Every finding on record at Riverside Oaks

Based on interviews and record review the facility failed to ensure the assessment accurately reflected the resident's status for one (1) of six (6) residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded on his Discharge Return Not Anticipated MDS assessment, observation end date 12/01/2025, for a physical behavioral symptom directed toward others that was exhibited on Sunday, 11/30/2025. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Record review of Resident #1's admission Record, dated 04/14/2026, revealed a [AGE] year-old male. He was admitted on [DATE] and discharged on 12/01/2025. Resident #1 had a Responsible Party noted on his contact list along with himself. Resident #1 and his Responsible Party had the same contact phone number. Record review of Resident #1's Medical Diagnosis tab in Resident #1's electronic medical record, undated and accessed 04/14/2026 at 05:38 p.m., revealed diagnoses included sepsis (a condition in which the body's extreme response to an infection become life-threatening), epilepsy (a brain disorder that causes seizures), and down syndrome (a genetic condition that can affect how the brain and body develop). Record review of Resident #1's Discharge Return Not Anticipated MDS Assessment, dated 12/01/2025 and signed as complete by the MDS Coordinator on 12/09/2026, revealed the resident was rarely/never understood and had severe cognitive impairment with a memory problem. Under Section E - Behavior of the MDS Assessment, Resident #1 was noted to have not exhibited any physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually). Frequency options for the behavior included: behavior not exhibited, behavior of this type occurred one (1) to three (3) days, behavior of this type occurred four (4) to six (6) days, and behavior of this type occurred daily. The Section Z- Assessment Administration of the MDS Assessment revealed the SW completed section, section(s) not identified, on 12/01/2026 and the MDS Coordinator completed section, section(s) not identified, on 12/09/2026. Record review of Resident #1's Progress Notes, dated 04/14/2026 for effective date range: 11/25/2025 to 12/07/2025, revealed:- On 11/30/2025 at 02:03 p.m., LPN A wrote Res passing female res who was sitting in her W/C in front of Nurses Station wheeled himself around res and punched her & kept going, res was not provoked, res is non-verbal & only oriented to self. Record review of facility incident report titled #285 Resident to Resident Altercation, dated 11/30/2025 at 01:30 p.m. with LPN A noted as person preparing report, revealed Res passing female res who was sitting in her W/C in front of Nurses Station wheeled himself around res and punched her & kept going, res was not provoked, res is non-verbal & only oriented to self. The date of closure for incident was not identified in the report. Record review of Resident #1's Care Plan Report, dated as Care Plan Closed Date: 12/02/2025, revealed the following focus: CANCELLED: the resident has a behavior problem - he wheeled passed a female resident sitting up at nurses' station and hit her in the face, which was unprovoked, date initiated 11/30/2025, date revised and cancelled 12/02/2025. Attempted interview with Resident #1 or Resident #1's Resident Representative on 04/16/2026 at 11:31 a.m. and 02:35 p.m. Left message with request for return call but unable interview. During an interview on 04/16/2026 at 09:29 a.m., the MDS Coordinator stated the SW completed Section E of the MDS. She stated the SW did her part, signed for her sections, and when the MDS was closed, she, the MDS Coordinator would sign the MDS as complete. She stated she did not go in and change or review the sections the SW completed. She stated if Resident #1's Discharge MDS was after 11/30/2025, the date of physical behavior, then the physical behavior should have been documented on the Discharge MDS. She stated if the facility incident report was not closed at the time of the MDS Assessment, the facility procedure was to go back to the MDS Assessment after the incident report was closed and to modify the MDS Assessment. She stated that there was not a follow up modification for this Discharge MDS Assessment and there possibly should have been. She stated the facility incident report for this incident was closed on 12/01/2026 at 01:00 p.m. She stated after reviewing the facility incident report, from what she read and from her personal experience, she would have coded the physical behavior. She stated the failure to document the physical behavior would not have impacted the resident's care or the care they would receive where they were discharging to, and it would not have impacted facility reimbursement. During an interview on 04/16/2026 at 02:00 p.m., the SW stated she worked on Section E for the MDS Assessments. She stated she reviewed information from the resident's progress notes and would use knowledge of having been notified of an incident to complete the information for that section of the MDS Assessment. She stated she was notified of resident-to-resident incidents either during her workday or the next workday morning if the incident occurred after her scheduled work hours, Monday to Friday 08:00 a.m. to 05:00 p.m. She stated she did not recall completing Resident #1's Discharge MDS Assessment; however, she did recall Resident #1. She stated the Discharge MDS Assessment not capturing his physical behavior could have been a mistake. She stated she did not believe the lack of documentation of a physical behavior symptom for Resident #1's Discharge MDS Assessment would not have impacted Resident #1's care. During an interview on 04/16/2026 at 03:02 p.m., ADON B stated the SW completed Section E- Behavior of the MDS Assessments. She stated she was not involved in the MDS Assessment documentation. She stated she did not believe Resident #1's Discharge MDS Assessment not including his physical behavioral symptom would have impacted anything, including his care. During an interview on 04/16/2026 at 03:28 p.m., the ED stated, to him Resident #1's Discharge MDS Assessment not including his physical behavioral symptom would not have impacted the resident's care, since the resident was discharging. He stated a missed MDS Assessment documentation of a physical behavioral symptom for a resident that would receive continued care by the facility might have impacted the resident's care planning. He stated the requested documentation for a resident, such as Resident #1, having been discharged or transferred would not generally include the MDS Assessment. Record review of facility policy Conducting an Accurate Resident Assessment, date implemented 12/20/2025, revealed: Policy:The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of assessment, by staff qualified to assess relevant care areas.Policy Explanation and Compliance Guidelines: .3. The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status.7. A registered nurse will sign and certify that the assessment/correction request is completed. Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment. Whether the MDS assessments are manually completed, or computer generated following data entry, each individual assessor is responsible for certifying the accuracy of responses relative to the resident's condition and discharge or entry status.

Based on observation, interview, and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for one (1) of six (6) residents (Resident #2) reviewed for clinical records. The facility failed to accurately document the location of Resident #1's 03/07/2026 fall in her care plan report. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. The findings included: Record review of Resident #2's admission Record, dated 04/15/2026, revealed an [AGE] year-old female. She was initially admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #2's Medical Diagnosis tab in Resident #2's electronic medical record, undated and accessed 04/15/2026 at 02:08 p.m., revealed diagnoses included parkinsonism (a disorder of the nervous system that affects movement, often including tremors), dementia (a general term for impaired ability to remember, think, or make decisions), and unspecified lack of coordination. Record review of Resident #2's Quarterly MDS Assessment, dated 02/06/2026, revealed the resident had a BIMS score of 9, indicating she was moderately cognitively impaired. She used a wheelchair and required partial/moderate assistance to transfer from sitting to lying, lying to sitting, sitting to standing, and from chair/bed to chair. She had not had a fall since admission/entry or reentry or the prior assessment. Record review of Resident #2's Progress Notes, dated 04/15/2026 for effective date range: 03/07/2026 to 03/09/2026, revealed:- On 03/07/2026 at 11:45 a.m., LPN C entered a SBAR Summary for Providers note. The note included: Situation :[sic] Change In Condition/s reported on this CIC Evaluation are/were: Falls and Nursing observations, evaluation, and recommendations are:Resident [sic] had a fall with no injuries.- On 03/07/2026 at 11:45 a.m., LPN C entered a Nursing- General Note and wrote Resident observed sitting on wheelchair pedals in dining room. Record review of Resident #2's Care Plan Report, undated and accessed 04/15/2026 at 03:59 p.m., revealed the following focus: The resident is [sic] risk for fall r/t BLE [bilateral lower extremities or both sides of lower legs] weakness.3/7/25 [sic]; [Resident #2] initially admitted on [DATE]]- fall in room ., date initiated 08/18/2025 and revised 03/23/2026. During an interview on 04/16/2026 at 10:38 a.m., LPN C stated she vaguely remembered Resident #2's change of condition and fall on 03/07/2026. LPN C stated Resident #2 fell in the facility dining room. LPN C stated she would enter interventions into a resident's care plan if she identified there was something that she could do to prevent a fall; however, she stated she did not enter any interventions into Resident #2's care plan following Resident #2's 03/07/2026 fall because Resident #2 had all the fall interventions already in place. LPN C denied entering in the room on Resident #2's care plan for the fall location. LPN C stated she thought the ADONs or DON entered the historical information in the residents' fall care plans. LPN C stated if the documentation of the location of the fall was inaccurate, it could be a safety issue for the resident by impacting the ability to find the resident. During an observation and interview on 04/16/2026 at 01:37 p.m., Resident #2 was observed lying in her bed with the bed positioned at a low height with the right side of the bed against the wall, a fall mat on the floor next to the left side of the bed, and the call light within reach. Resident #2 stated she had had a couple of falls while living at the facility due to accidents. She stated she did not really remember what happened but was not injured. She stated the staff took care of her and she had no concerns about the staff's response to her falls. During an interview on 04/16/2026 at 03:02 p.m., ADON B stated she was not present for Resident #2's fall. She stated the ADONs and DON were completing the care plans. She stated she was not sure why there would have been a discrepancy in Resident #2's care plan and stated she was unsure if she had completed the documentation or the DON. She stated she would have completed the care plan documentation if the DON was not present. She stated the documented location of the fall would not have impacted the resident, since the response to the fall, indicating the fall assessments and documentation forms, were the same. During an interview on 04/16/2026 at 03:28 p.m., the ED stated the charge nurse was responsible for completing the incident report and usually the charge nurse, the MDS Coordinator, or one of the administrative nurses, ADONs or DON, would complete the care planning. He stated he did not think the documentation of location of the fall would impact a resident's care. He stated the interventions were more based on the action of the fall or how the fall occurred. Record review of facility policy Incidents and Accidents, date implemented 10/01/2025 and date reviewed/revised 12/01/2025, revealed: Policy:It is the policy of this facility for staff to utilize the risk management- incident report in the electronic health record to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident.Compliance Guidelines: .2. Licensed staff will utilize the incident report under the risk management tab in the electronic health record to report incidents/accidents and assist with completion of any investigative information to identify room causes.10. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions. Record review of facility policy Fall Prevention, date implemented 10/01/2025 and date reviewed/revised 12/02/2025, revealed: Policy:Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Policy Explanation and Compliance Guidelines: .8. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed.9. When any resident experiences a fall, the facility will: . c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. Record review of facility policy Maintenance of Electronic Clinical Records, date implemented 10/01/2025, revealed: Policy:This facility will maintain electronic clinical records for each resident in accordance with acceptable standards of practice. Policy Explanation and Compliance Guidelines:1. A complete and accurate electronic clinical record will be maintained on each resident and kept accessible and systematically organized for appropriate personnel to deliver the appropriate level of care for each resident while maintaining the confidentiality of the residents' information.4. Electronic clinical records will contain at least, but are not limited to: . d. Nursing documentation . f. Care plans and services provided .

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 1 narcotic destruction storage area.The facility failed to ensure that all narcotics matched the accompanying logs. Two of Resident #31's Morphine Sulfate oral solution bottles did not match their accompanying logs as medication was being removed from one bottle to be administered and logged on the record for a second Morphine Sulfate oral solution which had not been opened. This failure could place the residents at risk of receiving a medication error or receiving less than therapeutic benefits from medications.Findings included:Record review of Resident #31's face sheet dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (disorder when blood flow to a part of the brain is blocked leading to lack of oxygen and nutrients). Record review of Resident #31's quarterly MDS dated [DATE], section C revealed a BIMS score of 3 that indicated severe cognitive impairment. Record review of Resident #31's narcotic records revealed a Controlled Substance Count Sheet for Morphine Sulfate Oral Solution with 29.25 milliliters documented and a Controlled Drug Receipt/Record/Disposition Form for Morphine Sulfate Solution with 20.5 milliliters documented. Observation of the facility's medication room for narcotic destruction storage on [DATE] at 3:25 p.m. revealed Morphine Sulfate oral solution for Resident #31 was 16 milliliters. The accompanying record log for the Morphine Sulfate oral solution had 29.25 milliliters as being documented as the current amount of medication. There was a small amount of liquid that was seen in the bottom of the accompanying Morphine Sulfate oral solution box that was the same color as the Morphine Sulfate liquid but not enough to account for the discrepancy. All other narcotics in the narcotic destruction storage matched their accompanying logs that were in the narcotic storage. Narcotics for destruction were kept behind two locks with the DON being the only person with access to the second lock's key. During interview on [DATE] at 3:25 p.m., the DON said she would investigate regarding the discrepancy regarding the Morphine Sulfate oral solution for Resident #31.During interview on [DATE] at 3:59 p.m., the DON said that Resident #31 had two Morphine Sulfate oral solution bottles with the second bottle being on the medication cart. One bottle had come from the facility's pharmacy and the other bottle had come from an outside pharmacy. The facility pharmacy's Morphine was full and unopened at 30 milliliters, but the accompanying log sheet had recorded 20.5 milliliters left. The DON said that staff had been charting on the wrong narcotic sheet which explained the discrepancy. The DON said she would notify the Consultant Pharmacist and correct the narcotic sheets. During interview on [DATE] at 4:14 p.m., the DON said the Morphine Sulfate oral solution record sheets for Resident #31 were corrected and the Consultant Pharmacist had been notified.During interview on [DATE] at 11:27 a.m., the DON said they did random medication cart audits a few times a month that included checking the carts for anything that was open that needed to be dated, for expirations, there were no loose pills, narcotics and everything was accounted for. The DON said the nurses counted narcotics every shift going on and off. The DON said the pharmacist came once a month and did medication cart audits and destroyed narcotics with the DON and one other nurse and verified that the paper and the medication matched what was to be destroyed. The DON said she did quite a bit of education regarding medications for the staff and did in-services whenever a problem like a medication error occurred. The DON said narcotic counts not being documented on the correct sheet would not negatively affect the resident unless the resident received the wrong medication. During interview on [DATE] at 4:06 p.m., the Pharmacist Consultant said she opened the narcotic boxes on the medication carts and checked two or three quantities to ensure they matched the perpetual inventory form and spot checked that medications were not expired. The Pharmacist Consultant said she checked that when medications were signed out on the inventory form that it was documented in the EHR, the pain level was documented and matched the pain level that was on the written form. The Pharmacist Consultant said she checked for trends of nurses signing out narcotics. The Pharmacist Consultant said she made sure the form matched the quantity being presented for destruction. The Pharmacist Consultant said she made sure they were discarding each medication individually into the drug destruction box, made sure they started the dissolution process in the box, made sure all proper documentation of drug destruction was completed, taped the box up after ensuring all controlled medication had been placed in the box then signed and dated the box. The Pharmacist Consultant said she made sure the box was behind two locks until the biohazard company could pick the box up. The Pharmacist Consultant said she had been the pharmacist a little over three years at the facility and had no concerns regarding drug diversion. The Pharmacist Consultant said a medication error could occur if the correct narcotic was not being documented on the correct form as the supply could be incorrect, a resident could run out and potentially be shorted resident care. The Pharmacist Consultant said she did in-services when requested. The Pharmacist Consultant said she came to the facility monthly unless requested to come special for something like an in-service.Record Review of facility's policy Management of Controlled Medications revised [DATE] revealed the facility staff will follow the method of accounting for controlled medications through receiving, administration, storage and destruction which meets the requirements of state and federal narcotic enforcement agencies.

Based on observations, interviews, and record reviews, 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 3 of 3 residents (Resident #1, Resident #4, and Resident #5) reviewed for infection control. 1. The facility failed to ensure CNA C performed Resident #1's catheter care according to facility policy and professional standards on 4/27/25. 2. The facility failed to ensure LVN E performed hand hygiene appropriately and donned PPE when providing catheter care to Resident #4 on 4/27/25. 3. The facility failed to ensure RN D performed hand hygiene appropriately when providing wound care to Resident #5 on 4/27/25. This deficient practice could affect all residents who require wound/catheter care placing them at risk for infection. Findings included: 1. Record review of Resident #1's Admission Record, dated 4/25/25, revealed the resident was readmitted to the facility on [DATE] with diagnoses which included: Acute Pyelonephritis (bacterial infection in the kidney), Acute Kidney Failure (condition in which kidneys suddenly are unable to filter waste from blood) , and Benign Prostatic Hyperplasia (prostate gland enlargement that can cause difficulty with urination). Record review of Resident #1's Order Summary, dated 4/25/25, revealed an order for Foley catheter care every shift, dated 3/23/25. Observation of catheter care for Resident #1's indwelling urinary catheter, on 4/27/25 beginning at 10:12 am, revealed CNA C performed catheter care for Resident #1. Further observation revealed CNA C held the indwelling catheter at the meatus (opening leading inside the body) and wiped the catheter four times from the point of insertion with outward strokes, away from the meatus. Further observation revealed CNA C did not clean Resident #1's genitals, perineum, or meatus. During an interview on 4/27/25 at 11:32 am, CNA C said peri-care included catheter care and thought that catheter care only included the catheter. CNA C said not cleaning the resident's genitals could negatively affect the resident because if the glans (tip of the penis in males or clitoris in females) was not cleaned the resident could get an infection, start stinking, or sometimes feces could get on the genitals. 2. Record review of Resident #4's Admission Record, dated 4/27/25, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Obstructive and Reflux Uropathy (obstruction in the urinary tract and backflow of urine into the bladder). Record review of Resident #4's Order Summary, dated 4/27/25, revealed orders for: Enhanced Barrier Precautions every shift. Follow Facility Policy - **USE for patients with any of the following .indwelling medical devices, regardless or MDRO colonization status Infection or colonization with an MDRO**, dated 3/23/25; Suprapubic Catheter Care every shift, dated 3/23/25. Observation of catheter care for Resident #4's suprapubic catheter, on 4/27/25 beginning at 9:19 am, revealed LVN E washed her hands for 10 seconds when she entered Resident #4's room. Further observation revealed LVN E exited Resident #4's room to retrieve a bedside table, and when LVN E returned to the resident's room she washed her hands for 8 seconds. Further observation revealed LVN E performed catheter care for Resident #4 without donning a gown. Once the procedure was completed LVN E removed her gloves and washed her hands for 9 seconds, donned clean gloves, and applied a clean dressing to Resident #4's catheter insertion site. During an interview on 4/27/25 at 10:52 am, LVN E said when she washed her hands during Resident #4's catheter care, she thought she washed her hands for at least 20 seconds each time, adding she was counting and thought she counted to twenty. LVN E further stated she sometimes counted 1 and 2 and or just lathered for a good while. LVN E said she was expected to wash her hands for 20-30 seconds. LVN E further stated it was important to perform hand hygiene as recommended to stop from spreading germs or contamination. LVN E said Resident #4 was on EBPs. LVN E further stated EBPs were required when providing care to residents with Foley catheters, suprapubic catheters, feeding tubes, and wounds. LVN E said she was supposed to wear a gown when she provided catheter care for Resident #4, but she forgot to put it on. LVN E said it was important to follow EBPs to prevent spread of germs and infections. 3. Record review of Resident #5's Admission Record, dated 4/27/25, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Type 2 Diabetes, and Hypertension. Record review of Resident #5's Order Summary, dated 4/27/25, revealed an order for Wound Treatment - Triple Antibiotic Ointment / Dry Dressing one time a day Cleanse the Skin Lesion/(Biopsy site) to the Left Anterior Lower Leg with w/c, pat dry, apply a thin layer of Triple antibiotic Ointment and cover with a dry dressing ., dated 4/22/25. Observation of wound care to Resident #5's left lower leg biopsy site, on 4/27/25 beginning at 10:46 am, revealed RN D performed wound care to Resident #5's left lower leg. Further observation of RN D revealed she washed her hands for 9 seconds once the wound care to Resident #5's left lower leg was completed. During an interview on 4/27/25 at 11:09 am, RN D said to her knowledge, she washed her hands for at least 30 seconds, but did not know for sure. RN D said she was expected to wash her hands for 20-30 seconds. RN D further stated it was important to perform hand hygiene as recommended to make sure all the germs were adequately cleaned off. RN D said not performing hand hygiene as recommended could affect residents negatively because not doing so could cause cross contamination and residents were prone to infection. During interview on 4/27/25 at 12:37 pm, the DON said staff were expected to perform hand hygiene before and after providing care, when going from dirty to clean, and when hands were visibly soiled for 20 seconds. The DON said it was important to perform hand hygiene as recommended to avoid infections or cross contamination. The DON further stated she, the IP, and the nurse managers were responsible for ensuring staff washed their hands as recommended/per facility policy. The DON said it was important to perform hand hygiene as recommended because it could potentially cause infection otherwise. The DON said staff were expected to follow EBPs when performing high contact care, such as, ADLs, catheter care, IVs, feeding tubes, ostomy care, and wound care for draining wounds. The DON further stated staff were expected to wear glove and gown when providing care for resident on EBPs. The DON said it was important to follow EBPs because the residents were at risk for infection when they had open areas or any type of invasive lines. The DON further stated she, the IP, and the ADONs were responsible for ensuring staff followed EBPs. The DON said not following EBPs could increase the residents' risk for infection. The DON said the staff were expected to follow the skills competency check-off when performing catheter care. The DON further stated when staff performed catheter care staff just cleaned the catheter, adding peri-care and catheter care were different and catheter care only included cleaning the catheter. The DON said it was important to perform catheter care according to facility policy/procedure, so the catheter was kept clean, and the resident did not get an infection. The DON further stated she, the IP, and the ADONs were responsible for ensuring catheter care was completed per facility policy. During the interview, the DON said the IP was out of town. During the interview, the State Investigator asked for a copy of the skills check-off list for catheter care; the document was not submitted prior to exit. During an interview on 4/27/25 at 1:00 pm, the Administrator said the facility followed CDC guidelines for hand hygiene and so staff were expected to perform hand hygiene for at least 20 seconds. The Administrator further stated it was important for staff to wash their hands as recommended to prevent the spread of bacteria and germs to the residents and the staff. The Administrator said staff were expected to follow EBPs when providing care to residents that required EBPs, such as residents with open draining wounds or catheters. The Administrator further stated the staff were expected to wear gloves, a gown, and face shield or glasses if needed when providing care to residents on EBPs. The Administrator said it was important for staff t follow EBPS because it prevented the spread of infection and germs to the resident and staff. Record review of the facility's policy titled Catheter Care, Urinary, revised September 2014, revealed: .Steps in the Procedure .7. Wash the resident's genitalia and perineum thoroughly .16 .cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward .17 .cleanse and rinse the catheter from insertion site to approximately four inches outward . Record review of the facility's policy titled Enhanced Barrier Precautions dated August 2022, revealed: .1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity .3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .g. device care or use ( .urinary catheter .) Record review of the facility's guidance titled Hand Hygiene Guidance, undated, revealed: .Healthcare facilities should: Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations . Record review of CDC webpage https://www.cdc.gov/clean-hands/about/index.html, titled Clean Hands, dated February 16, 2024, revealed: .How it works .2. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. 3. Scrub your hands for at least 20 seconds .

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for 4 of 4 plates with 2 of 3 staff. 1. DA A placed food on the plates-meat, baked potato, and carrots. While DA A fixed the plates, DA A left the work station several times, doffed (removed) his gloves and donned (put on) new gloves without performing hand hygiene. 2. DA B placed condiments, a roll, a carton of milk, and a cup of ice tea on the tray used a plate cover then placed on the cart to serve to the residents in the dining room. DA B left the work station once and doffed his gloves and donned clean gloves without using hand sanitizer or washing his hands. This deficient practice could effect residents that receive food from the kitchen and place them at risk for contamination of food. The findings included: 1. Observation on 07/10/24 at 11:46 AM revealed DA A left the work station four times where he served food on the plates, returned and doffed his gloves and donned a new pair of gloves without washing his hands or using hand sanitizer. During an interview with DA A on 07/10/24 at 11:46 AM, at the same time as the observation, DA A stated he knew to wash his hands when he changed gloves, but he was in a rush to get the plates served to the residents because of time. 2. Observation on 07/10/24 at 11:55 AM revealed DA B left his work station once and returned, doffed his gloves and donned a new pair of gloves without washing his hands or using hand sanitizer. During an interview with DA B on 07/10/24 at 11:55 AM, at the same time as the observation, DA B stated he did not think he needed to wash his hands since he was using gloves. During an interview with the NS on 07/10/24 at 11:46 AM, the NS stated that as long as he had been a cook, he was taught to use gloves during serving plates from set up to delivery. The NS stated he was not aware they needed to use hand sanitizer if they did not wash their hands before they put on new gloves. During an interview with the RD on 7/11/2024 at 2:20 PM, the RD stated if the staff were to wear gloves, they should either wash or sanitize their hands before donning clean gloves. The RD stated there was no policy on wearing gloves for dietary services. Record review of the facility's policy titled, Use of Plastic Gloves, dated 11/3/2004, revealed, Plastic gloves will be worn when handling food directly with hands to ensure that bacteria is not transferred from the food handlers' hands to the food product being served. Procedure: 1. Hands are to be washed before putting on gloves.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly for 1 of 5 residents (Resident #30) reviewed for medication storage in that: The facility failed to ensure medications were not left on Resident #30's bedside table. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered. The findings were: Record review of Resident #30's face sheet, dated 7/9/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnose that included unspecified Dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life), Chronic Kidney Disease ( medical term for the gradual loss of kidney function over three months), and Hypertension (is when the force of blood pushing against your artery walls is consistently too high). Record review of Resident#30's Quarterly MDS Assessment, dated 5/26/24, revealed a BIMS score of 99, which indicated resident was unable to complete the interview. Record review of Resident #30's Patient medication summary for July 2024 did not reveal an order to self-administer medications. Record review of Resident #30's care plan, dated 7/9/24, revealed [Resident's Name] self-administers medications at bedside Saline nasal spray. Observation on 7/9/24 at 10:10 a.m. revealed there was an over-the-counter pain relieving cream tube on Resident #30's bedside table. In an interview with Resident #30 on 7/9/24 at 10:30 a.m., the resident stated his family brings him any over-the-counter medications he may need as he did not like to bother the staff. During an interview with the DON on 07/09/24 at 1:10 p.m., the DON stated Resident #30 should only have a nasal spray at the bedside and not an over-the-counter pain-relieving cream. The DON stated a self-medication assessment had been conducted only for the nasal spray. The DON also stated Resident #30 might self-administer more medication than was ordered by the physician. The DON stated she currently had the ADON monitoring medications at the bedside weekly, and she oversaw this task monthly. Record review of the facility's policy titled, Self-administer medications, dated June 14, 2006, revealed, All medications for self-administration must be secured, patients' room in safe area.

Based on observation, interview, and record review, the facility failed to provide drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for 1 of 24 residents (Resident #4) reviewed for dietary services, in that: The facility failed to provide Resident #4 with milk at every meal which was noted on the resident's meal ticked and preference sheet, dated 10/30/2023 and signed by the NS, on 07/09/2024 at 1:15 PM which was lunchtime. This deficient practice could affect residents who have dietary preferences and result in weight loss or diminished quality of life. The findings included: Record review of Resident #4's electronic face sheet, dated 07/11/2024, reflected she was admitted to the facility on [DATE] with diagnoses that included: dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), intellectual disabilities (a chronic neurodevelopmental disorder that can affect a person's intellectual and adaptive functioning), major depressive disorder (a mental illness that can cause a persistent low mood, low self-esteem, and loss of interest in activities for at least two weeks), and disorder of bone density and structure (bone mineral density and mass decrease). Record review of Resident #4's quarterly MDS assessment, dated 05/26/2024, reflected the resident had scored an 11 out of 15 on her BIMS, which signified the resident was moderately cognitively intact. Further review revealed it was indicated the resident could understand and be understood, the resident required set-up or clean up assistance with meals, and the resident was not on a mechanically altered or therapeutic diet. Record review of Resident #4's comprehensive person-centered care plan (undated) reflected the resident was on a regular diet and preferred milk with each meal. Record review of Resident #4's Physician Orders dated 07/11/2024 reflected the resident was prescribed a regular diet. Record review of Resident #4's Diet History/Food Preference List dated 10/30/2023 reflected C, Current Beverage Preferences milk was checked off to be her preferred beverage with each meal, breakfast, lunch, and dinner. Observation on 07/09/2024 at 1:15 PM of Resident #4 in her room at lunchtime revealed the resident had her tray and there was no milk. Record review on 07/09/2024 at 1:15 PM of Resident #4's meal ticket revealed milk with each meal. During an interview with Resident #4 on 07/09/2024 at 1:16 PM, the resident stated she liked milk with each meal and the staff never brought it. When asked if she had informed the staff she shrugged her shoulders and shook her head. During an interview with the NS on 07/10/2024 at 10:22 AM, the NS stated he was the one who had assessed Resident #4 for her preferences and the milk should have been on her tray. The NS stated it was missed either by the nurse checking the tray or dietary staff, and further stated a resident's preference was important because it improved quality of life and would make the resident feel more at home. During an interview with the RD on 07/11/2024 at 1:28 PM, the RD stated the protocol for food preferences was the NS meets the resident and talks about their preference, and it they want the item each day. The RD stated it was noted on Resident #4's meal ticket that she was supposed to receive milk with every meal, and when the dietary staff and nurses were asked about why Resident #4 did not get milk, they did not know. The RD stated a resident's food preferences were important to assist in limiting weight loss and for the overall well-being of the resident. Record review of the Nutrition Services Policy & Procedure Manual, revised 10/2019, revealed, Food preferences will be honored as reasonable.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: The facility failed to ensure in the kitchen that three (3) ceiling vents in front of the Dietary Manager's office, six (6) ceiling panels in the dishroom, and four (4) ceiling panels in front of the refrigerators were clean and free of dirt and grease. This failure could place residents who received meals and snacks from the kitchen at risk for food borne illness. The findings included: Observation on 05/16/23 from 10:20 a.m to 11:05a.m., in the kitchen with the Dietary Manager revealed: 1- 3 ceiling vents measuring approximately 2x2 feet in front of entrance to the food service director's office were were dirty with dust particles accumulated in the vent spaces. 2-four(4) ceiling vents in the dish room measuring approximately 1x1.5 feet that were dirty witth grease accumulation and two (2) ceiling panels measuring approximately 2x2 feet above the dishmachine tray line appeared to have signs of water demarcation. 3- 4 ceiling panels measuring approximatly 2 x 2 feet in front of the refrigerators located above a food preparation table which were dirty with dirt particles covering the surface area. Interview with the Dietary Manager on 05/16/23 at 11:10 a.m., stated that a previous work order for cleaning of the vents and replacement of the ceiling panels had been given to the Maintenance Director. The Food Service Director stated that dirt and from the ceiling vents and panels could fall onto the prepared food. Interview with the Administrator on 05/16/23 at 11:15 a.m., stated that dirt and grease in the ceiling vents and on the ceiling panels could negatively affect the food preparation process. Record review of facility policy Sanitation of the Dietary Department in the Dietary Policy and Procedures manual dated 11/3/04 stated that the dietary staff shall maintain the sanitation of the Dietary Department through a comprehensive cleaning schedule.

Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program for 2 of 18 rooms on the hall (A) and 1 and 1 kitchen reviewed for pests, in that: The facility failed to ensure the pest control program was thoroughly working in all areas of the facility. 1. Resident #13 had multiple flies on her blankets and one fly on her face. 2. Flying insects were observed in the kitchen. 3. Room A 16 A bed had a 2 inches roach crawling on her wall. This failure could affect residents by increasing their risk of exposure to pests, vector-borne diseases, and infections. The findings were: 1.Record review of Resident #13's face sheet, dated 05/16/2023, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included: [COPD] a chronic inflammatory lung disease that causes obstructed airflow from the lungs, [Orthostatic hypotension] a condition in which your blood pressure quickly drops when you stand up after sitting or lying down and [Overactive bladder syndrome ] combination of symptoms that may cause you to urinate more frequently and have uncontrollable urges to pee. Record review of Resident # 13 quarterly MDS, dated [DATE], revealed a BIMS score of 15, which suggests the patient is cognitively intact. During an observation and interview on 05/16/2023 at 10:39 a.m., Resident #13 was observed lying in bed. There were multiple flies on her blankets and one fly on her face. When asked if the flies bothered her, (Resident #13), stated, Yes they bother me, they are here sometimes, and I don't know why , I place all my food in my refrigerator and store any food in containers with a lid . During an interview on 05/16/2023 at 10:15 a.m. with DON she was asked if residents' rooms were checked for hoarding and unnecessary food items removed. She stated, CNAs and nurses check rooms each shift, and unnecessary items are removed if residents allow us to. 2. Observation on 05/16/23 at 10:45 a.m revealed the presence of flying knats in the kitchen's dry storage room above the storage bins holding flour, rice, and sugar. Observation on 5/17/23 at 11:30 a.m. revealed the presence of flying knats in the kitchen's dry storage room above the storage bins holding flour, rice, and sugar. During an interview on 05/16/23 at 11:10a.m., with the Dietary Manager stated having the presence of knats in the kitchen could affect the overall sanitation of the kitchen. During an interview on 05/16/23 at 11:15a.m., with the Administrator stated that having the presence of knats in the kitchen could affect the overall sanitation of the food preparation process. Record review of the Dietary Policy and Procedure Manual for Sanitation and Infection Control dated November 2004 stated that if pests are seen in the kitchen the contractor is notified for pest control. 3. Record review of Resident in Room A 13 A bed's face sheet dated 5/18/2023 revealed she was admitted to the facility on [DATE]. Record review of Resident in Room A 13 A bed's Quarterly MDS dated [DATE] revealed Section C -Cognition Patterns, a BIMS score was 15/15 indicating the resident was (cognitively intact). Observation on 5/16/2023 at 2:14 p.m. revealed Resident in Room A 13 A bed's room had a 2-inch roach crawling on the wall during the initial rounds tour. During an interview on 5/16/2023 at 2:15 p.m. Resident in Room A 13 A bed stated there were roaches, all over and crawl on floor, walls and her bed. Resident in Room A 13 A bed's stated, There is a roach behind you on the wall . Resident in Room A 13 A bed stated this had been an issue for a while and had reaches crawl on her bed. During an interview on 05/17/2023 at 3:09 p.m. during a group meeting with 8 residents stated they did see roaches and gnats in their rooms and had seen pest control spray. During an interview 05/19/23 at 8:43 a.m. the surveyor informed the Administrator about the roach observed in Resident in Room A 13 A bed's room. The Administrator did not provide any comments and shook his head, up and down. During an interview on 05/16/23 at 11:10 a.m., with the Administrator stated that the presence of flying insects in the facility could affect the overall sanitation of the food preparation process and could negatively affect residents by spreading diseases throughout the building. During an interview on 05/17/2023 at 11:23 a.m., the administrator said his maintenance director was responsible for monitoring pests in the facility and notifying pest control, however since his maintenance director was on vacation, he was the backup. The administrator stated that pest control comes out monthly and as needed. The administrator stated that pest control serviced, his facility, at the beginning of this month, and they treated it with a fly program . The administrator stated Flies are an ongoing problem here when it rains. Record review of the pest control log revealed that pest control comes out monthly, with the last service being on 5/8/2023. Further review revealed that flies were not written as a concern. Record review of the facility contract with ( commercial pest control company ) , dated 1/5/23 revealed they are contracted for pest control services. Record review of an invoice for pest control services with ( commercial pest control company) dated 5/8/23 revealed the facility was treated with gel [NAME], for multiple insects . Record Review of facility policy Pest Control, 2001, revised May 2008, revealed that Facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. 27923 26869

Based on observation and record review, the facility failed to provide the required 80 square foot per resident in 3 of 54 resident rooms (Rooms A2, A3, A4) reviewed for bedroom measurements, in that: Based on measured rooms, A2, A3, A4 rooms were approximately between 77.75 and 78.5 sq. ft per resident. This failure could impede the ability of residents living in these rooms to attain their highest practicable well-being. The findings were: Offsite facility reviews on 05/15/2023 revealed an existing room size waiver from recertification survey, exit date 03/18/2022 which indicated room A2, A3 and A4 met the conditions of a room size waiver. Observation on 05/17/2023 at 3:30 p.m., revealed the square footage for rooms A2, A3, and A4 (which were licensed for 4 beds) was calculated to be between 311 and 314 square foot resulting between 77.75 and 78.5 square feet per resident. During an interview on 05/16/2023 at 11:15 a.m., the Administrator confirmed he wanted to continue the room waiver. Due to the ongoing remodel of the facility, the Administrator revealed there was still discussion to decide if room A2, A3 and A4 would still be used as 4 beds rooms or not. *

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 disease and infection for 1 of 3 residents (Resident #6) and, one of one dining room reviewed for infection control, in that: 1. While providing incontinent care for Resident #6, CNA A did not wash her hands before touching the resident and after touching a trash can with her bare hands. 2. CNA B and CNA C did not perform hand hygiene while assisting residents during the lunchtime meal. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1. Record review of Resident #6's face sheet, dated 11/04/2022, revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 6, which indicated severe cognitive impairment, required extensive assistance of one to two person for most ADL, and was indicated to always be incontinent of bowel and bladder. Record review of Resident #6's care plan with an effective date of 10/06/2022, revealed a care plan with a goal of Incontinence will be managed by staff without evidence of skin break down over the next 90 days. and interventions of Apply moisture barrier to buttocks, check for incontinence, clean and dry skin if wet or soiled, document when [NAME] is incontinent, perform complete assessment of skin,.note areas of redness. Observation on 11/04/2022 at 12:16 p.m. revealed while providing incontinent care for Resident # 6, CNA A touched the trash can with her bare hands and moved it. CNA did not wash or sanitize her hands before donning her gloves and touched Resident #6's skin. During an interview with CNA A on 11/04/2022 at 12:30 p.m., CNA A verbally confirmed she had touched the trash can and donned her gloves without washing or sanitizing her hands. She verbally confirmed the staff was receiving infection control training regularly. She sated touching the trash can and not washing her hands before touching the resident was placing the resident at risk for infection. During an interview with the DON on 11/04/2022 at 12:45 p.m., the DON verbally confirmed the CNA should have washed her hands prior to don her gloves after touching the trash can. She verbally confirmed it was a risk for cross contamination and could be a cause of infection for the resident. She verbally confirmed the staff had received infection control training and hand washing training. Review of CNA A's Handwashing skills checklist , dated 10/08/2022, revealed CNA A received competency for handwashing. 2. Observation of the lunch meal on 11/03/2022 from 12:32 p.m. to 12:40 p.m. revealed both CNA B and CNA C entered the dining room from the main hall and did not stop to perform hand hygiene. Further observation revealed CNA B sat down at one of the dining room tables and picked up an unidentified resident's spoon, handed it to her and then assisted the resident hand over hand with her meal. CNA C walked over to a different table and assisted an unidentified resident to remove his soiled smock (clothes protector). CNA C then walked to the next table and assisted a different resident with a divided plate. Further observation revealed the CNA C picked up the resident's spoon and filled it with food and the resident then picked it up to eat. CNA C walked to a 3rd table to assist a resident. CNA C first pushed a plate of food across the table out of the resident's reach. The plate belonged to another resident who had previously exited the dining room. CNA C then picked up the resident's fork, picked up empty sugar and salt packets from the table, placed them on the dirty plate that had been pushed across the table and then handed the fork and a cup of apples to the resident. At no time did CNA B or CNA C perform hand hygiene by using hand sanitizer or hand washing while assisting residents during the lunchtime meal. During an interview with CNA B and CNA C on 11/03/2022 at 12:40 p.m., CNA B revealed she should have sanitized her hands when she entered the dining room before she started to assist the resident. She stated, I always do, but I guess I got nervous and rushed because you are here. CNA C stated, I usually carry a little bottle of hand sanitizer in my pocket so I can sanitize between residents, but I went out to my car, and I just emptied my pockets and forgot to bring it back. During an interview with the DON on 11/03/2022 at 12:45 p.m., the DON confirmed staff should be sanitizing their hands prior to assisting residents with meals and between assisting multiple residents. Record review of CDC's, Hand Hygiene in Healthcare Settings, (www.cdc.gov/handhygiene/providers/index.html) last reviewed 11/04/2022, revealed, Clean Hands Count for Healthcare Providers . Protect yourself and your patients from potentially deadly germs by cleaning your hands. Be sure you clean your hands the right way at the right times . When and How to Perform Hand Hygiene . Use an Alcohol-Based Hand Sanitizer: Immediately before touching a patient, after touching a patient or the patient's immediate environment. Review of facility's policy, titled Handwashing/Hand hygiene, dated August 2019, revealed 7. Use an alcohol-based hand rub containing at least 62% alcohol [ .] l. after contact with objects in the immediate vicinity of the resident.

Based on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 5 residents (Resident # 1) reviewed for pressure ulcers in that: Resident # 1 did not receive wound care on an as needed basis on 07/02/2022 per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] This deficient practice could affect all residents who receive wound care treatments and place them at risk for worsening of existing pressure injuries or development of new pressure injuries. The findings included: Record review of face sheet printed 7/03/2022 revealed Resident # 1 was an [AGE] year-old female with an admitted [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident # 1 had a summary BIMS score of 15 which indicated the resident was cognitively intact with decision making. Section G - Functional Status revealed Resident # 1 required limited assistance with one-person physical assistance for bed mobility. Section H - bowel and bladder revealed Resident # 1 as always incontinent of bladder. Section M - Skin Conditions revealed Resident # 1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] .g., Braden, Norton, or other) and was not at risk of developing pressure injuries, had no unhealed pressure injuries, had no venous or arterial ulcers, no other ulcers, wounds or skin problems. Resident # 1 had a pressure reducing device for bed. Section V - Care Area Assessment triggered included: ADL [activities of daily living] Functional/Rehabilitation Potential, Urinary Incontinence, and Pressure Ulcer. Record review of Care Plan Report with an effective date 3/26/2022 indicated Resident # 1 revealed the following problems: Current skin concerns - pressure ulcers; with the following associated interventions: perform treatments per order, if no improvement times two weeks report to MD [ medical doctor]; monitor areas for increased breakdown, s/s [signs and symptoms] of infection - report to MD; Assess skin weekly and record findings in clinical records. Unstageable pressure ulcer to sacrum and right buttock, foot; with the following associated interventions: check and report skin redness, tears, swelling or pressure areas; nutritional screening; use pillows, pads, wedges to reduce pressure on heals (sp) and pressure points; do not massage skin over pressure areas, pressure reduction mattress. Pressure ulcer prevention; with the following interventions: pressure reducing equipment in chair; barrier cream, off-load boney prominences; float heels; lower H.O.B. [head of bed], utilize draw sheet to reposition; turn Q[every]2 hours. Record review of Wound Care assessment dated [DATE] for Resident # 1 revealed documentation of In-house date of onset 06/21/2022. Record review of Wound Care orders dated 6/29/22 for Resident # 1 revealed instructions to treat pressure injuries daily and PRN [pro re nata, or as needed] with w/c [wound cleanser], pat dry, apply a thin layer of THERAHONEY Wound Gel and cover with a dry dressing. Record review of Clinical Note entry by LVN A dated 6/29/22 for Resident # 1 revealed upon skin assessment, resident has unstageable pressure ulcer to sacrum, right buttock and abrasion to right foot, new TX [treatment] orders in place. Record review of Braden scale for predicting pressure sore risk for Resident # 1 dated 7/2/2022 revealed a score of 15 indicative of a mild risk for developing pressure ulcers . In an interview on 7/2/2022 at 4:30 PM, Resident # 1 stated she knew she had sores on her backside, but they were not uncomfortable or caused her pain. Resident # 1 stated over the last three or four days to the last week she has received much better care at this facility. Resident # 1 thought this improvement was due to changing from rehabilitative services to hospice care services. Resident # 1 stated as a retired nurse she knew the cancer was affecting her ability to care for herself and impacted her ability to think straight. Resident # 1 stated she felt her family members were blowing situations out of proportion. When asked to clarify what situations, Resident # 1 could not recall, but stated, Well now, my kids put cameras on me all the time. Resident # 1 stated she had no concerns to voice, as long as the level of service she received was maintained at the current, improved level. Resident # 1 stated that if the level of service started back sliding, only then would she consider making a complaint. Resident # 1 stated she did not fear any staff member purposely hurting or willfully neglecting her. Resident # 1 stated her wound care treatment was adequate. Resident # 1 stated the wound care was usually done daily on the day shift. Resident # 1 could not recall if any wound care treatments had ever been skipped. Resident # 1 stated that she knew the bandage had to be replaced after showers on one or two occasions. In an observation and interview on 7/2/2022 at 5:15 PM, the DON and LVN B repositioned Resident # 1 and assessed the wound care dressing. Resident # 1's adult brief was clean and dry with no wound care dressing. LVN B stated we will have to do wound care and place a dressing now. LVN B left the room to obtain the necessary supplies. The DON stated that the dressing may have been dislodged during incontinence care. LVN B returned and stated he had not been informed the dressing needed to be replaced. Wound care then initiated with proper wound care principles, infection control, sterile technique, and resident assessed for tolerance throughout procedure. In an interview on 7/2/2022 at 5:48 PM, CNA C stated she had been made aware by the DON that Resident # 1 should have had a dressing in place just prior to this interview. CNA C stated she was a rehire within the last week and had not worked with her assigned residents very much so far. CNA C could not recall if Resident # 1 had a dressing in place during the incontinent care procedure she had performed earlier. CNA C stated that if she had seen a soiled or dislodged dressing that would have triggered her to alert the nurse that the dressing needed to be replaced. CNA C stated she knew where to look up residents' care instructions. CNA C stated she would review the care instructions for all the residents she was charged with caring for before returning to provide direct care. In an interview on 7/2/2022 at 6:15 PM, the DON stated Resident # 1 had wound care provided at 9:07 AM that morning by the [unnamed] day shift nurse. The DON stated the CNA should have known Resident # 1 had a dressing under the adult brief according to the care instructions provided to CNAs. The DON stated the CNA should have alerted the nurse to assess the open to air wound. The DON stated the CNA should have alerted the nurse to a soiled, dislodged or missing wound care dressing. The DON stated there was no documentation on turning residents' every two hours as per the Care Plan. The facility did not provide documentation for wound care provided on 7/2/2022 at 9:07 AM, or CNA Care Instructions provided prior to exit. No policy or procedure instructions on wound care, following MD orders, or Care Plan interventions provided prior to exit.

Based on interview and record review, the facility failed to notify residents and/or the residents' Responsible Party (RP) or families by 5:00 PM the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other for COVID-19 for 1 of 1 facility. The facility failed to inform residents and/or the residents' RPs/family of confirmed COVID-19 in the facility by 5:00 PM the day after a confirmed case of COVID-19. This deficient practice could place residents, families, and responsible parties at risk of not being kept informed of the COVID-19 status in the facility. Findings included: Record review of facility's Clinical Notes Report dated 6/29/2022 revealed there were 43 of 54 notification completed between 8:43 AM and 1:04 PM on 6/29/2022 related to the COVID-19 outbreak testing initiated on 6/27/2022. In an interview on 7/2/2022 at 12:04 PM, the complainant stated he/she heard on 6/27/2022 on their in-room video surveillance, an off-camera staff member discussing moving residents to different rooms due to COVID-19 in the facility. The complainant stated that no one from the facility had contacted him/her as of yet to notify him/her of COVID-19 in the building. The complainant stated he/she still did not know if it was an isolated case in the staff or the resident population or if it was widespread. In an interview on 7/2/2022 at 3:30 PM, the administrator stated a contracted psychologist had visited 10 residents during the day on 6/27/2022. Later that evening the contracted psychologist felt ill and tested positive at home for COVID-19. The administrator stated the facility was notified on 6/27/2022 of the positive test result and this triggered facility wide testing of all residents and staff on 6/27/2022. None of the 10 residents the contracted psychologist visited exhibited symptoms. No other residents tested positive. One non direct care staff member tested positive; this staff member did not have contact with the psychologist or any residents or other staff. In an interview on 7/2/2022 at 6:15 PM, the DON stated Resident # 1 had been admitted to an offsite hospice facility on 6/27/2022 for unrelieved pain and therefore notification of the responsible parties for Resident # 1 was not required. In an interview on 7/3/2022 at 9:30 AM, the administrator stated all residents are assigned a Guardian Angel from administrative or office staff. The Guardian Angels are expected to make daily rounds on their assigned residents. The Guardian Angels are expected to make all the notifications to their assigned residents' responsible party in the event of a COVID-19 outbreak. The administrator stated that the Activities Director had been tasked to notify all the residents' responsible parties for the COVID-19 outbreak that occurred 6/27/2022. The administrator stated the Guardian Angels did not make the notification for the COVID-19 outbreak that occurred 6/27/2022. Record review of the facility's policy, Coronavirus - COVID-19 dated 6/1/2021 revealed 8.) educate and keep patients, patient responsible parties, employees and vendors updated on COVID 19 findings . Further review of the policy did not address prompt notification of positive COVID-19 in the facility to residents, residents' responsible parties/families. Review of the Texas HHS COVID-19 Response for Nursing Facilities [Version 4.3] dated 06/27/2022 indicated Reporting COVID-19 .CMS also requires NFs to keep all residents and their representatives up to date on the conditions inside the NF, such as when new cases of COVID- 19 occur. Inform residents, their representatives, and families by 5 p.m. the next calendar day following the occurrence of a single confirmed infection of COVID-19 or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. Provide updates weekly, or sooner, when there are new COVID-19 cases, or three or more residents or staff with new-onset of respiratory symptoms. Review of CDC (Centers for Disease Control) accessed on 7/5/2022 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html revealed HCP [health care professionals], residents, and families must be promptly notified about identification of [CONDITION(S)]-CoV-2 [COVID-19] in the facility and maintain ongoing, frequent communication with HCP, residents, and families with updates on the situation and facility actions.

Based on interviews and record reviews, the facility failed to purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of residents deposited with the facility for 1 of 1 facility reviewed for the surety bond, in that: The facility did not have a surety bond that covered all resident accounts with a total balance of $94,912.01. This deficient practice could place residents at risk of their personal funds not being assured. The findings were: Record review of the facility's Surety Bond revealed that it had an application date of 8/1/20 and an effective date of 8/1/20 along with a Rider dated 10/30/20 with an effective date of 10/23/20 for the amount of 80,000. Record review of a surety bond application revealed the bond application, undated, was unsigned and was for a bond amount of $95,000, with an effective date of 01/01/2022. Record review of the facility's list of resident trust funds revealed 35 residents had trust fund accounts which equaled a total of $94,912.01. During an interview on 03/18/2022 at 11:39 a.m., the Administrator stated the facility's current Surety Bond was an application only and that he was currently working on obtaining the necessary signatures from the hospital district. The Administrator stated he had been working to secure the necessary signatures on the application since January 2022. During an interview on 03/18/2022 at 12:05 p.m., the BOM stated the new Surety Bond was effective on 01/01/2022. The BOM, further, stated she was waiting for the signed surety agreement from the hospital district, which the Administrator was currently working on getting the signed document. The BOM stated the purpose of having an active Surety Bond was to protect the residents' funds. The BOM stated the previous Surety Bond with [name of bond company] was no longer active. During an interview on 03/18/2022 at 12:50 p.m., the Administrator stated the purpose of having a Surety Bond was to protect the residents' assets. During an interview on 03/18/2022 at 2:05 p.m., the Administrator stated the facility did not have a facility policy on Surety Bonds.

Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for daily living for 4 of 8 resident bedrooms (Resident #5, #13, #37 and #44) reviewed for maintenance in that: 1. Resident #5 had several broken slats on the window blinds. 2. Resident #13 had several broken slats on the window blinds and the wooden windowsill was cracked. 3. Resident #37 had several broken slats on the window blinds. 4. Resident #44 had several broken slats on the window blinds and a 2 inch by 2 inch wood trim measuring approximately 12 feet long was falling away from the back of the resident's wall behind the bed with several exposed nails. These deficient practices could place residents at risk of living in an unsafe, unclean, uncomfortable environment putting them at risk for a diminished quality of life. The findings included: 1. Record review of Resident #5's face sheet, dated 3/18/22, revealed an admitted [DATE] with diagnoses that included long term use of anticoagulants (blood thinners), [CONDITION(S)] (high cholesterol), depressive disorders, diabetes, pain, hypertension (high blood pressure) and urinary incontinence. Record review of Resident #5's most recent annual MDS assessment, dated 12/8/21, revealed the resident was severely cognitively impaired for daily decision-making skills. During an observation and interview on 3/18/22 at 8:41 a.m., Resident #5 stated she did not know how long she had been living in the facility. Resident #5 nodded her head and confirmed the broken slats on the window blinds in her room bothered her. Resident #5's left window blind was observed with 5 broken slats. During an interview on 3/18/22 at 9:45 a.m., CNA B confirmed Resident #5 had broken slats on the window blinds and stated she believed the slats were broken off by a former resident who discharged the day before. CNA B stated I'm not sure if anybody reported it. I did not report it, to be completely honest. CNA B stated there was a system for reporting the need for repairs by filling out a request in a white binder that was kept at the nurse's station. CNA B stated the broken window blind slats look terrible. 2. Record review of Resident #13's face sheet, dated 3/17/22 revealed an admitted [DATE] with diagnoses that included gout, [CONDITION(S)] (high cholesterol), vitamin deficiency, hypertension (high blood pressure), [CONDITION(S)] (swelling), pain, muscle weakness, kidney disease and chronic obstructive pulmonary disease. Record review of Resident #13's most recent annual MDS assessment, dated 12/28/21 revealed the resident was cognitively intact for daily decision-making skills. During an observation and interview on 3/16/22 at 8:47 a.m., Resident #13 stated she was aware of the broken slats on the window blinds. Resident #13 stated the staff who assisted her would brush up against the blinds causing them to break. Resident #13 stated the blinds had been broken for the past 3 to 4 months. The window blinds revealed 9 broken slats on the left window blind and 2 broken slats on the right window blind. The wooden windowsill on the right window was cracked almost in half. During an interview on 3/16/22 at 9:30 a.m., CNA A stated the broken window blind slats in Resident #13's bedroom had been that way for 2 months. CNA A stated, everybody comes in here, so everybody has seen them, they know they are broken. CNA A stated the MD was in charge of fixing things and had told the MD about the broken blinds. CNA A stated she was also aware of the cracked wooden windowsill in Resident #13's room and had a sharp edge and if somebody doesn't watch it they could get stuck with it. CNA A stated there was a system for reporting the need for repairs by filling out a request in a white binder that was kept at the nurse's station. During an observation and interview on 3/18/22 at 9:58 a.m., the MD confirmed Resident #13's bedroom window blinds had several broken slats and stated the broken wooden windowsill just happened because he did not notice it when he had been in Resident #13's room earlier that morning when he was checking water temperatures. 3. Record review of Resident #37's face sheet, dated 3/18/22 revealed an admitted [DATE] with diagnoses that included [CONDITION(S)] following [CONDITION(S)] disease (brain damage or spinal cord injury that leads to paralysis on one side of the body), depressive disorders, [CONDITION(S)] (high cholesterol) and [CONDITION(S)]. Record review of Resident #37's most recent quarterly MDS assessment, dated 2/11/22 revealed the resident was cognitively intact for daily decision-making skills. During an observation and interview on 3/18/22 at 8:29 a.m., Resident #37 stated she had been in the same room for 7 years and the blinds had always been broken like that. Resident #37 stated, it doesn't bother me only when it's sunny outside and it gets too bright. Maybe that's all they can afford. During an interview on 3/18/22 at 9:37 a.m., CNA A stated the broken window blind slats in Resident #37's room had been broken for at least a few months, it didn't just happen. CNA A stated the MD knew about it, everybody knows. CNA A stated, it looks trashy, it doesn't look appropriate. This is the resident's home, I wouldn't want it in my house, I would fix it. During an interview on 3/18/22 at 10:08 a.m., the MD confirmed there were broken slats on the window blinds in Resident #37's room. The MD did not acknowledge he was aware the slats on the window blinds were broken. 4. Record review of Resident #44's face sheet, dated 3/18/22 revealed an admitted [DATE] with diagnoses that included dementia, pain, [CONDITION(S)] (high cholesterol), anxiety disorder, hypertension (high blood pressure) and heart failure. Record review of Resident #44's most recent quarterly MDS assessment, dated 1/15/22 revealed the resident was cognitively intact for daily decision-making skills. During an observation and interview on 3/18/22 at 8:44 a.m., Resident #44 stated she had been living in the same room for the past 6 months. Resident #44 stated the broken window blind slats didn't look very good and the broken slats had been that way maybe 5 or 6 months. Resident #44's room was observed with 3 broken slats on the left blind and 5 broken slats on the right blind. Resident #44's room was also observed with a wooden trim measuring approximately 2 inches by 2 inches and 8 to 12 feet long pulling away from the wall with nails exposed behind the resident's bed. Resident #44 stated she was not aware of the wood trim falling from behind the bed. During an interview on 3/18/22 at 9:51 a.m., CNA B stated she had personally hung the curtains in Resident #44's room back in November 2021 and had not noticed the broken window blind slats. CNA B stated she had not noticed the wood trim falling off the wall from behind Resident #44's bed and stated, that is not safe because the board has exposed nails on it and we need to write that on the maintenance book. During an interview on 3/18/22 at 10:11 a.m., the MD stated he was not aware of the wooden trim falling off the wall in Resident #44's room. The MD stated the wooden trimmed appeared to be at least 12 feet long and the nails exposed was a safety hazard. The MD stated there was a system for reporting maintenance issues/repairs by filling out a request in a white binder that was kept at the nurse's station. The MD stated he looked in the maintenance log every time I walk by the nurse's station. Record review on 3/18/22 at 10:11 a.m., with the MD of the white binder identified as the Maintenance Log, kept at the nurse's station, revealed several entries by facility staff with request for repairs. The log revealed entries with a large check mark and the MD's initials which indicated the repair had been completed. There were no entries for request for repairs for Resident #5, #13, #37 or #44. During an interview on 3/18/22 at 10:15 a.m., the Administrator stated, the resident's rooms should be homelike. We know it was a concern and we're stuck in the middle of a transition. We know that it would be pointless to do a lot of aesthetic changes knowing that it is all going to be changed April 22 by the new owners. Residents and families have not complained.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Main Kitchen), in that: 1. There was an opened container of eclairs in the reach-in freezer not dated 2. There was a one, opened, bag of biscuit mix, one, opened, bag of gravy mix and one, opened, bottle of red food coloring in the dry goods area not dated. These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness. The findings were: 1. During an observation and interview on 03/15/ at 11:12 a.m. revealed one opened container of eclairs was in the reach in freezer with no date on it. The DM confirmed the eclairs should be dated with the opened date. 2. During an observation and interview on 03/15/ at 11:15 a.m. revealed one opened bag of biscuit gravy mix, one opened brown gravy mix and one opened bottle of red food coloring was in the dry storage area with no date on it. The DM confirmed both dry gravy mixes and the red food coloring should be dated with the opened date. Record review of the facility's policy, Food Storage, revised 03/2019, revealed Sufficient storage facilities are provided to keep foods, safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designated to prevent contamination. [ .] 15. Refrigeration . e. all foods should be covered, labeled and dated . 16 Frozen Foods . c. Foods should be covered, labeled, and dated. Record review of the Texas Food Establishment Rules (TFER), October 2015, §228.75(f)(1)(a) revealed: Refrigerated, ready-to-eat, time/temperature controlled for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and held at a temperature of 41 degrees Fahrenheit or less if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises A) the day the original container is opened in the food establishment shall be counted as Day 1 (I) A food specified in subsection (g) (1) or (2) of this section shall be discarded if it (B) is in a container or package that does not bear a date or day, or (C) is appropriately marked with a date or day that exceeds a temperature and time combination as specified in subsection (g) (1) of this subsection.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen, in that: The steam table in the kitchen was missing three of the five temperature knobs This deficient practice could place residents who ate meals/snacks from the kitchen at-risk for injury. The findings were: Observation on 03/17/2022 at 11:31 a.m., of the kitchen revealed the steam table had three of the five temperature knobs missing. During an observation and interview on 03/17/2022 at 11:32 a.m., the DM confirmed the missing knobs to adjust temperature on the steam table. The DM stated he started at this facility in January 2022 and the knobs were missing at that time. The DM also stated with not knowing what the temperature was set at the residents could be harmed from the food being too hot. During an observation and interview on 03/17/2022 at 11:45 a.m., the RD stated he did a sanitation audit in the beginning of the month and mentioned the missing knobs on this report. The RD further stated this audit report was given to several of the department head of the facility. During an interview on 03/17/2022 at 3:35 p.m., the MD confirmed he was aware of the missing knobs on the steam table in the facility kitchen. The MD further stated he was aware of it as of the week prior. The MD continued to state there was no work order to fix the steam table knobs because he had other priorities with residents on the hallways. The MD stated he was not responsible for doing equipment checks in the facility and the DM was responsible for letting him know when equipment in the kitchen needs to be fixed. The MD also stated the potential harm was the dietary staff would have a hard time adjusting the temperature on the steam table as a result of the missing knobs. During an interview on 03/17/2022 at 6:27 p.m., the DON was not able to answer what the potential harm was to residents due to the missing knobs on the steam table. The DON confirmed she received the sanitation audit report but only reads the recommendations regarding the nursing department. During an interview on 03/17/2022 at 6:46 p.m., the Administrator confirmed he was aware of the missing knobs on the steam table. The Administrator also confirmed there was not a work order to fix the steam table, however he further stated he had ordered the knobs earlier that same day on Amazon. The Administrator stated the DM was responsible for telling the MD when equipment in the kitchen needs repaired. The Administrator stated there should not be any potential harm to residents if the dietary staff completed their regular temperature checks on the cooked food. Record review of the facility's policy, Environmental/Safety Monitoring,, dated 11/2016, revealed no mention of kitchen equipment. Record review of the facility's job description for the MD, dated 01/2017, revealed, the overall purpose of the Maintenance Supervisor position is to plan, direct and control the overall maintenance of the facility's physical plant. This position must perform or oversee electrical, plumbing, carpentry, heating, ventilation, air conditioning, refrigeration and other technical tasks, as well as ensuring compliance with all local, state, and federal life-safety code regulations. Further record review revealed, . Maintains a basic preventative maintenance schedule . Identifies and corrects safety hazards . Responsible for assuring patient/resident safety . Perform other duties and tasks as assigned.

Based on observation and interview, the facility failed to promote and facilitate resident self-determination through support of resident choice for 1 of 14 residents (Resident #13) reviewed for bathing preferences, in that: The facility denied Resident #13's request to take morning showers. This failure could affect residents at risk of not being able to make choices about aspects of his or her life in the facility that were significant to the resident. Findings include: Record review of Resident #13's face sheet, dated 3/17/22, revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #13's most recent Annual MDS, dated [DATE], revealed the resident was cognitively intact for daily decision-making skills and required one-person physical assist with bathing. During an interview on 3/16/22 at 8:35 a.m., Resident #13 stated she had lived in the facility for over a year and had been receiving morning showers. Resident #13 stated the shower schedule had changed recently, could not determine how long ago, and stated the even numbered rooms on the A Hall, where she resided, were scheduled for evening showers and the residents on the odd numbered side of the A Hall were scheduled for morning showers. Resident #13 stated she had complained to facility staff about the change and was told by, a CNA, that the DON had made the changes to the shower schedules and Resident #13 could not change back to the morning shower schedule per the DON. Resident #13 stated she had not talked to the DON about the shower schedule but had voiced her complaint to the Administrator. Resident #13 stated the administrator told her he, could not do anything about it, only the DON. Resident #13 stated, a CNA, told her, if you want to get morning showers I would have to move to the other side of the hall and I don't want to move to the other side of the hall, I've been in this room for about 6 months, and I don't want to move. During an interview on 3/17/22 at 9:40 a.m., CNA G stated the shower schedule on the A Hall had recently changed, 2 to 3 weeks ago, by the DON. CNA G stated the resident on the even numbered rooms of the A Hall were scheduled to shower in the evenings and the residents on the odd numbered rooms of the A Hall were scheduled to shower in the morning. CNA G stated Resident #13 had complained about the shower schedule change and stated Resident #13 liked to taker her showers in the morning. CNA G stated she told Resident #13, I'm sorry, but if you want to change your shower schedule to mornings you would have to talk to the DON. CNA G stated there was no shortage of staff, so the change was not made for that reason. CNA G stated she did not know why the shower schedule was changed. During an interview on 3/17/22 at 4:03 p.m., CNA F stated the shower schedule on the A hall had recently changed. CNA F stated residents on the even numbered side of the A hall were scheduled to shower in the evenings and the residents on the odd numbered rooms of the A hall were scheduled to shower in the morning. CNA F stated, I don't know who really changed the schedule, but I know the DON had a say so about it. Don't exactly know what went down with that. CNA F stated he had heard Resident #13 had complained about the shower schedule change, but the resident had not complained to him and only heard it through the grape vine. CNA F stated he was aware Resident #13 preferred to take a shower in the mornings and the resident had a right to choose when they wanted to take a shower. During an interview on 3/17/22 at 5:24 p.m., CNA E stated the shower schedule on the A hall had recently changed the beginning of March 2022. CNA E stated residents on the even numbered side of the A Hall were scheduled to shower in the evenings and the residents on the odd numbered rooms of the A hall were scheduled to shower in the morning. CNA E stated the shower schedule was changed because, there were complaints by residents about not getting baths and the staff were telling the nurses residents were refusing. It got that one resident was refusing so much that they had to change it. CNA E stated Resident #13 complained about showering in the evening and told CNA E, I'm not a night shower, I'm a morning shower. CNA E stated she told Resident #13 she could not change her shower time without the DON. CNA E stated she believed Resident #13 had a right to choose when she wanted to take her shower. During an interview on 3/17/22 at 6:17 p.m., the DON stated the shower schedule was changed on the A hall recently due to staff not keeping up with showers. The DON stated she heard about, a resident, complaint about the shower schedule change the day after during the morning meeting. The DON stated she had not personally heard from any of the residents complain about the shower schedule change. The DON stated the shower schedule change was not due to staff shortages but, it was easier to keep up for the staff and the nurses to know who would need to be showered. We obviously can't do 100% showers in the morning. The DON stated it was the resident's right to shower whenever they wanted to. During an interview on 3/17/22 at 6:59 p.m., the Administrator stated Resident #13 had complained to him about the recent shower schedule change and stated Resident #13 had been getting showers in the morning. The Administrator stated, I'm all about resident rights, but if all 40 residents wanted to have a shower in the morning it would be difficult to do it. Record review of the facility's policy, Statement of Patient's Rights, undated, revealed in part, .The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section .(e) Respect and dignity. The resident has a right to be treated with respect and dignity, including: (3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents .(f) Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice .

Based on interview and record review, the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 1 of 5 residents (Resident #20) whose assessments were reviewed in that: Resident #20's most recent annual MDS assessment did not accurately reflect the resident was PASRR (Pre-admission Screening and Resident Review) positive. This failure could place residents at risk for not receiving the appropriate care and services. The findings included: Record review of Resident #20's face sheet, dated 3/18/22 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #20's PASRR Level 1, completed on 4/1/18 revealed the Resident was triggered for Developmental Disability. Record review of Resident #20's PASRR Comprehensive Service Plan Form, dated 1/12/22 revealed the resident was PASRR positive for IDD (Intellectual and Developmental Disabilities.) Record review of Resident #20's most recent comprehensive MDS assessment, dated 9/26/21, under Section A1510, Level 2 PASRR conditions revealed the section was left blank and the resident was not identified as PASRR positive. During an interview on 3/17/22 at 6:02 p.m., the DON confirmed Resident #20 was identified as PASRR positive due to IDD status and the comprehensive MDS assessment did not reflect the resident's PASRR status. The DON stated she was not sure who exactly was responsible for that section of the comprehensive MDS assessment and further stated the facility just hired a new MDS coordinator but would not be starting until 3/21/22. The DON stated, it was just a data entry error and Resident #20 was receiving services. Record review of the facility's policy, Comprehensive Assessments and the Care Delivery Process, revision date 12/2016, revealed in part, .Comprehensive assessments will be conducted to assist in developing person-centered care plans .1. Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions .2. Assessment and information collection includes .a. Assess the individual. (1) Gather relevant information from multiple sources, including .c) symptom or condition-related assessments .f) consultant report .h) evaluations from other disciplines .

Based on record review and interview, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 1 resident (Resident # 101) reviewed for baseline care plans. The facility did not develop a baseline care plan within 48 hours of Resident #101's admission. This deficient practice could affect newly admitted residents and could result in residents not receiving the necessary care and services needed. The findings were: Record review of Resident #101's face sheet, dated 3/17/22 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #101's baseline care plan revealed a completion date of 3/16/22. During an interview on 3/17/22 at 5:47 p.m., the DON stated Resident #101's baseline care plan should have been completed within 24 to 48 hours from admission. The DON confirmed the baseline care plan for Resident #101 showed it was 6 days late. The DON stated the facility had recently converted to electronic records starting 12/31/21 and could not determine if the baseline care plan was initiated at the time of admission. The DON stated the admitting nurse was responsible for the baseline care plan. Record review of the facility's policy, Care Plans - Baseline, revision date 12/2016, revealed in part, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident withing forty-eight (48) hours of admission .1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission .