she had ADL self-care deficit and required moderate assistance with toileting, transfers, bed mobility, and dressing, and she was independent with eating. The care plan also indicated she had limited mobility, and she was a high risk for falls with interventions to ensure resident was aware of the need to call for assistance, assist with toileting, and assist with transfers. The care plan did not indicate Resident #5 had a fall on 07/19/25 and always required a cervical collar. Record review of Resident #5’s order summary report dated 07/31/25 did not indicate she had an order for the cervical collar. Record review of Resident #5’s hospital encounter dated 07/25/25 indicated she was to always wear the cervical collar when up and out of bed. During an observation on 07/28/2025 at 11:32 AM Resident #5 was sitting in her room in her wheelchair with a cervical collar on her neck. During an interview on 07/31/2025 at 4:55 PM MDS Coordinator Q said she was responsible for completing and updating the care plans for Resident #5. She said she should have care planned the fall on 07/19/2025 in Resident #5’s bathroom and interventions of non-slip strips should have been added but failed to mention the cervical collar. MDS Coordinator Q said they usually had morning meetings daily and they updated the care plans each day, but she did not know how she missed updating Resident #5’s care plan. She said the failure placed a risk of not ensuring the staff were providing the proper care. During an interview on 07/31/2025 at 5:04 PM the DON said she expected the cervical collar and the most recent fall on 07/19/25 with interventions to be included in the care plan. The DON said MDS Coordinator Q was responsible for ensuring Resident #5’s care plan was updated. She said the failure placed the risk of the staff not knowing how to care for Resident #5 and could possibly cause further injuries. During an interview on 07/31/2025 at 5:10 PM the Administrator said the fall on 07/19/25 and the cervical collar use should have been in the care plan along with the intervention for the care. He said MDS Coordinator Q was responsible for updating the care plans for Resident #5. The Administrator said the management staff discussed falls and admissions daily in the meetings. He said the failure placed a risk of harm to the Resident #5 or a repeat of the same incident/fall. 2.Record review of Resident #112’s face sheet, dated 07/31/25 indicated he was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, dysphagia (medical term for difficulty swallowing solids, liquids, or both), dementia (the loss of cognitive functioning — thinking, remembering, and reasoning), hypertension (high blood pressure), and gastroesophageal reflux disease also known as GERD (a digestive disorder where stomach acid frequently flows back into the esophagus, irritating the lining. Record review of Resident 112’s annual MDS assessment, dated 07/10/25, indicated Resident #112 was understood and understood by others. Resident #112 was moderately impaired in decision making. The MDS indicated Resident #112 required assistance with her ADLs such as eating and personal hygiene. The MDS indicated she was altered mechanical diet. Record review of Resident 112’s Physician order dated 06/27/25 revealed Resident #112 had a Regular diet Mechanical Soft texture, Nectar Thickened consistency. Record review of Resident #112’s comprehensive care plan, dated 03/07/25, revealed Resident #112 had a Regular diet, mechanical soft texture, with thin consistency. The intervention was for staff to provide and serve diet as ordered. During an observation and interview on 07/31/25 at 10:39 a.m., RN G looked in Resident #112’s medical records and said she had an order for nectar thick liquid consistence. He said since she required nectar thick liquids it should have been care planed. During an interview on 07/31/25 at 11:07 a.m., the DON said the MDS Coordinator was responsible for the care plans. She said they talked about the resident’s changes during the morning stand-up meeting and the clinical meeting every Wednesday. She said she could not say why the MDS Coordinator F had not updated Resident #112’s care plans. The DON said the nectar thick liquids should have been on Resident #112’s care plan. She said the purpose of the care plans was to keep everyone informed of the resident's wishes and care. During an interview on 07/31/25 at 12:14 p.m., the Administrator said the MDS Coordinator was responsible for the care plans. He said care plans were done for the care the resident needed. He said interventions were put in place so that staff would know what care the resident required. He said department heads were responsible for ensuring the staff was following the care plan. Record review of the facility policy titled, “Comprehensive Person-Centered,” revised 01/23, indicated, “Policy: A comprehensive, person-centered care plan that includes measurable objective and timetable to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident. #13 Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident conditions change.”

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 28 residents (Resident #110) reviewed for ADLs. The facility failed to provide Resident #10's showers as scheduled for the month of July 2025. These failures could place residents at risk of not receiving needed services and care, decreased self-esteem, and a decreased quality of life. Findings included: Record review of Resident #110's face sheet dated 07/31/2025 indicated he was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), atrial fibrillation (irregular, often rapid heart rate), and type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Record review of Resident #110's Comprehensive MDS assessment dated [DATE] indicated he was understood by others and understood others. The MDS assessment indicated Resident #110 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #110 required partial/moderate assistance with showering/bathing. Record review of Resident #110's care plan revised 07/25/2025 indicated he had an ADL self-care performance deficit related to chronic obstructive pulmonary disease and to provide a sponge bath when a full bath or shower was not tolerated. Record review of Resident #110's shower sheets indicated he received showers on 07/18/2025, 07/23/2025, 07/25/2025, 07/28/2025, and 07/30/2025. There was no shower sheet for 07/21/2025. During an observation and interview on 07/28/2025 at 11:31 AM, Resident #110 said he had only received one bath since his admission, and it was one week ago. Resident #110 said he could not stand the smell of himself. Resident #110 said he did not know when his scheduled bath days were. Resident #110 said the only reason he had gotten the shower was because he reported it to the DON, and she made them give him a shower. Resident #110's hair appeared greasy and disheveled. During an interview on 07/31/2025 at 2:17 PM, CNA C said Resident #110 received his showers on Monday, Wednesday, and Friday on the 2 PM-10 PM shift. CNA C said Resident #110 did not refuse his showers. CNA C said she had not missed giving Resident #110 any showers, and she was not aware that he missed any showers. CNA C said it was important for the residents to receive their showers, so they did not have bad smells. During an interview on 07/31/2025 at 4:04 PM, LVN D said it had not been reported to her that the residents were not receiving showers. LVN D said she was not aware of Resident #110 missing any showers. LVN D said it had not been reported to her that Resident #110 refused any showers. LVN D said it was important for the residents to receive their showers for dignity. During an interview on 07/31/2025 at 4:08 PM, the DON said recently it had not been reported to her that residents were not receiving showers. The DON said she had not been told Resident #110 refused showers. The DON said Resident #110 had not reported to her he missed showers and that he may have told the ADONs. The DON said the ADONs were responsible for reviewing the shower sheets to ensure the residents received their showers. The DON said it was important for the residents to receive their showers because they did not want them to get skin issues or infections, and it was also for their dignity. During an interview on 07/31/2025 at 4:47 PM, the Administrator said showers should be completed according to the shower schedule. The Administrator said the CNAs were responsible for the showers, and the nurses should monitor the showers were completed every shift. The Administrator said if the residents did not receive their showers, it could affect their hygiene and for infection control. Record review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised March 2018, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) .

Based on interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 6 residents reviewed for quality of care. (Resident #123) The facility failed to begin neurological checks when Resident #123 had an unwitnessed fall on 07/30/25 at 3:10 PM. These failures could place residents at risk of a delay in treatments for the resident's conditions.Findings included: Record review of Resident #123's face sheet dated 7/31/25 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses diabetes mellitus (disease in which results in too much sugar in the blood stream), high blood pressure, cerebrovascular disease(group of conditions that impact the brain's blood flow), normal pressure hydrocephalus (where excessive spinal fluid builds up in the ventricles), and history of falling. Record review of Resident #123's admission MDS dated [DATE] indicated she could understand others and could make herself understood. The MDS also indicated she had a BIMS score of 11 which meant she had moderately impaired cognition. The MDS also indicated she required substantial/maximal assistance from staff for toileting, bathing, moderate assistance with transfers and setup for eating. The MDS also indicated she received antipsychotic medications during the last 7 days or since admission to the facility. Record review of Resident #123's care plan dated 07/29/25 indicated she was at risk for falls r/t disorientation and increased risk of bleeding/bruising due to antiplatelet therapy with interventions to handle resident carefully when turning, positioning, or transferring, and sudden change in mental status, SOB, nose bleeds and report such findings to physician. Record review of Resident #123's fall note dated 07/30/25 at 3:10 PM indicated Resident #123 was found her on the floor beside her bed. During an observation and interview on 07/31/2025 at 09:50 AM Resident #123 was sitting in her wheelchair in the dining room with a family member. Resident #123 said she had a fall and she was ok but had anxiety. During an interview on 07/31/25 at 11:55 AM the DON said Resident #123 had an unwitnessed fall on 07/30/25 and should have had neurological checks check initiated at the time of the fall but the nurse failed to begin the neurological checks. She said she expected neurological checks to be completed on all unwitnessed falls or if a there was a fall with a resident hitting their head. The DON said she spoke with LVN E about the incident and LVN E said she did not feel like Resident #123 hit her head. The DON said the failure to complete neurological checks could place a risk for unknown injuries or change in condition. During an interview on 07/31/25 at 12:28 PM LVN E said she went into Resident #123's room after her fall and she just assumed that she did not hit her head because the way she was laying on the floor. LVN E said she examined Resident #123 and did not feel any bumps but she said the DON further instructed her on 07/31/25 to always begin neurological checks if a resident fall was unwitnessed. LVN E said the failure to start neurological checks after the fall could place Resident #123 at risk for internal bleeding or other issues if she hit her head. During an interview on 07/31/2025 at 4:30 PM The ADON F said the charge nurse at the time of the fall was responsible for starting neurological checks. She said the charge nurse should have assessed the resident, determined any injuries, and looked around and try to figure out how it happened. The ADON said the charge nurse should have notified the Medical Director, the DON, and Resident #123's family. She said neurological checks were expected to be completed for residents that had unwitnessed falls. The ADON F said not completing neurological checks could have caused the nurse to miss a change in condition. During an interview on 07/31/2025 at 5:15 PM the Administrator said he expected the charge nurse to follow the policy for falls and she should have begun neurological checks immediately after the fall when unwitnessed. He said the failure could have caused harm and the nurse could have missed a change in condition. Record review of the facility policy Policy for Resident and Visitor Accident Report revised 06/05/2025 indicated:Policy: The facility will conduct an investigation of all incidents involving residents of the facility.B. Resident Incidents/Accidents:1. If you witness an accident, you must immediately summon help.2. License nurse must: a. Examine the resident and obtain vital signs. B. If the resident hit his/her head or if the incident was unwitnessed initiate neurological checks.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 3 residents (Residents #11) reviewed for accident hazards. The facility failed to ensure Resident #11 did not smoke a cigarette in the facility on 12/08/2024 and 07/11/2025. The facility failed to ensure Resident #11 was provided supervision while smoking on 07/29/2025. These failures could place residents at risk of accidents, injuries, or burns. Findings included: Record review of Resident #11's face sheet dated 07/31/2025 indicated he was a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), schizoaffective disorder bipolar type (mental health condition that is marked by a mix of symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania), and heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #11 was able to make himself understood and usually understood others. The MDS assessment indicated Resident #11 had a BIMS score of 12, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #11 required partial/moderate assistance with personal hygiene and bathing and set-up or clean-up assistance for toileting. The MDS assessment did not indicate Resident #11 used tobacco. Record review of Resident #11's care plan revised 07/15/2025 indicated on 07/11/2025 he was placed on a smoking schedule because he was found smoking in his room. Cigarettes and lighter were put in the nurse's cart. Resident # 11's care plan indicated to educate and encourage him to follow the facility designated smoking areas and policy, and he required supervision while smoking. Resident #11's care plan indicated he had an ADL self-care performance deficit related to impaired balance, and he was at risk for falls and injuries. Record review of Resident #11's Order Summary Report dated 07/31/2025 indicated Supervised smoking schedule. 7am 9am 11am 1pm 3pm 5pm 7pm 9pm every shift. Can go out supervised to smoke caught smoking in room with a start date of 07/12/2025. Record review of Resident #11's Smoking Safety Evaluations indicated: 06/11/2024- Resident #11 did not require supervision for smoking. Completed by the Clinical Services Coordinator. 12/08/2024- Resident #11 was confirmed a safe smoker/vaper. A note indicated resident was re-educated to smoke only outside of the building for safety reasons will continue to monitor. Completed by Nurse T. 01/29/2025- Resident #11 was confirmed a safe smoker/vaper. A note indicated resident appears to be a safe smoker at this time. However, resident has failed in the past to comply with smoking policies. Completed by the Social Worker. 04/28/2025- Resident #11 was confirmed to be a safe smoker/vaper. A note indicated no concerns being unsupervised. Completed by the Social Worker. 07/11/2025- Resident #11 was confirmed as not a safe smoker/vaper and must be supervised. Completed by the Social Worker. Record review of Resident #11's progress notes indicated: 12/08/2024 8:01 AM, Subjective : Patient is smoking in his room. Objective : Room smelled of cigarette smoke. Assessment : Patient caught smoking a cigarette in his room. DON notified. Plan : Education on the dangers of smoking indoors and near O2 explained to patient. Contraband (cigarettes and lighters) taken and placed in locked cart. Patient must ask nurse before going out to smoke. Nurse H8:23 AM, Patient caught smoking in his room. 11 cigarettes confiscated along with 9 lighters and locked in the med cart. LVN H 03/12/2025 6:21 AM, Skilled Nurse was informed by aid that Kitchen staff had seen resident on the floor outside the 300 hall exit door, SN made his way to the hall to see resident was in his wheelchair besides his bedroom door. Resident was asked what had happened and he stated that he went outside and began digging through the trash for cigarette butts so he could smoke, resident went further to claim that he had been outside since 1am which was demonstrably false since resident received his medication at 2:30am. Residents vital signs were taking [sic] and as follows: BP 101/57, Pulse 83, O2 97, Temp 96.9. Resident denied being in any pain r/t to fall. SN requested from resident a UA sample to check for UTI and resident refused, resident was also asked if it would be ok to ask the physician to put an order for a lab draw, resident once again refused. Resident has been and continues to be educated on the dangers of continually exiting the building at Night. The Resident was accompanied outside to smoke at the start of his daily smoking schedule. LVN K 04/27/2025 11:40 AM, Four lighters were confiscated from the resident's possession. Resident is still on supervised smoke breaks and is not allowed to keep paraphernalia in his room/possession. Those items must be locked on the nurse's cart. LVN H 07/11/2025 11:51 PM Resident observed by the aide coming out of his room smoking a cigarette wheeling himself down the hall way. When told he couldn't smoke in the building, he needed to put the cigarette out he stated I know am not supposed to smoke in the building am going out. Resident escorted out to smoke, assessed no burn injuries noted, notified the DON and Administrator, took all resident's cigarettes and lighter put the in the nurse's cart, resident was educated and reminded that he was to be put on a smoke schedule and be supervised. He verbalized understanding. LVN L 07/11/2025 10:09 AM LATE ENTRY Reason for smoking/vaping safety evaluation: Fire Safety compromised Facility policy is that all residents who smoke/vape must be supervised, regardless of safety or ability: NoIt [sic] is confirmed resident is NOT a safe smoker/vaper and must be supervised. Social Worker. During an observation and interview on 07/29/2025 starting at 11:22 PM, Resident #11 was observed coming out of his room in his wheelchair propelling himself. Resident #11 wheeled himself down the end of the 300 hall and let himself outside to the smoking area. Resident #11 had the code to go outside. LVN M was in the room with the resident at the end of the hall, the door was open, but Resident #11 passed by without LVN M's knowledge. When outside Resident #11 lit his cigarette and started smoking. Resident #11 was unsupervised by the facility staff. Resident #11 said the nurse up front gave him his cigarettes and a lighter, and he had them in his pocket. Resident #11 said he went outside alone to smoke. Resident #11 said one of the times he had gone out to smoke he fell outside because he got too close to the edge and fell off the concrete. The concrete on the patio of the smoking area was higher than the grass around it, it was not leveled. Resident #11 said he laid on the ground until the lady from the kitchen found him. Resident #11 said he did not remember when it was or how long he laid on the ground until he was found. During an interview on 07/29/2025 at 11:26 PM, CNA N said Resident #11 required supervision when smoking. CNA N said the nurses should have the smoking materials, and she tried to supervise the residents when she saw them going out to smoke because it was nighttime and for safety reasons. CNA N said she was not always able to supervise the residents when they went to smoke outside because sometimes, she did not see them if she was in another resident's room. CNA N said most of the time she was the only CNA on the hall at night. CNA N said it was important to provide supervision to residents while they smoked for safety reasons and because they could catch themselves on fire. CNA N said about 2-3 months ago Resident #11 was found outside on the floor by a kitchen aide when the kitchen aide came in around 5 am. CNA N said that night she tried to supervise him the best she could. CNA N could not remember when the last time she saw Resident #11 was prior to him being found outside. During an interview on 07/29/2025 at 11:36 PM, LVN O said it was her 2nd day working at the facility. LVN O said she did not know who required supervision while smoking. LVN O said the only way she would know was if it was an order. LVN O said she was Resident #11's nurse, and the nurse prior to her told her Resident #11 had been out to smoke at 9 PM. LVN O said it was important for the residents who required supervision to be supervised while smoking so they would not injure themselves or anyone else. During an interview on 07/29/2025 at 11:50 PM, LVN M said he decided based on the resident if they required supervision or not. LVN M said the smoking schedule for both unsupervised and supervised was from 8 AM-9 AM, 12 PM-1 PM, 2 PM-3 PM, and then before dinner was the last smoking time. LVN M said the nurse's keep the cigarettes and lighters for both the supervised and unsupervised smokers. LVN M said Resident #11 did not have any smoking privileges because he had lost them due to smoking in his room. LVN M said all the residents who smoked had the code to get in and out of the door on their own. LVN M said unsafe smoking could result in harm to others and harm to themselves. LVN M said Resident #11 could catch the room on fire or cause burns. During an interview on 07/29/2025 at 11:52 PM, LVN D said she had taken Resident #11 to smoke at 7 PM, and supervised him. LVN D said Resident #11 should not have any cigarettes or lighters. LVN D said if Resident #11 had cigarettes and lighters it was a safety issue for himself and others. During an interview on 07/29/2025 at 11:55 PM, ADON P said she started working at the facility on 06/27/2025. ADON P said residents who were considered safe could keep their own cigarettes and lighters and smoke whenever they wanted, but the residents who were considered unsafe were not able to keep their lighters and cigarettes and had to follow the smoking schedule. ADON P said Resident #11 was the only resident who was considered unsafe because he smoked in the building. ADON P said Resident #11 should not have any smoking materials that the nurse should have them. ADON P said she had asked the staff to take him to smoke at 10 PM. ADON P said all the residents who smoked had the code to go outside to the smoking area, and the residents could go out there when they wanted. ADON P said Resident #11 was allowed to go sit outside and he knew the code to get in and out. ADON P said during the day she checked Resident #11 frequently to ensure he did not have any smoking materials. ADON P said she did not know how Resident #11 was getting the lighters and cigarettes. During an interview on 07/30/2025 at 9:38 AM, the Social Worker said she observed the residents smoking to make sure they did not have any dexterity problems, and she completed the smoking evaluations. The Social Worker said she ensured the residents were aware of the smoking policy, and she enforced it. The Social Worker said if the residents were not following the smoking policy she would take to the Administrator and the nursing staff to determine the next action. The Social Worker said the DON directed her on when to conduct smoking evaluations on the residents. The Social Worker said she has evaluated Resident #11 as a safe smoker because she felt he was safe. Until 7/11/2025, when there was a concern of him smoking so she made him unsafe. The Social Worker said Resident #11's cigarettes and lighters were taken away from him. The Social Worker said if a resident required supervision while smoking, and they were not supervised it placed themselves and others safety at risk. During an interview on 07/30/2025 at 9:53 AM, the DON said Resident #11 was considered an unsafe smoker a couple weekends ago because he was trying to smoke in his room. The DON said the end of last year Resident #11 had done the same thing, and they had placed him on supervised smoking. The DON said Resident #11 would come to them every day and tell them he had learned his lesson, and he was not going to do it anymore, so in April 2025 he was deemed a safe smoker. The DON said on 12/08/2024 Resident #11 was in his room smoking, and he said he had done it because it was too cold to go outside. The DON said from 12/08/2024 to 04/28/2025 Resident #11 should have been a supervised when smoking. The DON said on 04/27/2025 Resident #11 was not supposed to have lighters, and they did not know how he got the lighters because they were checking his room periodically. The DON said on 04/28/2025 Resident #11 was deemed a safe smoker because he kept asking them about smoking and he had not had anymore episodes, so they said they were going to give him a chance and deemed him safe to smoke unsupervised. The DON said they should not have deemed him safe to smoke because he was still breaking the rules. The DON said because Resident #11 was not following the smoking policy it placed himself and others at risk for safety issues. The DON said on 07/11/2025 when Resident #11 was smoking in his room she told the staff to remove all his lighters and cigarettes. The DON said Resident #11 said he did not know why he smoked in his room. The DON said he was placed on a smoking schedule and required supervision when smoking. The DON said Resident #11 should not have been smoking alone outside the night of 07/29/2025. The DON said Resident #11 should never have possession of any cigarettes or lighters that somebody should be assisting him to go out and smoke, and his cut off time was maybe 9 PM. The DON said Resident #11 was placed on 1:1, and they searched his room again and they found 1 box of cigarettes. The DON said on 03/12/2025 she was notified that Resident #11 was found outside on the ground. The DON said she was not notified he had been looking in the trash for cigarette butts. The DON said if she would have been notified, he should have been re-evaluated for his smoking safety and placed on 1:1. The DON said Resident #11 had not had any burns or injuries related to smoking. The DON said only the residents who required supervision had a cut off time for their smoking. The residents who were unsupervised could smoke at any time. While interviewing the DON, the Social Worker entered and said on 12/08/2025 Resident #11 was in his room smoking, therefore, he should have been considered an unsafe smoker. The DON said Nurse T completed the smoking evaluation incorrectly. The DON said Nurse T no longer worked at the facility. The Social Worker said if a resident required supervision for smoking it should be on a list at the nurses' station. The Social Worker said smoking in the building could cause the building to blow up. The Social Worker said not conducting the smoking evaluations correctly was unsafe and placed them at risk of causing a fire or the building blowing up. The Social Worker said Resident #11 not being supervised could result in him hurting himself. During an interview on 0731/2025 at 5:31 PM, the Administrator said on 12/08/2024 when Resident #11 smoked in his room they took his cigarettes and placed him on supervised smoking. The Administrator said from 12/08/2024-04/27/2025 he was supposed to be supervised for smoking. The Administrator said on 07/11/2025 the CNA saw Resident #11 smoking in the facility and stopped him, and he was placed on supervised smoking again. The Administrator said Resident #11 should not have been smoking unsupervised the night of 07/29/2025, and he should not have had any smoking materials. The Administrator said Resident #11 had a BIMS of 14, he was alert and oriented and liked to go outside. The Administrator said Resident #11 had violated the smoking policy and it placed him at risk for danger to others, but he had never burned himself. The Administrator said Resident #11 was required supervision when smoking because he tried to smoke in his room. The Administrator said this could result in the building burning down. Record review of the Facility Smoking Policy-Supervised and Unsupervised revised 11/2024, signed by Resident #11 on 01/30/2025, indicated, It is the responsibility of the facility to provide a safe and hazard free environment for those residents having been assessed as being safe for Facility smoking privileges. The facility is responsible for informing residents, staff, visitors and other affected parties of facility smoking policies through verbal means, distribution and posting. This policy is intended to minimize the risks to: Residents who smoke, including possible adverse effects on treatment Passive smoke to others Fire. The facility is responsible for enforcement of smoking policies. Smoking is prohibited in any room, or area within facility. Smoking is prohibited where flammable liquids, combustible gas or oxygen are stored, and in any other hazardous location. These areas are posted with non-smoking area signs. Residents wishing to smoke while at the facility will have a Smoking Safety Evaluation completed by the interdisciplinary team to determine the resident's ability to follow smoking policies safely If resident is determined to be a Safe Smoker (Facility please check one option) Resident can smoke unsupervised, resident can keep their smoking supplies, and smoke in designated areas at their leisure OR Resident can smoke unsupervised, facility will keep all smoking supplies, and resident can smoke in designed areas at their leisure. If resident is determined to be an Unsafe Smoker then they must be supervised at all times when smoking. Facility staff will keep all smoking supplies and smoking times will be established by the facility and adhered to by the resident. A supervised smoking schedule will be posted and residents will be required to smoke with supervision only, according to the schedule. If a resident is in violation of this facility smoking policy, the Administrator and/or designee will meet with the resident and/or responsible party to discuss the violation. 30 day or immediate discharges may be issued at the discretion of the Administrator/designee pending the severity of the smoking/alcohol violation.

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 5 residents reviewed for respiratory care. (Resident #42) The facility failed to administer Resident #42's oxygen as ordered on 07/28/25, 7/29/25, and 7/30/25. This failure could place residents who receive respiratory care at risk for developing respiratory complications.Findings included: Record review of Resident #42's face sheet dated 07/31/25, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (lung condition caused by damage to the airways that limit airflow), lung cancer, and acute respiratory failure (lung condition when the lungs cannot exchange oxygen and carbon dioxide properly). Record review of Resident #42's admission MDS assessment dated [DATE], indicated she was sometimes understood and sometimes understood others. Resident #42 had a BIMS score of 12, which indicated her cognition was moderately impaired. Resident #42 received oxygen therapy. Record review of Resident #42's comprehensive care plan dated 07/29/25, indicated Resident #42 had oxygen therapy related to respiratory illness. The care plan interventions indicated oxygen at 2 liters per minute via nasal cannula continuously. May titrate to 3-4 liters per minute to keep oxygen saturations greater than 90 percent. Record review of Resident #42's order summary report dated 07/29/25, indicated Resident #42 had an order for oxygen at 2 liters per minute via nasal cannula continuously. May titrate to 3-4 liters per minute to keep oxygen saturations greater than 90 percent every shift with an order date of 07/18/25. Record review of Resident #42's respiratory administration record dated 07/01/25-07/31/25, indicated she had an order for oxygen at 2 liters per minute via nasal cannula continuously and may titrate to 3-4 liters per minute to keep oxygen saturations greater than 90 percent. The administration record indicated Resident #42 had received oxygen every shift since Resident #42 admitted on [DATE]. During an observation on 07/28/25 at 11:22 AM, Resident #42 was in her bed and received oxygen at 5 liters per minute via nasal cannula. During an observation on 07/28/25 at 3:26 PM, Resident #42 was in her bed and received oxygen at 5 liters per minute via nasal cannula. Record review of Resident #42's progress note dated 07/28/25 at 11:05 PM and signed by RN S, indicated .Resident is up watching television at present.O2 @ 5 LPM via NC. During an observation on 07/29/25 at 09:47 AM, Resident #42 was in her bed and received oxygen at 5 liters per minute via nasal cannula. During an observation and interview on 07/29/25 at 4:48 PM, Resident #42 was in her bed and received oxygen at 5 liters per minute via nasal cannula. Resident #42's family member was at her bedside and said Resident #42's oxygen was supposed to be set at 5 liters because it was what Resident #42 had received when she was at the hospital. During an observation on 07/30/25 at 09:27 AM, Resident #42 was in her bed and received oxygen at 5 liters per minute via nasal cannula. During an observation and interview on 07/30/25 at 9:39 AM, LVN R went into Resident #42's room and observed the oxygen setting. LVN R said Resident #42's oxygen was set at 5 liters. LVN R reduced Resident #42's oxygen rate to 4. LVN R said the oxygen was set at the ordered rate of 4, but Resident #42's family member plays with it. LVN R said the nurse was responsible for checking the oxygen during their morning rounds. LVN R said failure to administer the oxygen at the ordered rate could cause Resident #42 to receive too much oxygen. During an interview on 07/30/25 at 2:35 PM, the Pulmonary Nurse Practitioner said when she saw Resident #42 at the facility her oxygen was constantly set at 5-6 liters and has had to bring it down to 4. She said she had educated the husband on not changing the oxygen setting. The Pulmonary Nurse Practitioner said Resident #42 had a 10-liter oxygen concentrator because she had end stage lung disease and if she had an emergency where she needed more oxygen, then she would have the correct concentrator. During an interview on 07/30/25 at 3:43 PM, Resident #42's family member said he did not touch the oxygen concentrator. He said the doctor at the hospital placed Resident #42's oxygen at 5 liters and he has not moved the settings. During an interview on 07/31/25 at 12:25 PM, the DON said she expected oxygen to be administered as ordered. The DON said the nurses were responsible for ensuring the oxygen was set at the ordered rate. She said failure to administer the oxygen at the ordered rate placed the resident at risk for desaturation or receiving too much oxygen. During an interview on 07/31/25 at 12:51 PM, the Administrator said he expected physician orders to be followed and the oxygen to be set at the ordered rate. He said the nurses were responsible to check during their shift that those orders were in place. Record review of the facility's policy Oxygen Administration and Oxygen Safety reviewed and revised on 07/23/25, indicated . The purpose of this procedure is to provide guidelines for safe oxygen administration and oxygen safety guidelines. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on interview and record review, the facility failed to ensure the drug regimen was free from unnecessary drugs for 1 of 5 residents reviewed for medications. (Resident #123) The facility failed to ensure Resident #123 had a diagnosis or adequate indication for quetiapine (Seroquel) (An antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder). The facility failed to ensure the proper consent form 3713 was completed prior to administering the medication quetiapine (Seroquel). This failure could place residents who received antipsychotic medications at risk of receiving unnecessary medication. Record review of Resident #123's face sheet dated 7/31/25 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses diabetes mellitus (disease in which results in too much sugar in the blood stream), high blood pressure, cerebrovascular disease, normal pressure hydrocephalus, and history of falling. The face sheet did not indicate Resident #123 had a diagnosis of vascular dementia. Record review of Resident #123's admission MDS dated [DATE] indicated she could understand others and could make herself understood. The MDS also indicated she had a BIMS score of 11 which meant she had moderately impaired cognition. The MDS also indicated she required substantial/maximal assistance from staff for toileting, bathing, moderate assistance with transfers and setup for eating. The MDS also indicated she received antipsychotic medications during the last 7 days or since admission to the facility. Record review of Resident #123's base line care plan dated 07/17/25 and unsigned by a nurse indicated she was a diabetic and alert. The baseline care plan also indicated Resident #123 was taking psychotropic medications. The baseline care plan did not indicate Resident #123 had vascular dementia, any cognitive loss, nor did she have an approved diagnosis for the medication Seroquel. Record review of Resident #123's pharmacy recommendations dated 07/21/25 and provided to the facility on [DATE] indicated Resident #123 had an order for the antipsychotic medication quetiapine (Seroquel) and consents were required to be on the form 3713 provided by Texas Health and Human Services. The pharmacy recommendations also indicated Resident #123 was not confirmed to have an approved psychiatric diagnosis documented to support the use of the antipsychotic medication quetiapine (Seroquel). Record review of Resident #123's order summary report dated as of 07/29/25 indicated she had an order for:Quetiapine Fumarate oral tablet 25mg Give 1 tablet by mouth at bedtime for depression with a start date of 07/17/25 and no end date. Record review of Resident #123's EMR indicated she had the form 3713 for the antipsychotic medication quetiapine (seroquel) completed on 07/30/25 by the DON after surveyor intervention. During an interview on 07/31/25 at 11:35 AM, the DON said Resident #123 should not be taking quetiapine (Seroquel). She said she normally looked at resident's medications when they admit to the facility after the nursing team (DON and ADONs) reviewed new residents in the morning meeting, but she guessed they missed Resident #123's orders. The DON said Resident #123 should have an approved diagnosis to take quetiapine (Seroquel) and the consent form 3713 should have been completed by the admitting nurse or DON and ADON. The DON said the pharmacy consultant had been to the facility and should have made a recommendation as well but she had not reviewed the reports for Resident #123. She said the failure placed a risk for Resident #123 to have had adverse reactions to the medication. During an interview on 07/31/2025 at 4:34 PM, the facility Psychiatric Nurse Practitioner said she had seen Resident #123 on Tuesday 07/29/25 but she did not get to review her medications until Wednesday 07/30/25 and she discontinued the quetiapine (Seroquel) medication and began another medication Remeron (medication given for depression). She said Depression was not an approved diagnosis for any resident to take quetiapine (Seroquel). The Psychiatric Nurse Practitioner said the failure placed Resident #123 at risk for heart problems, irregular heartbeats, and a stroke. During an interview on 07/31/2025 at 5:13 PM, the Administrator said he was not familiar with the antipsychotic medications and consents but if needed he would have consulted the DON for those things. The Administrator said he expected the nurses to complete the necessary consents to give the medication. He said he expected the staff to follow the policy for antipsychotic medications and he assumed the risk was harm to resident. The Administrator said the risk was not following the policy and giving the patient medication without the proper consent. Record review of the facility policy Medication Management revised 10/01/19 indicated:Policy: In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use.D. The resident's medication regimen is evaluated when one or more of the following occur. When there is a significant negative change from baseline (designated with an asterisk*), medications should be ruled out as a cause in accordance with the policy on adverse consequence detection and prevention (See Preventing Adverse Consequences and Medication Errors Section). a. admission or re-admission.k. Unnecessary drugs - Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used - i. In excessive dose (including duplicate drug therapy) .iv. Without adequate indications for its use.

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 6 residents (Resident #60) and 1 of 3 medication carts (300-Hall nurse medication cart) reviewed for drugs and biologicals. 1. The facility failed to ensure Resident #60's medication labels for her amlodipine, carbidopa-levodopa, clopidogrel, and hydralazine matched her physician order. 2. The facility failed to ensure LVN D secured the 300-Hall nurse medication cart when it was not in use and unattended on 07/29/2025. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.Findings included: 1. Record review of Resident #60's face sheet dated 07/31/2025 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included essential (primary) hypertension (high blood pressure), dysphagia oropharyngeal phase (disorder or impairment in swallowing), and acute on chronic combined systolic and diastolic congestive heart failure (disorder in which the heart's ability to contract and relax is impaired). Record review of Resident #60's Comprehensive MDS assessment dated [DATE] indicated she was rarely/never understood, and she rarely/never understood others. The MDS assessment indicated Resident #60 was not able to be interviewed for the BIMS because she was rarely/never understood. The Staff Assessment for Mental Status indicated Resident #60 had a long-term and short-term memory problem. Record review of Resident #60's Order Summary Report dated 07/31/2025 indicated: NPO diet with a start date of 06/10/2025. Amlodipine 10 mg give 1 tablet via g-tube one time a day with a start date of 06/11/2025. Carbidopa-Levodopa 25-100 mg give 1 tablet via G-Tube three times a day with a start date of 07/29/2025. Clopidogrel 75 mg give 1 tablet via G-Tube one time a day with a start date of 07/30/2025. Hydralazine 100 mg give 1 tablet via G-tube three times a day with a start date of 07/29/2025. During an observation of medication administration and an interview on 07/29/2025 starting at 9:12 AM, RN G prepared and administered Resident #60's medications via her g-tube. Resident #60's medication labels for the following indicated to administer the medications by mouth: amlodipine 10 mg give 1 tab by mouth once daily carbidopa and levodopa 25/100 give 1 tab by mouth three times daily clopidogrel 75 mg give 1 tab by mouth daily hydralazine 100 mg give 1 tablet by mouth three times a day.RN G said Resident #60 did not take anything by mouth. RN G said the order should match the medication label. RN G said he did not notice the medication label was not correct. RN G said the nurse was responsible for getting the medication label fixed. RN G said the nurses should be making sure the label was correct, and if it was not, they should call the pharmacy to let them know. RN G said the medication label not having the correct route could lead to a mistake. 2. During an observation and interview on 07/29/2025 at 3:04 PM, there was an unlocked, unattended medication cart towards the end of the 300 Hall. LVN D was observed coming down the hallway to the medication cart. LVN D said she was responsible for the 300-hall nurse medication cart, and she had stepped away because she was looking for one of her residents. During an interview on 07/29/2025 at 4:35 PM, LVN D said it was important for the medication cart to be locked when not in use and unattended so the residents could not get into the medication cart and get medications that did not belong to them. During an interview on 07/31/2025 at 4:10 PM, the DON said it was the nurse's responsibility to ensure the medication cart was locked when they walked away. The DON said they needed to ensure it was lock because they did not want any residents to wander over and take medications or somebody could take anything off the medication cart. The DON said the person administering medications should ensure the label was correct and the correct route was on the medication label. The DON said somebody missed it that the ADONs were supposed to be checking the medication carts every other day or at least weekly. The DON said if someone did not know Resident #60 could not receive medications by mouth, they could give it by mouth, and she could aspirate (could go into her lungs). During an interview on 07/31/2025 at 4:48 PM, the Administrator said the medication carts should be locked at all times when the nurse was not close by it. The Administrator said if the medication cart was left unlocked anyone could go by and have access to the medications or confused residents. The Administrator said dangerous things could happen. Record review of the facility's policy titled, Storage of Medications, reviewed 06/24/2025, indicated, 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. 9. Unlocked medication carts are not left unattended. Record review of the facility's policy subject, Labeling of Medications, revised 10/01/2019, indicated, A. When there is a change to a physician order, the nurse receiving the order will affix a Direction Change sticker or equivalent to the label if there is no change in the medication. This sticker will be placed so as not to obliterate any other required information on the medication label. B. When such label appears on the container, the medication nurse checks the resident's medication administration record (MAR) or the physician's order for current information. C. The dispensing pharmacy is informed prior to the next refill of the prescription so the new container will contain an accurate label. 13. Improperly or inaccurately labeled medications are rejected and returned to the dispensing pharmacy.

Based on interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 4 residents (Resident #7) reviewed for hospice services. The facility failed to maintain Resident #7's hospice binder containing information related to hospice services provided for the resident such as the most recent plan of care, hospice election form, and physician recertification. These deficient practices could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Findings included:Record review of Resident #7's face sheet, dated 07/31/25, indicated he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included schizophrenia (a chronic brain disorder characterized by symptoms like hallucinations, delusions, and disorganized thinking), anxiety (a feeling of unease, worry, or fear, often experienced as a normal reaction to stress), and depression (a common mental health condition characterized by persistent sadness and a loss of interest in activities, significantly impacting daily life). Record review of Resident #7's quarterly MDS assessment, dated 07/19/25, indicated he was severely cognitive impaired on decision making. He was able to make himself understood and he was able to understand others. The MDS indicated Resident #7 was on hospice services. Record review of Resident #7's comprehensive care plan revised 04/21/25 indicated Resident #7 had a terminal prognosis and was on hospice services. The intervention was to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met, and for the nursing staff to provide maximum comfort for the resident. Record review of Resident #7's physician orders dated 04/09/25 indicated an order for {name} hospice. Record review of Resident #7's hospice binder revealed it did not have the Physician certification of the terminal illness, care plan, IDG (Interdisciplinary Group) meeting or Hospice election form. The last recertification was dated 02/20/25-05/20/25. During an observation and interview on 07/30/2025 at 2:38 p.m., ADON F look at Resident #7's hospice binder. She said the binder did not contain any orders, IDG meetings, plan of care or an updated recertification. She said the hospice company was supposed to bring the information needed in his binder. She said she was not sure how often the binder should be updated but would go ask and come back with an answer. ADON F said she was told by the DON that the binder should be updated every90 days and with any change of condition. She said she was responsible for ensuring the binder was updated. She said it was important for the hospice binder to be updated so staff was aware of his plan of care. During a phone interview on 07/30/2025 at 4:25 p.m., the hospice Office Manager said the binders at the facility should contain any supporting notes or documentation needed for Resident #7. She said they met every two weeks for the IDG meetings and said the documentation should be updated at least every 2 weeks after the IDG meetings. She said they had someone at the office who faxed the information to the facility but had been told the facility was throwing the information away or not updating the books. She said it was important to have the binders at the facility to help the facility know the care and services they were providing. During an interview on 07/31/2025 10:39 a.m., RN G said the hospice book should include the name of the hospice, diagnosis, sign in sheet and face sheet. He said management was responsible for ensuring the hospice binders were updated. He said any information the hospice company had for Resident #7 should be at the facility for effective communication because our care was combined. During an interview on 07/31/2025 at 12:04 p.m., the DON said ADON F was responsible for ensuring the hospice binders were updated. She said the books should be updated yearly and as changes were made. The DON said the failure to ensure those documents were at the facility was due to a lack of communication with the facility and the hospice company. She said all information done by hospice should be at the facility for communication and care coordination. During an interview on 07/31/2025 at 12:11 p.m., the Administrator said it was the ADON's responsibility to ensure all hospice documents were up to date. He said the books should be updated for effective communication between hospice and the facility for the care of the residents. Record review of the facility Hospice Agreement, dated 02/19/25, revealed, Hospice Patient medical records shall be in compliance with Federal State, and local laws and regulations. and with Medicare and Medicaid guidelines. Facility and Hospice shall prepare and maintain complete medical records for Hospice Patients receiving facility services and Hospice services in accordance with the Agreement and shall include all treatments, progress notes. authorizations, physician orders and other pertinent information. Originals of all documents of services provided by Hospice shall be filed and maintained by Hospice at the Hospice office. Copies of all documents of services provided by Hospice shall be filed and maintained in the Facility chart.

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 and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #22 and Resident #53) and 2 of 2 staff (Treatment Nurse and Laundry Supervisor) reviewed for infection control. 1. The facility failed to ensure the Treatment Nurse changed her gloves when she removed Resident #22's dirty dressing on 07/29/25. 2. The facility failed to ensure the Treatment Nurse used proper PPE when providing wound care for Resident #53 on 07/30/25. 3. The facility failed to ensure the Laundry Supervisor was aware of Resident #53 being under contact isolation. These failures could place residents and staff at risk for cross-contamination and the spread of infection.Findings included: 1. Record review of Resident #22’s face sheet dated 07/31/25, indicated an [AGE] year-old female who readmitted to the facility 11/26/24. Resident #22 had diagnoses of dementia (memory loss) and muscle weakness. Record review of Resident #22’s quarterly MDS assessment dated [DATE], indicated she was able to be understood and understood others. Resident #22 had a BIMS score of 13, which indicated her cognition was intact. Resident #22 had one stage 3 pressure ulcer that was present upon admission/entry or reentry. Record review if Resident #22’s comprehensive care plan revised on 05/09/25, indicated she had a stage 3 pressure injury/ulcer to sacrum (triangular bone at the base of the spine). The care plan interventions included to administer treatments as ordered and monitor for effectiveness. Record review of Resident #22’s order summary report dated 07/31/25, indicated Resident #22 had an order to cleanse sacrum with wound cleanser/normal saline, apply collagen, skin prep to surrounding tissue or peri wound, secure with bordered gauze every day with an order date of 05/09/25. Record review of Resident #22’s treatment nurse MAR dated 07/01/25-07/31/25 indicated her wound care was provided daily. During an observation and interview on 07/29/25 at 10:24 AM, the Treatment Nurse entered Resident #22’s room disinfected the bedside table and washed her hands. The Treatment Nurse came back to her cart and obtained the wound care supplies. The Treatment Nurse and ADON F applied PPE and entered Resident #22’s room to perform wound care to Resident #22 sacrum. They both washed their hands and applied gloves. Resident #22 was turned to her right side. The Treatment Nurse removed Resident #22’s soiled dressing from her sacrum and disposed it in trash. The Treatment nurse then proceeded to cleanse Resident #22’s wound with normal saline and gauze. The Treatment Nurse failed to remove her dirty gloves before she cleaned Resident #22’s wound. The Treatment Nurse removed her gloves, washed her hands and proceeded to complete Resident #22’s wound care treatment. The Treatment Nurse and ADON F removed their PPE and washed their hands. The Treatment Nurse said she “could have sworn” she had washed her hands after she removed Resident #22’s dirty dressing. The Treatment Nurse said she was responsible for ensuring infection control was maintained when providing wound care and failure to do so placed the resident at risk for infection. During an interview on 07/31/25 at 12:25 PM, the DON said she expected wound care to be completed as ordered and infection control to be maintained. The DON said the Treatment Nurse should have changed her gloves when she removed Resident #22’s dirty dressing. She said failure to do so placed the resident at risk for infection. The DON said the Treatment Nurse was responsible for ensuring infection control was maintained when she performed wound care treatments. During an interview on 07/31/25 at 12:51 PM, the Administrator said he expected wound care to be performed as ordered and the facility’s infection control policy and procedure be followed. The Administrator said the nurses and the Treatment nurse were responsible to ensure infection control was maintained when wound care was performed. He said failure to do so placed the resident as risk for infection. The Administrator said the Treatment Nurse had told him that was not what had happened, regarding not changing her gloves after removal of the dirty dressing, the day the wound care was observed. 2.Record review of Resident #53’s face sheet dated 07/31/25 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses adult failure to thrive, elevated white blood cell count, malnutrition, and systemic inflammatory response syndrome. Record review of Resident #53’s admission MDS indicated she rarely made herself understood and could rarely understand others. The MDS also indicated she had short-term memory problems and long-term memory problems. Record review of Resident #53’s comprehensive care plan indicated she required enhanced barrier precautions for her feeding tube with interventions in place to provide signage on outside of room, enhanced barrier precautions during high-contact care including wound care. The care plan did not include contact isolation precautions. Record review of Resident #53’s order summary report indicated she had and order for: Isolation Precautions: Contact R/T (MRSA in wound exposure) every shift Initials acknowledge the following: Resident resided in room alone, and received all medications, participated in activities, received all meals, when applicable received all rehab services, and received all ADL care, in room the entire shift. every shift with a start date of 07/15/2025 and no end date. During an observation and interview on 07/30/25 at 2:04 PM the Laundry Supervisor was in the laundry and showed surveyor what the staff used when a resident was under contact isolation (which included an apron and gloves). She said the facility did not have any residents under contact isolation, but when the facility did have residents under contact isolation, their laundry was sent out in clear water-soluble bags and washed separately from other residents to prevent the spread of infection. During an observation and interview on 07/30/25 at 2:50 PM the Treatment Nurse went into Resident #53’s room, turned light on, spoke with Resident #53, moved bedside table, removed Resident #53 belongings on bedside table, and cleaned her bedside table to use for wound care supplies but failed to DON PPE prior to entering the room. The treatment nurse exited the room and used hand sanitizer for her hands and Donned PPE (gown and gloves) to perform the wound care for Resident #53. She performed wound care using proper technique. The Treatment Nurse then removed PPE to exit and only one biohazard box was in room for trash. Resident #53’s room did not have a box for soiled linen. The treatment nurse said she saw the contact isolation on Resident #53’s door and she should have placed the Gown and gloves on prior to entering the room to clean as well as provide care. She said there should also had been another isolation box in the room for soiled linen to be sent to the laundry. The Treatment Nurse said the failures placed increased risk for infection for residents and staff. During an interview on 07/31/2025 at 5:35 PM the DON said she expected the staff to [NAME] PPE prior to going into a resident’s room who is under contact isolation and the proper biohazard boxes to be in the room. She said the risk was increased infection for Resident #53 and spread of infection for the staff. She said the nursing staff were responsible for ensuring everyone is aware. During an interview on 07/31/2025 at 5:40 PM the Administrator said he expected nursing staff to be responsible for all infection control. He said all staff should follow the infection control policy. The Administrator said the failures placed a risk of infection and increased infection for Resident #53. Record review of the facility policy “Infection Control and Prevention revised 10/2022 indicated: Policy statement An infection and prevention program (IPCP)is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection…10) The Attending Physician and the interdisciplinary team will determine the treatment plan for the resident. a. If transmission-based precautions or other preventative measures are implemented to slow or stop the spread of infection, the Infection Preventionist will collect data to determine the effectiveness of such measures…11. Prevention of infection…7. Implementing appropriate isolation precautions when necessary…” Record review of the facility’s policy “The [Facility Corporate Name] Skin Integrity Prevention and Treatment Program” revised 07/2018, indicated “Wound Care. a. will follow the Non-Sterile Dressing Change Competency Protocol… c. Adheres to infection control best practices…”.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 21 residents (Resident #1 and Resident #2) reviewed for infection control. 1. The facility failed to ensure CNA D and CNA E wore PPE while providing catheter care on Resident #2 on 03/26/25. 2. The facility failed to ensure LVN A wore the proper PPE (gown and gloves), changed her gloves, and performed hand hygiene while performing wound care on Resident #1 on 03/25/25. These failures could place residents and staff at risk for cross-contamination and spread of infection and could potentially affect all others in the building. Findings Include: 1.Record review of a face sheet dated 03/26/25, indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of chronic kidney disease (your kidneys exhibit mild damage, indicated by a slightly reduced estimated glomerular filtration rate), retention of urine (the inability to completely empty the bladder, either acutely (suddenly) or chronically (gradually)), benign prostatic hyperplasia with lower urinary tract symptoms (prostate gland was growing, putting pressure on the urethra and bladder, causing urinary problems like frequent urination, weak stream, and difficulty emptying the bladder). Record review of Resident 2's admission MDS assessment, dated 03/07/25, indicated Resident #2 understood and was understood by others. Resident #2's BIMS score was 15 indicating he was cognitively intact. The MDS indicated Resident #2 required assistance with his transfers, toileting, dressing, hygiene, and set up for eating. The MDS indicated he had an indwelling catheter. Record review of Resident #2's care plan dated 03/03/25, did not indicate enhanced barrier precaution. Record review of Resident #2's order summary dated 03/26/25, indicated foley catheter care every shift and as needed, with a start date of 03/02/2025. During an observation on 03/26/25 at 10:45 a.m., CNA D and CNA E performed catheter care on Resident #2. They both had on gloves but did not have on a gown as part of the appropriate PPE. This surveyor observed no enhance barrier precaution sign on the door or PPE at the door. During an interview on 03/26/25 at 1:30 p.m., RN F stated she did not know what happened to the enhanced barrier precaution sign and PPE, it was at the door the day before. RN F stated it was the nurse's responsibility to make sure the enhanced barrier precaution sign and PPE was at the door. RN F stated if the CNAs were unsure if they needed to wear PPE for a resident with a catheter they should have asked the nurse. RN F stated it was important to use PPE for a resident with a catheter to prevent infection. During an interview on 03/26/25 at 1:38 p.m., CNA D stated she should have asked the nurse if she needed to wear a gown during catheter care. CNA D stated it was important to wear the appropriate PPE during catheter care to prevent the spread of infection. CNA D stated the harm to the resident could be urinary tract infection. During an interview on 03/26/25 at 1:42 p.m., CNA E stated she should have asked the nurse if Resident #2 was in enhanced barrier precautions since he had a catheter. CNA E stated it was important for residents with a catheter to be in enhance barrier precaution, so the resident did not get an infection. CNA E stated the harm of providing catheter care without wearing a gown either the staff or the resident could be exposed to an infection. During an interview on 03/26/25 at 3:00 p.m., the DON stated all of the nursing staff was responsible for ensuring a enhanced barrier precautions sign and PPE was at the residents door and the staff knew to wear PPE while preforming care. The DON stated enhanced barrier precautions were important to keep from passing bacteria. The DON stated the harm to the resident was infection. The DON stated the staff was in-serviced on enhanced barrier precautions as needed, on hire, and annually. During an interview on 03/26/25 at 3:30 p.m., the Administrator stated he expected all staff to follow the guidelines on the sign posted on the door. The Administrator stated the staff was aware of Resident #2 in enhanced barrier precaution. The Administrator stated the sign on the door and the setup outside the door was there the day before. The Administrator stated he made routine rounds to ensure staff was following the guidelines and the DON had given several in-services on enhanced barrier precautions. The Administrator stated the staff should be wearing the proper PPE (gown and gloves) to protect themselves and to keep the spread of infection from other residents. 45879 2.Record review of Resident #1's face sheet, dated 03/27/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included arthritis (conditions that cause joint pain, swelling, and stiffness), diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), anxiety (characterized by excessive and persistent worry, fear, and nervousness) and dementia (diseases that affect memory, thinking, and the ability to perform daily activities). Record review of Resident #1's quarterly MDS assessment, dated 01/26/25, indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 14, which meant she was cognitively intact. The MDS indicated Resident #1 required help with toileting, bed mobility, dressing, transfers, and personal hygiene, and was independent with eating. The MDS indicated Resident #1 had an open lesion, and it required treatment. Record review of Resident #1's physician's orders dated 03/03/25, indicated, Clean left axilla (the area on the human body directly under the shoulder joint) with normal saline, pay dry, apply silver gel, calcium alginate, and cover with bordered gauze every day shift every Monday, Wednesday, and Friday for metal piece sticking out of left axilla. Record review of Resident #1's care plan revised on 06/11/24 indicated Resident #1 had an actual impairment to her skin integrity to the left axilla related to an open area where her humerus repair hardware had broken through the skin. The intervention was for staff to follow the facility protocol for treating the injury. Record review of Resident #1's care plan dated 01/16/25 indicated Resident #1 required Enhanced Barrier Precautions, also known as EBP (infection control practices designed to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes by focusing on gown and glove use during high-contact resident care activities) related to her wound. The interventions were for staff to use EBP during high-contact resident care activities as applicable, such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, wound care (any skin opening requiring a dressing), and other areas determined to require EBP. During an observation on 03/24/25 at 12:30 p.m., an Enhanced Barrier Precautions sign and a cart were outside Resident #1's room. During an observation on 03/26/25 at 9:15 a.m., LVN A applied gloves, entered Resident #1's room to set up her supplies without a gown on, exited the room, and changed gloves without performing hand hygiene. LVN A re-entered Resident #1's room without a gown, applied gloves, and removed the dressing from Resident #1's left axilla. LVN B did not remove her gloves or perform hand hygiene before cleaning the wound to Resident #1's left axilla with normal saline. LVN A applied silver gel, calcium alginate, and a bordered dressing to Resident #1's left Axilla. LVN A did not change her gloves or perform hand hygiene, then gathered all her trash with the same dirty gloves, pulled up Resident #1's bed covers, and placed her bedside table over the bed. During an interview on 03/26/25 at 9:35 a.m., LVN A said she did not realize she did not change gloves or perform hand hygiene during the wound care for Resident #1. She said she should have changed her gloves and performed hand hygiene when going from dirty to clean to prevent infection in the wound. LVN A said she did not wear the proper PPE when entering Resident #1's room or while performing wound care. She said Resident #1 was on EBP, and she should have worn a gown and glove while in Resident #1's room to prevent the spread of infection. During an interview on 03/26/25 at 3:03 p.m., the DON said she expected staff to perform hand hygiene when they entered or exited a room, when visibly soiled, between dirty and clean, and between glove changes. The DON said the importance of hand hygiene was infection control. The DON said Resident #1 was on EBP, and when staff was in her room to perform care such as wound care, they should have on a gown and gloves to prevent infection. During an interview on 03/26/25 at 4:37 p.m., the Administrator said he expected staff to perform hand hygiene as needed, before and after providing care, in between care, and between glove changes. He said if Resident #1 was on EBP and the nurse was performing wound care, the nurse should have had on a gown and gloves. The Administrator said the importance of hand hygiene and following EBP was infection prevention and cross-contamination. Record review of the facility's police titled Infection Prevention and Control, revised date of 03/18/25, indicated Policy statement: an infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Record review of the facility's police titled Handwashing-Hand Hygiene, revised date of 10/2020, indicated, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: #2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. #7. Use an alcohol-based hand rub containing at least 62% alcohol or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; k. After handling used dressings, contaminated equipment, etc.; #10. Hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Record review of the facility's policy titled Enhanced Barrier Precautions, dated 04/01/24, indicated Enhanced Barrier Precautions for residents with any of the following: wounds and indwelling medical devices even if the resident was not known to be infected Indwelling medical device example include central lines, urinary catheters, feeding tubes, and tracheostomies

Based on interview and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents were provided for 1 or 5 residents reviewed for accidents. (Resident #1) CNA A did not use a gait belt while assisting Resident #1 to transfer to scales to be weighed. Resident #1 fell , resulting in the refracturing of her left femur (large bone in the top portion of leg). This was determined to be past non-compliance with actual harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents who require assistance with transfers at risk for accidents and injury. Findings included: A face sheet dated 03/12/21 indicated Resident #1 was [AGE] years old and admitted on [DATE] with diagnoses of fracture of the left femur and [CONDITION(S)] of the left knee. Resident #1 was discharged to acute care hospital on 12/02/20. Consolidated physician orders dated 12/2020 indicated Resident #1 was admitted on [DATE] with diagnosis of left femoral fracture. The order indicated physical therapy was to be provided five times a week for gait training and gait abnormalities. The most recent MDS dated [DATE] indicated Resident #1 had moderately impaired cognition and required extensive two-person assistance with ADLs including transfer. The MDS indicated the resident was not steady when moving from seated to standing position, walking, moving on and off toilet, or surface-to-surface transfer and only able to stabilize with staff assistance. She used a walker and wheelchair to ambulate. The most recent care plan dated 11/19/20 indicated Resident #1 had an ADL self-care performance deficit related to fractured femur and limited mobility. Resident #1 was able to ambulate with the extensive assistance of two people and used a wheelchair for all mobility and required the assistance of one person to propel the wheelchair. Resident #1 required extensive assistance to move between surfaces and in and out of bed. Resident #1 was a high risk for falls related to femur fracture and surgery and had balance problems. Nursing staff were to follow fall protocol. The care plan indicated to assure staff were aware that the resident is on fall precautions. Physical therapy notes dated 11/30/20 indicated Resident # 1 had progressed to perform 75 percent of ambulation on level surfaces with 25 percent support from staff. During an interview on 03/11/21 at 7:25 p.m. A family member said Resident #1 was transported from the facility to a local hospital for treatment following a fall on 12/02/20. Resident #1 was transferred from that hospital to a different hospital in the area where surgery was performed to repair eight new fractures above the knee and to remove the original rods and pins. New rods and a steel plate were used from the knee to the hip. Resident #1 passed away on 01/26/21 after developing blood clots due to Resident #1 immobility. A review of hospital records dated 12/2/20 at 4:40 p.m. indicated Resident #1 was brought to the emergency department after falling at a long-term care facility. Resident #1 had an acute (abrupt onset or new) fracture of her left femur. The record indicated Resident #1 would be transferred to a different hospital for surgical intervention. Review of a Provider Investigation Report dated 12/02/20 the administrator showed Resident #1 fell while being weighed by CNA A. CNA A did not use a gait belt to support Resident #1 when transferring from wheelchair to the scales. A written statement with the facility investigation dated 12/02/20 written by CNA A showed .when I turned to pick up paper, so I can write down her weight she was with her walker. She fell . During an interview on 03/12/21 at 11:50 a.m. the administrator said she conducted the investigation into the incident on 12/02/20. CNA A should have used a gait belt when transferring Resident #1 to be weighed on 12/02/20. CNA A was suspended for 10 days pending investigation and received extensive one-on-one in-service training by the Physical Therapist before allowed to return to work. The administrator said it is facility policy for staff to use a gait belt each time they are assisting a resident in transfer or ambulation. All CNA's received in-service on using a gait belt after the incident with Resident #1 on 12/02/20. The administrator said CNA A had been employed at the facility since 2015 and had no other incidents prior to the incident with Resident #1. During an interview on 03/12/21 at 2:00 p.m., CNA A said on 12/02/20 she took Resident #1 to the shower room to be weighed. She thought Resident #1 was able to stand with her walker without assistance. When she realized Resident #1 started to lose balance she allowed Resident #1 to slide down her body to the floor. CNA A said she did not use a gait belt. She said she was suspended for two weeks pending investigation. She said when she returned to work, she had extensive transfer/gait belt training by the physical therapist before she was allowed to work with residents. CNA A said if she had used a gait belt she would have been able to stabilize Resident #1 and prevented the fall. During an interview on 03/15/21 at 1:10 p.m. a physical therapist said Resident #1 received physical therapy since her admission and was doing well. She said Resident #1 was considered contact guard assistance on level surfaces which meant she was able to do about 75 percent of the work for transfer and ambulation on level surfaces and staff should physically hold on to the gait belt during all functional mobility attempts. The PT said the small incline to walk on to the scale was not a level surface and Resident #1 would have needed more staff support to safely navigate. She said on 12/02/20 she was walking down the hall and heard someone screaming. She said when she entered the shower room where residents were weighed and saw Resident #1 in a semi-reclining position on the floor at the bottom of a one-inch incline leading up to the scales. She said she saw CNA A standing about two feet from Resident #1. She said Resident #1 was screaming and said, I don't know where she (CNA A) was, but she was not anywhere near me or she would have caught me. PT said there was not a gait belt on Resident #1 and CNA A did not use a gait belt to assist Resident #1. She said staff were to always to use a gait belt when transferring a resident or assisting with ambulation. During an interview on 03/15/21 at 12:45 a.m. regional nurse consultant said she was the director of nursing at the time of the incident on 12/02/20 when Resident #1 fell while being weighed. The regional nurse said CNA A failed to follow facility policy by not using a gait belt to transfer Resident #1 from her wheelchair to the scales, even though Resident #1 was using a walker to get on the scales. She said CNA A should have used a gait belt and supported Resident #1 while getting on and off the scale. The regional nurses said CNA A told her during the investigation she turned to write down the weight and Resident #1 lost her balance and fell . The regional nurse said CNA A never told her she allowed Resident #1 to slide down her body. The regional nurse said Resident #1 told her If she (CNA A) had been behind me I would not have fallen. The regional nurse said Resident #1 reported CNA A was on her cell phone when she fell . The regional nurse said she did not believe CNA A allowed Resident #1 to slide down her body because she did not say that during the investigation. The surveyor determined the facility was in non-compliance on 12/2/20 through 12/20/20 and took the following actions to correct the non-compliance: Review of employee records showed CNA A was suspended on 12/02/20 for 10 days pending investigation for failing to follow facility policy on using gait belts. CNA A returned to work on 12/20/20 with one-on-one training of transfer/ambulation and use of gait belts by Physical Therapist. Review of In-service records showed on 12/02/21 CNAs received training on using a gait belt for transfers and ambulation. Review of In-service records showed on 12/20/21, CNA A received one-on-one training on using a gait belt for transferring and all ambulation assistance. Observations of two CNA's on 12/15/21 at 1:25 p.m. and 1:36 p.m. showed CNA B and CNA C had gait belts around their waist and were observed using the gait belts when assisting residents to transfer. During interviews CNA B and CNA C said they were required to use gait belts for all transfers and when assisting residents to ambulate. They said they received training on using gait belts for all transfers and ambulation assistance on 12/2/20. Review of an undated Gait Belt Policy indicated It is the policy that all facility certified nursing assistance are to wear and use a gait belt during Resident Transfers .Upon employment, each CNA will be issued a gait belt, you are expected to come to work on your scheduled days with your gait belt. Any CNA that fails to have and use their gait belt will be issued a written warning on the matter .

Based on observation, interview and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections were maintained for the facility related to COVID-19 (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older) on 4 of 4 halls. (Hall 100, 200, 300 and 400). The facility failed to follow appropriate isolation protocols for residents #14, #20, #54 and #51. The facility did not ensure CNA D and CNA E performed hand hygiene during incontinent care for Resident #23. The facility did not ensure Residents #14, #54, #49, #56, #52, and #64 were placed on the COVID-19 unit when they tested positive for COVID-19. The facility did not ensure Residents #20, #51, #26, #30, #69, #33, #39, and #27 were quarantined when their roommates tested positive for COVID-19. The facility did not ensure Residents #18, #10, #12 and #6 were promptly moved to the COVID-19 unit when they tested positive for COVID-19. The facility did not ensure clean linens were transported and stored in a way to keep them from being contaminated. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 12/2/20. While the IJ was removed on 12/4/20 the facility remained out of compliance at a potential for more than minimal harm with a scope identified as wide spread due to the facility's need to complete in-service trainings and evaluate the effectiveness of the corrective actions. These failures could place residents at risk for exposure to COVID-19, health complications, and death. Findings included: Record review of the CDC (Centers of Disease Control and Prevention) website at https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-[MEDICATION(S)]-testing.html > accessed 10/23/20 indicated Considerations for interpreting [MEDICATION(S)] test results in nursing homes Testing of symptomatic residents or HCP. If an [MEDICATION(S)] test is positive, no confirmatory test is necessary. -Residents should be placed in Transmission-Based Precautions or HCP should be excluded from work. -If the resident or HCP is the first positive test for [CONDITION(S)]-CoV-2 within the facility (i.e., an index case), an outbreak response should be initiated immediately. If an [MEDICATION(S)] test is presumptive negative, perform RT-PCR immediately (e.g., within 48 hours). -Symptomatic residents and HCP should be kept in transmission-based precautions or excluded from work until RT-PCR results return. Some [MEDICATION(S)] platforms have higher sensitivity when testing individuals within 5 days of symptom onset. Clinical discretion should be utilized to determine if individuals who test negative on such platforms should be retested with RT-PCR. Note: if an individual has recovered from [CONDITION(S)]-CoV-2 infection in the past 3 months and develops new symptoms suggestive of COVID-19, alternative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the CDC website at https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-[MEDICATION(S)]-testing.html> accessed 10/23/20 indicated If a confirmatory RT-PCR test is performed within 48 hours, individuals should be assumed infectious until the confirmatory test results are completed. For instance, if a symptomatic resident test presumptive negative on [MEDICATION(S)] test and a RT-PCR is performed, the resident should remain in Transmission-Based Precautions until the RT-PCR test results. If an asymptomatic HCP working in a nursing home without an outbreak and in a county with low community prevalence tests [MEDICATION(S)] positive, they should be excluded from work until a negative RT-PCR test is available. Record review of the facility policy titled, Testing Policy and Procedure, dated September 2020, stated .Approved Tests Facility will utilize either PCR or [MEDICATION(S)] testing to meet the CMA testing expectations. Facility can utilize testing devices sent by CMS to achieve CMS testing compliance. Facility will default to CDC guidance on the use of POC rapid [MEDICATION(S)] testing devices in the absence of local and/or state guidance .CDC outlines the appropriate use of point of care rapid tests including but not limited to: 1) For a person with symptoms suggestive of COVID-19 when [CONDITION(S)] load is the highest. 2) For a person with a known exposure to COVID-19 to diagnose if they contracted COVID-19 (note a person may take up to 14 days to develop the infection after exposure). 3) Screening of individuals in high risk congregate settings (such as a nursing home) who may be asymptomatic or in a pre-symptomatic phase .Evaluating results .When using a rapid [MEDICATION(S)] test for diagnostic purposes: 1) Positive test results do not need to be confirmed, unless clinical suspicion of a false positive is high. 2) Negative diagnostic test results are considered presumptive negative and should be confirmed with a PCR test when the pretest probability is relatively high (especially if the patient is symptomatic or has known exposure) because of the higher number of false positives . Record review of a Departmental (Environmental Services) - Laundry and Linen Policy dated January 2020 indicated, The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen .consider all soiled linen to be potentially infectious and handle with standard precautions .clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts . During an interview on 12/2/20 at 2:00 p.m. the DON said the Residents' wasn't moved to the COVID unit because corporate suggested that since there are false [MEDICATION(S)] positive tests to follow up with a PCR prior to moving to the COVID unit. 1. Record review of Resident #14 face sheet dated 12/4/20 indicated Resident #14 was an [AGE] year-old female, readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #14 recent MDS dated [DATE] indicted Resident #14 was sometimes understood and sometimes understand others. The MDS indicated Resident #14 had severe cognitive impairment. The MDS indicated Resident #14 required two-person extensive assistance with bed mobility, transfers, toileting and bathing. The MDS indicated Resident #14 required one-person extensive assistance with personal hygiene. Record review of Resident #14 recent care plan dated 3/16/20 indicated Resident #14 will be observe for signs and symptoms of COVID-19; document and promptly report signs and symptoms: fever, coughing, sneezing, sore throat, respiratory issues. Record review of Resident #14 nurses' notes dated 11/28/20 reflected Resident #14 had a temperature of 100.1, oxygen saturation 84% on room air and Resident #14 appeared to be shortness of breath. Resident #14 was placed on oxygen at 2 LPM and was given two tylenol. Record review of Resident #14 Respiratory Infection Screener on 11/28/20 did not indicate elevated temperature, low oxygen saturation or shortness of breath. Record review of Resident #14's COVID-19 rapid [MEDICATION(S)] test dated 11/29/20 reflected Resident #14 had a positive test result for COVID-19. Record review of Resident #14's COVID-19 PCR test dated 11/29/20 reflected Resident #14 had a positive test result for COVID-19. Record review of Resident #14 nurses' notes dated 11/29/20 reflected resident #14 preliminary rapid COVID-19 test result noted positive. Record review of Resident #14 chest x-ray dated 11/29/20 revealed a substance denser than air such as pus, blood, or protein, which lingers within the lungs. During an interview and observation on 11/30/20 at 12:00 p.m. Resident #14 was observed cohorting the same room with Resident #20 [negative COVID-19 status] at room [ROOM NUMBER] [cold zone]. The DON said Resident #14 remained in her room on the cold hall with Resident #20 because the facility wanted to confirm the positive [MEDICATION(S)] test with a PCR test. The DON said it takes 24-48 hours to confirm results. Record review of Resident #14 nurses' notes dated 12/3/20 reflected Resident #14 was sent to a local hospital on 12/3/20 due to Resident #14 was having difficulty breathing, respirations ranging between 24-26, temperature of 100.4 and oxygen saturation 67% on 6 LPM. Resident #14 nurses' note dated 12/3/20 reflected Resident #14 passed away at 9:30 AM at a local hospital. 2. Record review of Resident #20 face sheet dated 12/4/20 indicated Resident #20 was a [AGE] year-old female, readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #20 recent MDS dated [DATE] indicated Resident #20 rarely/never understood and rarely/never understand others. The MDS does not indicate Resident #20 BIMS Score. The MDS indicated Resident #20 required two-person extensive assistance with bed mobility, transfers, toileting, personal hygiene and bathing. Record review of Resident #20 recent care plan dated 3/16/20 indicated Resident #20 will be observe for signs and symptoms of COVID-19; document and promptly report signs and symptoms: fever, coughing, sneezing, sore throat, respiratory issues. Record review of Resident #20's COVID-19 rapid [MEDICATION(S)] test dated 11/29/20 reflected Resident #20 had a negative test result for COVID-19. Record review of Resident #20's COVID-19 PCR test dated 11/29/20 reflected Resident #20 had a negative test result for COVID-19. 3. Record review of Resident #54 face sheet dated 12/4/20 indicated Resident #54 was an [AGE] year-old female, readmitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #54 recent MDS dated [DATE] indicated Resident #54 usually understood and usually understand others. The MDS indicated Resident #54 had severe cognitive impairment. The MDS indicated Resident #54 required one-person limited assistance with bed mobility, transfers, toileting and personal hygiene. The MDS indicated Resident #54 required one-person extensive assistance with bathing. Record review of Resident #54 recent care plan dated 10/27/20 indicated Resident #54 will be observe for signs and symptoms of COVID-19; document and promptly report signs and symptoms: fever, coughing, sneezing, sore throat, respiratory issues. Record review of Resident #54's COVID-19 rapid [MEDICATION(S)] test dated 11/25/20 reflected Resident #54 had a positive test result for COVID-19. Record review of Resident #54 nurses' notes dated 11/25/20 reflected resident #54 tested positive for COVID-19. 4. Record review of Resident #51 face sheet dated 12/4/20 indicated Resident #51 was a [AGE] year-old female, readmitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #51 recent MDS dated [DATE] indicated Resident #51 rarely/never understood and sometimes understand others. The MDS does not indicate Resident #51 BIMS Score. The MDS indicated Resident #51 required extensive assistance of two person with bed mobility, transfers, toileting and bathing. The MDS indicated Resident #51 required extensive assistance of one person with personal hygiene. Record review of Resident #51 recent care plan dated 3/16/20 indicated Resident #51 will be observe for signs and symptoms of COVID-19; document and promptly report signs and symptoms: fever, coughing, sneezing, sore throat, respiratory issues. Record review of Resident #51's COVID-19 rapid [MEDICATION(S)] test dated 11/25/20 reflected Resident #51 had a negative test result for COVID-19. During an observation on 11/30/20 at 3:28 p.m., Resident #54 was observed cohorting the same room with Resident #51[negative COVID-19 status] at room [ROOM NUMBER] [cold zone]. Record review of Resident #51's nurses' notes dated 12/3/20 reflected Resident #51 rapid [MEDICATION(S)] test dated12/3/20 had a negative test result for COVID-19. Record review of Resident #51 nurses' notes dated 12/3/20 reflected Resident #51 had a temperature of 99.0, decreased appetite. Review of Resident #51's nurses' notes dated 12/4/20 reflected Resident #51 was noted to be in respiratory distress, oxygen saturation 82% on room air, pulse 126, and respirations 22. Resident #51 oxygen saturation was between 85%-87% with oxygen at 2LPM. No interventions noted on nurses' notes. Review of Resident #51's nurses notes dated 12/4/20 reflected Resident #51 oxygen saturation was 85% on 3LPM. Resident #51 nurses noted dated 12/4/20 reflected the physician was notified and Resident #51 was sent out to a local hospital for evaluation. During an interview on 12/4/20 at 2:11 p.m., the DON said Resident #54 remained in her room with Resident #51 on the cold hall because the facility wanted to confirm the positive [MEDICATION(S)] test with a PCR test. 5. Record review of Resident #23 face sheet dated 12/4/20 indicated Resident #23 was a [AGE] year-old female, readmitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #23 recent MDS dated [DATE] indicated Resident #23 usually understood and usually understand others. The MDS indicated Resident #23 had severe cognitive impairment. The MDS indicated Resident #23 required extensive assistance of two person with bed mobility, transfers, toileting and bathing. The MDS indicated Resident #23 required extensive assistance of one person with personal hygiene. Record review of Resident #23 recent care plan dated 11/16/20 indicated Resident #23 was incontinent of bowel and bladder. The care plan indicated Resident #23 requires extensive assistance of one person for personal hygiene. During an observation on 12/1/20 at 9:47 a.m., CNA D and CNA E applied gloves but did not wash or sanitize their hands after entering Resident #23's room to provide incontinence care. CNA D and CNA E did not sanitize or wash their hands between gloves changes or after removing soiled linen. CNA D did not sanitize or wash her hands before entering the clean linen room to obtained Resident #23 a gown. During an interview on 12/1/20 at 10:09 a.m., CNA E said she should have washed or sanitized her hands prior to entering Resident #23's room, between gloves changes and after discarding Resident #23 soiled linen. CNA E said she forgot to wash or sanitized her hands prior to entering the room, between gloves changes and after discarding Resident #23 soiled linen. During an interview on 12/1/20 at 10:13 a.m., CNA D said she should have washed or sanitize her hands prior to entering Resident #23's room, between gloves changes, and prior to obtaining Resident #23 incontinent gown from the clean linen room. During an interview on 12/4/20 at 2:11 p.m., the DON said she expected the CNAs to perform proper hand hygiene prior, during and after incontinent care. The DON said she expected CNA D to wash her hands prior to entering the clean linen room after providing incontinent care for Resident #23. During an interview on 12/4/20 at 2:43 p.m., the administrator said CNAs should performed hand hygiene prior to and between glove changes and after discarding soiled linen when providing incontinent care. The administrator said he expected CNA D to wash her hands prior to entering the clean line room after providing incontinent care for Resident #23. 6. Record review of consolidated physician orders dated 12/4/20 indicated Resident #49 was [AGE] years old, readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated Resident #49 was placed on droplet precautions on 12/3/20 related to COVID-19. The most recent MDS dated [DATE] indicated Resident #49 usually understood others, usually made herself understood, and had moderate cognitive impairment. The MDS indicated Resident #49 required supervision with bed mobility, transferring, locomotion on and off the unit, dressing, and toileting; limited assistance with eating and personal hygiene; and extensive assistance with bathing. The care plan updated on 10/11/20 indicated Resident #49 had an ADL self-care deficit. The care plan was not updated to address Resident #49's change in COVID-19 status on 11/25/20. A rapid COVID-19 test dated 11/25/20 indicated Resident #49 was positive for COVID-19. A nurse's note dated 11/25/20 at 4:15 p.m. indicated Resident #49 was transferred to a room without a roommate (room [ROOM NUMBER]B) from room [ROOM NUMBER]A related to a COVID-19 positive test. A nurse's note dated 11/25/20 at 11:05 p.m. indicated Resident #49 was transferred from room [ROOM NUMBER]A to room [ROOM NUMBER]B related to a positive COVID-19 test. The nurse's note indicated Resident #49 remained on the cold hall after testing positive for COVID-19. A nurse's note dated 12/3/20 indicated Resident #49 was transferred to the COVID-19 positive unit (Hall 200). Respiratory infection screeners from 11/20/20 to 12/4/20 indicated Resident #49 had COVID-19 symptoms of productive cough where [MEDICATION(S)] was produced on 11/30/20. During an observation on 11/30/20 at 12:52 p.m., Resident #49 was in room [ROOM NUMBER]B (cold hall) with a sign on her door that said to see nurse before entering. During an observation on 12/1/20 at 9:50 a.m., Resident #49 was in room [ROOM NUMBER]B, a room on the cold hall (hall designated for residents negative for COVID-19). During an observation on 12/2/20 at 11:15 a.m., Resident #49 was in room [ROOM NUMBER]A (cold hall) with no isolation precautions in place. Resident #49 had a roommate (Resident #26). During an interview on 12/2/20 at 11:55 a.m., LVN A said Resident #49 was moved to room [ROOM NUMBER]B related to a positive rapid COVID-19 test, was not moved to COVID unit because awaiting PCR results. LVN A said Resident #49 was moved back into room [ROOM NUMBER]A with her roommate when she received a negative PCR test. LVN A said Resident #49's roommate (Resident #26) was not and had not been on isolation precautions. During an interview on 12/3/20 at 3:43 p.m., the DON said she now knew a positive [MEDICATION(S)] test indicated residents were COVID-19 positive. The DON said she was completing an audit to determine which residents had a positive [MEDICATION(S)] test and needed to move to the hot hall. The DON said her audit included which residents were the positive residents' roommates that needed to be quarantined. A resident roster provided by the DON on 12/4/20 at 9:15 a.m. indicated Resident #49 was moved to a room on the COVID-19 positive hall. 7. Record review of consolidated physician orders dated 12/4/20 indicated Resident #26 was [AGE] years old, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated Resident #26 was placed on droplet precautions on 12/3/20 related to COVID-19 exposure. The most recent MDS dated [DATE] indicated Resident #26 usually made herself understood, usually understood others, and had moderate cognitive impairment. The MDS indicated Resident #26 required extensive assistance with bed mobility, transferring, dressing, eating, toileting, personal hygiene, and bathing. The care plan updated on 10/5/20 indicated Resident #26 had an ADL self-care deficit related to bilateral lower extremity amputations. The care plan indicated Resident #26 was at risk for COVID-19 and the facility would follow the COVID-19 protocols for screening/precautions. A rapid COVID-19 test dated 11/25/20 indicated Resident #26's roommate (Resident #49) was positive for COVID-19. Nurse's notes dated from 11/4/20 to 12/4/20 did not indicate Resident #26 was on COVID-19 isolation precautions related to her roommate testing positive for COVID-19. During an observation on 11/30/20 at 3:33 p.m., Resident #26 was lying in bed in room [ROOM NUMBER]B. Resident #26 was not on isolation precautions. There was no isolation cart with PPE in it outside her room and there was no sign on the door of her room indicating to see the nurse before entering the room. During an observation on 12/1/20 at 1:33 p.m., Resident #26 was lying in bed in room [ROOM NUMBER]B. Resident #26 was not on isolation precautions. There was no isolation cart with PPE in it outside her room and there was no sign on the door of her room indicating to see the nurse before entering the room. During an observation on 12/2/20 at 11:15 a.m., Resident #26's roommate (Resident #49) was in back in her room (room [ROOM NUMBER]A - cold hall) with no isolation precautions in place. During an interview on 12/2/20 at 11:55 a.m., LVN A said Resident #26 was not on isolation precautions related to her roommate having a positive COVID-19 test. During an observation on 12/3/20 at 10:59 a.m., Resident #26 was lying in bed with no isolation precautions in place. There was no isolation cart with PPE in it outside her room and there was no sign on the door of her room indicating to see the nurse before entering the room. During an interview on 12/3/20 at 3:43 p.m., the DON said she now knew a positive [MEDICATION(S)] test indicated residents were COVID-19 positive. The DON said she was completing an audit to determine which residents had a positive [MEDICATION(S)] test and needed to move to the hot hall. The DON said her audit included which residents were the positive residents' roommates that needed to be quarantined. A resident roster provided by the DON on 12/4/20 at 9:15 a.m. indicated Resident #26 was on warm/quarantined hall. 8. Consolidated physician orders dated 12/1/20 indicated Resident #30 was [AGE] years old, readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders did not address isolation precautions for Resident #30. The most recent MDS dated [DATE] indicated Resident #30 sometimes understood others, sometimes made himself understood, and had severe cognitive impairment. The MDS indicated Resident #30 required extensive assistance with bed mobility, transferring, dressing, eating, toileting, personal hygiene, and bathing. The care plan updated on 10/11/20 indicated Resident #30 had an ADL self-care deficit and required assistance with ADLs. The care plan indicated Resident #30 was at risk for COVID-19 and the facility would follow the COVID-19 protocols for screening/precautions. A rapid COVID-19 test dated 11/23/20 indicated Resident #30's roommate was positive for COVID-19. A resident roster provided by the administrator on 11/30/20 at 11:20 a.m. indicated Resident #30's roommate was on the COVID positive unit. Nurse's notes dated from 11/12/20 to 12/2/20 did not indicate Resident #30 was on COVID-19 isolation precautions related to his roommate testing positive for COVID-19. During an observation on 11/30/20 at 3:40 p.m., Resident #30 was lying in bed with his eyes open, unable to answer questions. Resident #30 was not on isolation precautions. There was no isolation cart with PPE in it outside his room and there was no sign on the door of his room indicating to see the nurse before entering the room. During an interview on 12/2/20 at 11:55 a.m., LVN A said Resident #30 had not been on isolation precautions related to his roommate having a positive COVID-19 test. 9. Record review of consolidated physician orders dated 12/4/20 indicated Resident #69 was [AGE] years old, readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated Resident #69 was placed on droplet precautions on 12/3/20 related to COVID-19 exposure. The most recent MDS dated [DATE] indicated Resident #69 usually made himself understood, usually understood others, and had moderate cognitive impairment. The MDS indicated Resident #69 required supervision for bed mobility, transferring, dressing, toileting; limited assistance with personal hygiene; and extensive assistance with bathing. The care plan updated on 11/9/20 indicated Resident #69 had an ADL self-care deficit and required assistance with ADLs. The care plan indicated Resident #69 was at risk for COVID-19 and the facility would follow the COVID-19 protocols for screening/precautions. A rapid COVID-19 test dated 11/23/20 indicated Resident #69's roommate was positive for COVID-19. A resident roster provided by the administrator on 11/30/20 at 11:20 a.m. indicated Resident #69's roommate was on the COVID positive unit. Nurse's notes dated from 11/12/20 to 12/4/20 did not indicate Resident #69 was on COVID-19 isolation precautions related to his roommate testing positive for COVID-19. During an observation on 11/30/20 at 3:45 p.m., Resident #69 was propelling himself in his wheelchair in the hallway. Resident #69 was wearing a surgical mask in the hallway. Resident #69 was not on isolation precautions. There was no isolation cart with PPE in it outside his room and there was no sign on the door of his room indicating to see the nurse before entering the room. During an observation on 12/1/20 at 2:21 p.m., Resident #69 was in the hallway outside his room and was wearing a surgical mask. Resident #69 was not on isolation precautions. There was no isolation cart with PPE in it outside his room and there was no sign on the door of his room indicating to see the nurse before entering the room. During an observation on 12/2/20 at 11:18 a.m., Resident #69 was in another resident's room on Hall 300 with his surgical mask down below his nose. Resident #69 left the resident's room and did not pull his mask up until he was approximately 10 feet down the hallway. There was no isolation cart with PPE in it outside his room and there was no sign on the door of his room indicating to see the nurse before entering the room. During an interview on 12/2/20 at 11:55 a.m., LVN A said Resident #69 was not on isolation precautions related to his roommate having a positive COVID-19 test. During an observation on 12/3/20 at 10:59 a.m., Resident #69 was lying in bed, asleep with no isolation precautions in place. There was no isolation cart with PPE in it outside his room and there was no sign on the door of his room indicating to see the nurse before entering the room. During an interview on 12/3/20 at 3:43 p.m., the DON said she now knew a positive [MEDICATION(S)] test indicated residents were COVID-19 positive. The DON said she was completing an audit to determine which residents had a positive [MEDICATION(S)] test and needed to move to the hot hall. The DON said her audit included which residents were the positive residents' roommates that needed to be quarantined. A resident roster provided by the DON on 12/4/20 at 9:15 a.m. indicated Resident #69 was on warm/quarantined hall. 10. Record review of consolidated physician orders dated 12/4/20 indicated Resident #33 was [AGE] years old, admitted to facility on 5/21/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated Resident #33 was placed on droplet precautions on 12/3/20 related to COVID-19 exposure. The most recent MDS dated [DATE] indicated Resident #33 usually understood others, usually made herself understood, and had severe cognitive impairment. The MDS indicated Resident #33 required extensive assistance with bed mobility, transferring, dressing, eating, toileting, personal hygiene, and bathing. The care plan updated on 10/13/20 indicated Resident #33 had an ADL self-care deficit and required assistance with ADLs. The care plan indicated Resident #33 was at risk for COVID-19 and the facility would follow the COVID-19 protocols for screening/precautions. A rapid COVID-19 test dated 11/23/20 indicated Resident #33's roommate was positive for COVID-19 . A resident roster provided by the administrator on 11/30/20 at 11:20 a.m. indicated Resident #33's roommate was on the COVID positive unit. Nurse's noted dated from 11/16/20 to 12/3/20 did not indicate Resident #33 was on COVID-19 isolation precautions related to her roommate tested positive for COVID-19 until 12/3/20. During an observation on 11/30/20 at 2:53 p.m., Resident #33 was lying in bed asleep. Resident #33 was not on isolation precautions. There was no isolation cart with PPE in it outside her room and there was no sign on the door of her room indicating to see the nurse before entering the room. During an observation on 12/1/20 at 1:58 p.m., Resident #33 was lying in bed asleep. Resident #33 was not on isolation precautions. There was no isolation cart with PPE in it outside her room and there was no sign on the door of her room indicating to see the nurse before entering the room. During an observation on 12/2/20 at 11:00 a.m., Resident #33 was lying in bed asleep. Resident #33 was not on isolation precautions. There was no isolation cart with PPE in it outside her room and there was no sign on the door of her room indicating to see the nurse before entering the room. During an interview on 12/2/20 at 11:55 a.m., LVN A said Resident #33 was not on isolation precautions related to her roommate having a positive COVID-19 test. During an observation on 12/3/20 at 10:59 a.m., Resident #33 was lying in bed, asleep with no isolation precautions in place. There was no isolation cart with PPE in it outside her room and there was no sign on the door of her room indicating to see the nurse before entering the room. During an interview on 12/3/20 at 3:43 p.m., the DON said she now knew a positive [MEDICATION(S)] test indicated residents were COVID-19 positive. The DON said she was completing an audit to determine which residents had a positive [MEDICATION(S)] test and needed to move to the hot hall. The DON said her audit included which residents were the positive residents' roommates that needed to be quarantined. A resident roster provided by the DON on 12/4/20 at 9:15 a.m. indicated Resident #33 was on warm/quarantined hall. 11. During an observation on 11/30/20 at 3:12 p.m., the clean linen cart on Hall 300's front flap was flipped up, and the clean linens were exposed. The linen cart had clean incontinent pads, flat sheets, fitted sheets, gowns, blankets, towels, rags and adult briefs. CNA B retrieved a clean incontinent pad from the clean linen cart and walked approximately 15 feet down the hallway with the incontinent pad open to air. CNA B stopped in the hall, returned to the cart and placed the pad in a plastic bag to transport down hall. During an observation on 12/1/20 at 9:45 a.m., Hall 300's linen cart was not sealed on the edges and clean linens were exposed including clean towels, blankets, gowns, and sheets. The front flap of the linen cart was worn and torn along the front. The torn areas exposed clean linens. A tear on the right side was approximately 1 foot long and was gaping; and the tear on the left side was approximately 5-6 inches long and was gaping. During an observation on 12/1/20 at 10:09 a.m., CNA C carried clean linens (a fitted sheet and a flat sheet) to a resident

Based on observation, interview and record review, it was determined the facility failed to ensure one resident (Resident #1) of four residents reviewed received adequate supervision and assistive devices to prevent accidents and injuries. Resident #1 was transported in the facility van improperly in a Geri-chair and without proper torso seatbelts and straps to secure the resident and the chair. During transport, the chair tipped over and resulted in a fracture of the resident's right femur. These failures resulted in an acute fracture for Resident #1 with increased pain and discomfort. These failures had the potential to affect all six residents who utilized the van for transport, including Resident #1. Findings included: The quarterly MDS assessment, dated 04/27/2012, reflected Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment reflected Resident #1 did not speak, rarely or never made herself understood and rarely or never understood others. The assessment reflected she had both short and long-term memory loss and was severely cognitive impaired. The Functional Status section of the assessment reflected Resident #1 was totally dependent on two staff for bed mobility, transfers, dressing, personal hygiene and bathing. The assessment reflected Resident #1 did not stand or walk and required the assistance of one staff for locomotion on and off the unit. The assessment also reflected Resident #1 had functional limitation in range of motion in both upper and lower extremities. The most current care plan dated 04/29/2012 reflected Resident #1 was unresponsive to environmental stimuli, had no ability to communicate verbally, and required staff assistance for all ADLs. The interventions to be implemented for ADLs included two people to assist with bathing, turning and positioning and a mechanical lift to transfer her from the bed to the Geri chair. The care plan also reflected the Geri chair was necessary for proper body alignment, as she could not sit up in a wheelchair. On 06/06/2012 at 11:15 AM Resident #1 was observed lying in her bed, which was in the low position. She did not show any signs of pain or discomfort. On 06/07/2012 at 8:45 AM, Resident #1 was observed by the surveyor and LVN A. She was lying in bed with both of her legs positioned straight in bed. A small blister on her right knee was almost completely healed and there was no swelling noted. Resident #1 did not show any signs of pain or discomfort. 1) Review of the Incident/Accident Report dated 05/21/2012 at 7:00 PM revealed the nurse aides found a scratch on Resident #1's right knee during incontinent care and informed the nurse. The nurse noted the right knee was swollen, there was a scratch on the left knee and the resident exhibited signs of pain upon range of motion of the leg. The nurse put an ice pack on the knee, called the physician and received orders to x-ray the knee. Resident #1 was transferred to the emergency room for evaluation. Review of the hospital emergency room records dated 05/22/2012 revealed the following: "Triage Assessment: General: Appears in no apparent distress, well-developed, well nourished, well groomed ... Pain: Noted to be grimacing, pt. (patient) grimaces when knee is moved, Unable to use pain scale, pt. is non-verbal...pt has a small lac/abrasion on her left knee, Musculoskeletal: Circulation, motion, and sensation intact. Capillary refill is brisk in bilateral toes. Range of Motion limited in right knee. Swelling present in lateral aspect of right knee. Posterior aspect of right knee, medial aspect of right knee." The report also reflected Resident #1 had diagnoses, which included GERD, CVA, Respiratory Failure, Hypertension, Diabetes, [DIAGNOSES REDACTED], Peg tube placement and Craniotomy. Review of the Right Femur x-ray done on 05/22/2012 at the emergency room revealed a Non-displaced distal femoral fracture, Joint effusion above the knee and Atherosclerotic change in the right superficial femoral artery. Review of the right knee x-ray done on 05/22/2012 at the emergency room revealed a Non-displaced distal femoral; fracture with small joint effusion and degenerative osteoarthritic change about the knee involving the medial and lateral femoral compartments. Review of the facility's Provider Investigation Report, dated 05/30/2012, revealed at approximately 3:00 PM on 05/21/2012, the staff was providing incontinent care to Resident #1 and noticed a scratch over her right knee. The report reflected at approximately 8:00 PM the nurse noticed the resident's right knee was swollen and an ice pack was applied and Tylenol was given. An x-ray was ordered and done and the resident was transferred out to the emergency room for evaluation. Resident #1 came back the same day with a brace on her right leg. The investigation found that on 05/21/2012, Resident #1 sustained an injury during a van transport while the resident was in her Geri chair. The report reflected the resident was secured in the facility's van in her Geri chair. The van driver had to make a quick stop and the chair tipped to the left side but did not tip over. The resident's daughter was in the van during transport and she tipped the chair back, so that it was on all four wheels. The report reflected the resident remained strapped into the chair. Review of the facility's summary of the incident regarding Resident #1 revealed the driver demonstrated to the staff how he placed the resident and her Geri chair in the van. He stated he placed a safety strap through the opening at the end of the arm rests and cinched it down really tight; the strap was over her legs, just above the knees. He stated he applied the chair wheels brakes and placed a strap around the back of each of the wheels but none at the front of the chair. The Van Driver stated there was a shoulder strap and harness in the van, but he did not put it on the resident as it was to the right of her and it would not have been positioned across her body. The Van Driver stated during the transport, he had to apply the brakes suddenly and the chair tipped to the left with the two wheels on the right side coming up off the floor. The resident's family member was present and accompanying the resident in the van. The driver stated the family member placed the chair back down on the floor. He stated the resident's family member stated she thought the resident was okay. This occurred on the way to a physician's visit. The Van Driver stated when transporting the resident back to the facility, he did apply four safety straps to the wheels of the chair. The report reflected the facility's Van Driver was suspended pending completion of the investigation. He was in-serviced on driver and vehicle safety policies and completed return demonstrations. A vehicle maintenance check list was completed. The facility implemented Geri chairs would no longer be used for transports in the facility van. The report reflected the Van Driver was allowed to return to work. 2) On 06/06/2012 at 10:40 AM, an interview was conducted with the Van Driver. He stated he transported Resident #1 in her Geri-chair, not a wheelchair. He demonstrated how he placed the chair and the resident in the van for the surveyor. He got Resident #1's Geri chair, then lowered the hydraulic lift located at the rear passenger side of the van. Once the lift was lowered to the ground, he pulled the Geri chair backwards onto the van where the resident would have been facing the side of the van. He locked the rear wheels of the Geri chair and there were no lock s for the front wheels on the chair. He then placed two hooks on the back wheels of the chair and pulled the straps tight to secure the rear wheels of the chair. He pulled a single seat belt through the arms of the chair across the legs of the resident, just above her knees. He stated he could not put a shoulder harness on her as it would not pull across her chest tight enough. The Van Driver then explained he was driving the van with the resident's family member and the resident were in the back. A car in front of him stopped when the light changed and he had to stop suddenly. He stated he heard one of them say, "Oh" but was not sure which one, the resident or her family member. He stated the Geri chair tipped over, not all the way, but the wheels on the right side came up off the floor. The family member pulled the chair back so all wheels were down on the floor. He stated he heard Resident #1's family member ask, "Momma are you okay?" He stated he asked the family member if they were alright. The family member responded that he/she thought so. He stated Resident #1 did not grimace or act like she was in pain when they took her out to her doctor's appointment. He confirmed on the return trip to the facility, he positioned the chair and resident facing the front of the van and he secured all four wheels with the hooks and straps. The Van Driver stated he did not tell the nurses because he thought the resident's family member would tell them. He confirmed he had been in-serviced and they were no longer going to transport any residents in Geri chairs. Resident #1 now had to go by stretcher and ambulance. He confirmed he had been transporting Resident #1 to all appointments with her in the Geri chair. He also stated he had been told to report all incidents which occurred on the van to the nurses and Administrator. On 06/06/2012 at 2:45 PM during an interview with the Van Driver, he confirmed he had not applied any seatbelt harnesses to Resident #1 on either trip of the transport because it would not fit right. 3) On 06/06/2012 at 11:28 AM, an interview was conducted with Resident #1's family member who was present in the van at the time of the incident. He/She stated they did not see exactly what happened. He/She confirmed Resident #1 was in her Geri-chair and the Van Driver did not stop quickly. He/She stated it was just a slow stop; the light was yellow and he just stopped. The family member stated the chair slid and the resident's upper torso shifted in her chair, but not her legs. The resident's legs remained straight with the seatbelt across the lower legs. He/She stated Resident #1 had no control of her upper body and her body shifted and the chair tilted toward the left. Resident #1's family member then explained when the chair tilted over to the left side, he/she jumped up and pushed the chair back down. The family member remembered moving the resident's upper body back to the middle of the chair, but stated he/she did not have to straighten the resident's legs. The family member added he/she thought the buckle on the seatbelt across the legs probably caused the scratch on the resident's knee. The family member confirmed Resident #1 had been transported in her Geri-chair to appointments before and this was not something he/she would have thought could happen. He/She felt it was just an accident. 4) On 06/06/2012 at 4:00 PM during an interview with the Administrator, it was revealed when Resident #1 was admitted to the facility, she had been told by the former Maintenance Director, who had moved out of state, that Resident #1 was transported in her Geri-chair and there had been no problems. On 06/06/2012 at 3:30 PM, an interview was conducted with the DON. She stated she was notified about the red spot and swelling of Resident #1's right knee. She stated after the x-ray came back with the [DIAGNOSES REDACTED]. She revealed the family member told her about it. Resident #1 came back from the emergency room with a brace on her right leg. Resident #1 developed a blister from the brace and the physician gave the order to keep it off and to have her go see an orthopedic specialist. The DON then stated she was not aware Resident #1 was being transported in the van in her Geri-chair until the incident. She stated there would be no residents, including Resident #1, transported in the van in a Geri-chair again. Resident #1 would be going on a stretcher via ambulance transport for all appointments. 5) The physician orders [REDACTED]. The orders further reflected Resident #1 was to have a Geri chair while out of bed to maintain proper body alignment and position due to her inability to hold her upper body position properly. Review of the MAR for the month of May 2012 for Resident #1 revealed she had not received any pain medications for the month of May until 05/22/2012, the day after her injury was sustained. On 05/22/2012, Resident #1 received two doses of Acetaminophen. Resident #1 received a total of 13 doses of Lortab 5 ml (7.5/500 mg per 15 ml) from 05/22/2012 through 05/31/2012. She received two doses on 05/22/2012, 05/25/2012, 05/26/2012 and 05/27/2012. She received one dose of Lortab per day on 05/23/2012, 05/24/2012, 05/28/2012 through 05/31/2012. 6) The Resident Census and Conditions of Residents form, CMS 672, dated 06/06/2012, reflected a census of 88 residents in the facility. The facility administration also provided a list of six residents who utilized the facility van for transport, including Resident #1.