Every finding on record at San Jose Nursing Center

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 3 of 12 residents (Resident #1, #21, and #37) reviewed for accuracy of records:1. The facility failed to document in Resident #1's treatment records the use of heel protectors at bedtime every evening shift per physician's orders for April 2026 on 4/9/26, and 4/14 - 4/30/2026, and the entire month of May 2026.2. The facility failed to document the diagnoses for use of antipsychotic medications on Resident #21's admission sheet.3. The facility failed to correctly transcribe a portion of the name of one medication to Resident #37's June 2026 MAR.These failures could affect residents whose records were maintained by the facility and could place the residents at risk of errors in care and treatment. The findings included: 1. Record review of Resident #1's face sheet dated 6/24/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, mental disorders due to known physiological condition (a mental or behavioral disturbance caused by a medical condition affecting the body or brain), seizures (episodes of abnormal, sudden electrical activity in the brain that temporarily disrupt normal brain function), and autistic disorder (a developmental condition that affects how a person communicates, interacts with others, learns and behaves). Record review of Resident #1's most recent comprehensive MDS assessment dated [DATE] reflected the resident was severely cognitively impaired for daily decision-making skills, was dependent on staff for mobility and ADLs care and was at risk of developing pressure ulcers/injuries. Record review of Resident #1's Physician Orders for June 2026 reflected the following: - Heel protectors at bedtime every evening shift with order date 4/9/26 and no end date Record review of Resident #1's Treatment Administration Records reflected there was missing documentation on the April 2026 record on 4/9/26, and 4/14/26 – 4/30/26, and no documentation for the entire month of May 2026 for Resident #1's use of the heel protectors. Record review of Resident #1's comprehensive care plan dated 4/10/26 and revised on 6/10/26 reflected the resident had a skin problem and had 2 unstageable pressure ulcers (a pressure injury in which the extent of tissue damage cannot be determined because the wound bed is unobscured by slough [dead tissue that is soft and stringy] and eschar [dead tissue that is thick or leathery]) on the right and left hip, 2 unstageable boils on the back and 2 Stage 2 pressure ulcers (partial-thickness loss of skin with exposed dermis [the thick layer of skin located beneath the outer layer of skin]) on the shoulders, and 1 Stage 3 pressure ulcer (full-thickness loss of skin) on the foot. Resident #1's care plan reflected the wounds mentioned above were healed on 6/10/26 and the care area had a line marked across it. Resident #1's care plan did not include the resident used heel protectors. During an interview on 6/24/26 at 9:54 a.m., the LVN Treatment Nurse stated Resident #1 had several wounds that had recently deemed resolved/healed and interventions to prevent the resident from re-developing wounds included turning and repositioning and heel protectors. The LVN Treatment Nurse stated Resident #1 was supposed to be wearing heel protectors while in bed and should continue to use them otherwise he could develop another sore. During an interview on 6/25/26 at 5:03 p.m., the DON stated, missing documentation on the treatment records was a problem and there was no excuse for that. The DON stated she believed the staff were ensuring Resident #1 was provided the heel protectors based on the wounds had been resolved/healed, but staff just weren't documenting it. 2. Record review of Resident #21's admission sheet dated 12/06/2024, documented a [AGE] year-old male resident with diagnoses including hypertension (high blood pressure), seizure disorder, cognitive communication deficit, and traumatic brain injury. Record review of Resident # 21's MDS dated [DATE] documented a BIMS score of 11 indicating moderate cognitive impairment and recorded the use of antipsychotic, antianxiety, anticoagulant, diuretic, and anticonvulsant medications. Record review of Resident #21's order summary included orders for Rexulti with an order date of 11/26/2025, Aristada with a start date of 8/14/2025, and Haldol with an order date of 6/07/2026. Rexulti was ordered as Rexulti 4 mg, give 1 tab po daily DX: schizoaffective bipolar type. Aristada was ordered as Aristada, 882 mg IM monthly DX: bipolar disorder. Haldol was ordered as Haldol 5 mg, give 5 mg po Q6H prn DX: bipolar disorder. Record review of Resident #21's care plan with an initiation date of 12/05/2024, did not document the resident was treated with an antipsychotic medication. 3. Record review of Resident #37's admission sheet dated 1/04/2018 with a re-admission date of 9/10/2022 documented a [AGE] year-old female resident with diagnoses including schizophrenia, Parkinson's disease, dementia, seizure disorder/convulsions, hallucinations, and delusional disorder. Record review of Resident #37's MDS dated [DATE] documented a BIMS should not be conducted due to the resident is rarely/never understood. Further review of the MDS recorded the use of antianxiety and anticonvulsant medications. Record review of Resident #37's care plan with an initiation date of 01/12/2022 documented the resident had Seizures Potential for Injury related to history of seizures ., with a goal of Resident will have no injuries due to seizures. Record review of Resident #37's order summary included an order for the anticonvulsant medication Keppra solution with an order date of 6/18/2026. Keppra was ordered as Keppra 100 mg/mL, give 10ML PGT 2X DAILY. Record review of Resident #37's June 2026 MAR revealed Keppra had been handwritten on the MAR as Keppra 100 mg/5 mL give 10 mL = 1000 mg pgt B.I.D. 06/18/26. During an interview with LVN B on 6/25/2026 at 8:30 AM, LVN B stated she had written part of the name of Resident #37's medication order incorrectly on the MAR but would clarify what she had written down with the doctor's order. LVN B stated she always gave the resident 10 mL of medication to equal 1000 mg according to the directions on the pharmacy label on the medication and the directions on the MAR which matched the directions on the doctor's order. LVN B compared what she had written on the MAR with the doctor's order and updated the name of the medication written on the MAR to reflect the doctor's order of Keppra 100 mg/mL, give 10 mL pgt twice daily. LVN B stated it was important for handwritten orders on the MAR to match the label on the medication bottle and the doctor's order, because if they were giving medication incorrectly there could be an adverse effect. During an interview on 6/25/26 at 5:03 p.m., the DON stated missing documentation on the resident and treatment records was a problem and there was no excuse for that. The DON stated orders on the MAR should match the facility order summary, the medication label from the pharmacy, and the original doctor's order to make sure they were giving the right medication and the correct dose. The DON believed Resident #37 received the correct dose of medication based on there being only one strength of Keppra solution on the market and the directions for use matched the directions on the doctor's orders. Record review of the facility document titled, Operational Policy and Procedure Manual, Medical Records, undated reflected in part, .The purpose of charting and documentation is to provide.A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care.Rules for Charting and Documentation.Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc., as well as routine observations. Treatments.Documentation pertaining to treatments should include.Date and time each treatment administered.Name of person administering the treatment.Specific duties performed.Reason(s) for a resident's refusal of the treatment.Signature and title of person recording data.

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 reviewed for food safety requirements.1. The facility failed to label and date half a tomato wrapped in clear wrap in the reach in refrigerator; the Dietary Supervisor's hair was not completely covered by a hair restraint, and the facility failed to provide a readily accessible hands-free covered trash receptacle in the kitchen. Kitchen staff were required to touch the trash can lid to dispose of waste.2. The facility failed to label and date two bundles of green leaf lettuce wrapped in plastic, one opened gallon container of milk, and one bin of tomatoes, bell peppers, and celery stored in the refrigerator; and failed to hold the pureed broccoli at the minimum safe food holding temperature.These failures could place residents at risk for spread of infections, food contaminations, food-borne illnesses, and diminished quality of life. The findings included: 1. During an observation and interview on 6/23/26 at 9:06 a.m., during an initial inspection of the facility kitchen, a tomato cut in half and wrapped in clear wrap was observed in the reach in refrigerator. The cut tomato was unlabeled and undated. The Dietary Supervisor stated the tomato in the reach in refrigerator was supposed to be labeled and dated to help determine when it would expire. The Dietary Supervisor stated the cut tomato could not be in the refrigerator for more than 3 days and if it could not be determined how long the item had been in the refrigerator and if a resident ate it, they could get sick. The Dietary Supervisor wore a hair restraint in a manner that the hair on the forehead was not covered by the hair restraint. The Dietary Supervisor stated, the hair restraint should cover all her hair, including the hair on her forehead to prevent hair from falling on the food, or anything that was in the kitchen. A large metal trash can with a detachable lid used to dispose of waste was observed in the kitchen. The Dietary Supervisor stated the trash can was used to dispose of used paper towels after the staff washed their hands in the sink. The Dietary Supervisor stated touching the trash can lid after washing your hands was cross contamination because the trash can lid was dirty because other staff touched the lid. The Dietary Supervisor stated, it's like you really didn't clean your hands. The Dietary Supervisor stated the kitchen staff had used the same metal trash bin for a long time. During an interview on 6/24/26 at 9:13 a.m., the Administrator stated he purchased a new hands-free trash receptacle for the kitchen because if staff touched the metal trash can with a detachable lid, after staff washed their hands, it was considered cross contamination which could result in a resident getting sick due to contamination. 2. During an interview with the Administrator on 6/24/2026 at 4:41 PM, the Administrator stated all food items stored in the kitchen should 2. During an observation of the facility kitchen on 6/24/2026 at 2:44 PM, two bundles of green leaf lettuce wrapped in plastic wrap were stored in the refrigerator with no date, one opened gallon container of milk was stored in the refrigerator with no opened date, and one bin of tomatoes, bell peppers and celery was stored in the refrigerator with no date. During an interview with [NAME] A on 6/24/2026 at 2:56 PM, [NAME] A stated the undated items should have been dated. [NAME] A stated they were supposed to date items after opening or repackaging them so they would know when they were acquired and when they would go bad. [NAME] A stated if residents ate food that had gone bad, they could get sick. During an interview with the Dietary Supervisor on 6/24/2026 at 3:02 PM, the Dietary Supervisor stated items in the refrigerator should be dated when opened or repackaged because the items could go bad and not be safe to eat. The Dietary Supervisor stated residents could get sick if they ate spoiled food. be dated, because after 24 or 48 hours it must be thrown away. The Administrator stated undated items should not be given to the residents, because if they were outdated residents could experience gastrointestinal effects. During an observation of the facility kitchen on 6/25/2026 at 11:34 AM the pureed broccoli for the lunch service was held at 130 degrees. During an interview with [NAME] C on 6/25/2026 at 11:39 AM, [NAME] C stated the minimum holding temper for the pureed broccoli should have been 155 degrees. [NAME] C stated if foods were not held to the proper holding temperature, they could become contaminated with bacteria and be dangerous for the residents to consume. During an interview with the DON on 6/25/2026 at 5:02 PM, the DON stated she expected for all prepared foods to be held at the proper temperature before serving. The DON stated it was important for foods to be held at the appropriate temperature to prevent bacteria growth which could cause digestive problems for the residents. Record review of the facility document titled Temperature Mini-Poster, revised 2002, noted Keep Hot Foods Hot 140 degrees . Record review of the facility document titled Storage of Food and Chemicals, undated reflected in part, .Storage of Food.ALL food items must be COVERED, LABELLED, and DATED. Record review of the facility document titled Food Service Hygiene, undated reflected in part, .Employees.Food service personnel must be in good health and practice good hygienic food-handling techniques.Employees must meet acceptable standards of personal hygiene and appearance.Hair clean and worn in manner that it can be completely covered by hair restraint.Storage.All items are labeled and dated before storing.Handling.Foods are held at temperatures below 40 degrees or above 140 degrees except for intervals when food is being prepared.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 12 residents (Resident #1, #19, #21, and #25) reviewed for care plans:1. The facility failed to ensure Resident #1's care plan reflected the resident was at risk for pressure ulcers and used heel protectors.2. The facility failed to ensure Resident #19's care plan reflected the resident was treated with antipsychotic medications.3. The facility failed to ensure Resident #21's care plan reflected the resident was treated with antipsychotic medications.4. The facility failed to ensure Resident #25's care plan reflected the resident was treated with antipsychotic medications.These deficient practices could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. The findings included: 1. Record review of Resident #1's face sheet dated 6/24/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, mental disorders due to known physiological condition (a mental or behavioral disturbance caused by a medical condition affecting the body or brain), seizures (episodes of abnormal, sudden electrical activity in the brain that temporarily disrupt normal brain function), and autistic disorder (a developmental condition that affects how a person communicates, interacts with others, learns and behaves). Record review of Resident #1's most recent comprehensive MDS assessment dated [DATE] reflected the resident was severely cognitively impaired for daily decision-making skills, was dependent on staff for mobility and ADLs care and was at risk of developing pressure ulcers/injuries. Record review of Resident #1's Physician Orders for June 2026 reflected the following: - Heel protectors at bedtime every evening shift with order date 4/9/26 and no end date Record review of Resident #1's comprehensive care plan dated 4/10/26 and revised on 6/10/26 reflected the resident had a skin problem and had 2 unstageable pressure ulcers (a pressure injury in which the extent of tissue damage cannot be determined because the wound bed is unobscured by slough [dead tissue that is soft and stringy] and eschar [dead tissue that is thick or leathery]) on the right and left hips, 2 unstageable boils on the back and 2 Stage 2 pressure ulcers (partial-thickness loss of skin with exposed dermis [the thick layer of skin located beneath the outer layer of skin]) on the shoulders, and 1 Stage 3 pressure ulcer (full-thickness loss of skin) on the foot. Resident #1's care plan reflected the wounds mentioned above were healed on 6/10/26 and the care area had a line marked across it. Resident #1's care plan did not include the resident used heel protectors. During an interview on 6/24/26 at 8:48 a.m., the DON stated she was responsible for developing the residents' care plans and the MDS. The DON stated, Resident #1 admitted with pressure sores, but all the wounds were healed. The DON stated Resident #1 was still considered at risk for pressure injuries related to his immobility and was not sure if the resident continued to use heel protectors. The DON stated that heel protectors were used to relieve pressure on the feet and used as a preventative. During an observation and interview on 6/24/26 at 8:17 a.m., Resident #1 was observed sitting up in bed and was being assisted with feeding by CNA E. Resident #1 was observed with the heel protectors resting on the foot of the bed but not wearing them. Resident #1 had a handwritten note posted on the wall next to the resident's bed that indicted, Bunny boots (heel protectors) on at all times. CNA E stated she believed Resident #1 was supposed to always have heel protectors on but was not sure. CNA E stated she did not know why Resident #1 had to wear the heel protectors but believed he needed them due to bedsores. During an interview on 6/24/26 at 9:54 a.m., the LVN Treatment Nurse stated Resident #1 had several wounds that had recently deemed resolved/healed and interventions to prevent the resident from re-developing wounds included turning and repositioning and heel protectors. The LVN Treatment Nurse stated Resident #1 was supposed to be wearing heel protectors while in bed and should continue to use them otherwise he could develop another sore. During an interview on 6/25/26 at 11:30 a.m., the ADON stated Resident #1 had several wounds on admission and heel protectors were used at the time. The ADON stated Resident #1 no longer had wounds and heel protectors were no longer required. The ADON stated the resident care plans were developed by the IDT (inter disciplinary team) and the DON revised and updated the care plans as needed. The ADON stated, Resident #1's use of heel protectors should be care planned because the care plan was what the staff used to rely on how to take care of the resident and included any orders by the doctor. During a follow up interview and record review on 6/25/26 at 2:41 p.m., the DON stated she had completed a significant change MDS for Resident #1 that indicated the resident no longer had wounds. The DON stated, Resident #1's MDS would continue to trigger risk for pressure ulcers and revised the care plan to include the resident was supposed to wear heel protectors while in the bed and the resident often refused to wear them. The DON presented the revised care plan dated 6/25/26 and the DON stated the significant change MDS was completed on 6/23/26. 2. Record review of Resident #19's admission sheet dated 8/22/2025 documented a [AGE] year-old male resident with diagnoses including type 2 diabetes mellitus, unspecified signs and symptoms involving cognitive function, hyperlipidemia (high cholesterol), and Alzheimer's disease. Record review of Resident #19's MDS dated [DATE] documented a BIMS score of 0 indicating severe cognitive impairment, and recorded the use of antipsychotic and hypoglycemic medications. Record review of Resident #19's order summary included an order for Abilify with an order date of 5/15/2026. Abilify was ordered as Abilify 2 mg, give 2 mg po daily, DX: Unspecified signs and symptoms involving cognitive functions/aware. Record review of Resident #19's care plan with an initiation date of 9/09/2025, did not document the resident was treated with an antipsychotic medication. 3. Record review of Resident #21's admission sheet dated 12/06/2024, documented a [AGE] year-old male resident with diagnoses including hypertension (high blood pressure), seizure disorder, cognitive communication deficit, and traumatic brain injury. Record review of Resident # 21's MDS dated [DATE] documented a BIMS score of 11 indicating moderate cognitive impairment and recorded the use of antipsychotic, antianxiety, anticoagulant, diuretic, and anticonvulsant medications. Record review of Resident #21's order summary included orders for Rexulti with an order date of 11/26/2025, Aristada with a start date of 8/14/2025, and Haldol with an order date of 6/07/2026. Rexulti was ordered as Rexulti 4 mg, give 1 tab po daily DX: schizoaffective bipolar type. Aristada was ordered as Aristada, 882 mg IM monthly. Haldol was ordered as Haldol 5 mg, give 5 mg po Q6H prn DX: Bipolar Disorder. Record review of Resident #21's care plan with an initiation date of 12/05/2024, did not document the resident was treated with an antipsychotic medication. 4. Record review of Resident #25's face sheet undated reflected a [AGE] year-old female admitted into the facility on 6/20/19 with diagnoses that included hypertension (high blood pressure), diabetes (condition where the body has trouble controlling the amount of sugar in the blood), Vitamin D deficiency, and dementia (general term for a decline in memory, thinking, and reasoning abilities that is severe enough to interfere with a person's daily life and independence) with behavioral disturbances. Record review of Resident #25's most recent quarterly MDS assessment dated [DATE] reflected the resident was severely cognitively impaired for daily decision-making skills and was treated with antipsychotic medications. Record review of Resident #25's comprehensive care plan with revision dated 5/20/26 did not reflect that the resident was treated with an antipsychotic medication. Record review of Resident #25's Physicians Orders for June 2026 reflected the following: - ABH Gel 1MG/25MG/1MG cream, apply 1ML to skin topically as needed every 6 hours for anxiety/agitation with order date 3/18/26 and no end date Record review of Resident #25's Medication Administration Record and Treatment Administration Record for June 2026 reflected the resident was treated with ABH cream on 6/17/26. During an interview on 6/25/26 at 5:03 p.m., the DON stated Resident #25 had an active physician's order for the use of ABH, and since ABH was considered an antipsychotic because it contained Haldol, it should have been care-planned because the medication had side effects and the staff should be aware of that and what interventions should be in place for monitoring side effects. Record review of the facility document titled Comprehensive Care Plans, undated reflected the following, .A facility must develop a comprehensive care plan for each resident that includes measurable short-term and long-term objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.The comprehensive care plan must describe the following.the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being as required.and.any services that would otherwise be required.but are not provided due to the resident's exercise of rights, including the right to refuse treatment.The comprehensive care plan must be.developed within seven days after completion of the comprehensive assessment.periodically reviewed and revised by a team of qualified persons after each assessment.

Based on observation, interview, and record review, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 3 carts (west ramp medication aide cart) reviewed for pharmacy services. The facility failed to ensure the controlled substance reconciliation log was signed for accuracy of medication quantities during shift change. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain and anxiety, and a decreased quality of life.The findings included: During an observation of the west ramp medication aide cart on 6/26/2026 at 9:00 AM, the controlled medication reconciliation log revealed 17 signatures were missing from the log between 6/01/2026 and 6/26/2026. During an interview with Med Aide D on 6/26/2026 at 9:06 AM, Med Aide D stated it was important to conduct the audit and sign the reconciliation log at every shift change. Med Aide D stated it was important for the log to be signed to ensure medications are available for the residents. Med Aide D stated if the log is not signed at shift change, the medication audit could be inaccurate. Med Aide D stated if medications were missing, residents could receive a medication they were not prescribed and experience adverse effects or untreated pain if their prescribed medication was unavailable. During an interview with the DON on 6/26/2026 at 9:40 AM, the DON stated, the controlled medication reconciliation log should be signed off at every cart exchange. The DON stated her expectation for staff was to sign the log at every audit to make sure both staff members agreed to the amount of medication left in the cart. The DON stated if the log was not signed each time, and the count was inaccurate, it could indicate a medication might not have been given. The DON stated if a resident's medication was not available it could affect the resident mentally or physiologically. Record review of the facility policy titled Policy for Control Drug-Count Record, undated, noted Nurses must sign the control drugs-count record sheet at the end of every shift with the incoming nurse to acknowledge that they have counted the control drugs on hand and have found that the quantity of each mediation counted is in agreement with the quantity stated on the controlled drug administration record.

Based on observation, interview and record review the facility failed to post the nurse staffing data daily at the beginning of each shift for 1 of 4 days (6/26/26) reviewed for nursing staffing:The daily posted nurse staffing data had the previous day's nurse staffing data for 6/25/26, instead of the 6/26/26 nurse staffing data. This deficient practice could affect all residents and could result in residents and visitors being unaware of staffing levels in the facility.The findings included:Observation on 6/26/26 at 10:18 a.m. reflected the Daily Nursing Staff Hours posted in front of the nurse's station revealed the daily nursing staff hours from the previous day, 6/25/26 instead of the current day 6/26/26.During an interview on 6/26/26 at 10:20 a.m., RN G stated she started her shift on 6/26/26 at 6:00 a.m. and she was responsible for ensuring the current nursing staff hours were posted on the wall. RN G stated it was important to post the current nursing staff hours because it showed how many nurses were working the floor and the current census. During an interview on 6/26/26 at 10:24 a.m., the DON stated the nursing staff hours were supposed to be updated daily so the residents and family members could see how many nurses were working at any given time.Record review of the facility document titled Policy for Daily Nursing Staffing Sign, undated reflected in part, .The daily staffing sign must be posted on a prominent location by the 6-2 nurse on a daily basis. This sign will include the number of nurses (RN, and LVN), CNAs, Medication Aides and Restorative Aides on duty every shift, as well as the total number of hours they work.

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 residents reviewed for dignity.The facility failed to ensure CNA E did not feed Resident #1 while standing over him.This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.The findings included:Record review of Resident #1's face sheet dated 6/24/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, mental disorders due to known physiological condition (a mental or behavioral disturbance caused by a medical condition affecting the body or brain), seizures (episodes of abnormal, sudden electrical activity in the brain that temporarily disrupt normal brain function), and autistic disorder (a developmental condition that affects how a person communicates, interacts with others, learns and behaves).Record review of Resident #1's most recent comprehensive MDS assessment dated [DATE] reflected the resident was severely cognitively impaired for daily decision-making skills and was dependent on staff for feeding.Record review of Resident #1's comprehensive care plan dated 4/10/26 reflected the resident had a self-care deficit and was fed by staff related to being incapable of holding utensils, comprehending utensil use, leaving food uneaten if not assisted, unable to communicate food preferences, and the potential for weight loss. Resident #1's comprehensive care plan had interventions that included assisting the resident with eating.During an observation and interview on 6/24/26 at 8:17 a.m., Resident #1 was observed sitting up in bed and assisted by CNA E. CNA E was observed standing at the bedside providing Resident #1 with a beverage. CNA E stated she was helping Resident #1 with eating and was supposed to be sitting at eye level with the resident. CNA E pointed to a metal chair folded up on the opposite side of Resident #1's room and stated, she had been feeding the resident while sitting before the State Surveyor entered the resident's room but was done feeding the resident and wanted to offer him a beverage. CNA E stated the reason she should have been sitting when assisting Resident #1 was because it was more dignified than standing over him. CNA E stated, I felt like I was done feeding him (Resident #1) and I just wanted to give him a little more of the fluids.During an interview on 6/24/26 at 3:27 p.m., CNA F stated Resident #1 required staff assistance when feeding. CNA F stated, when feeding Resident #1 while in the bed, we should be standing. I always stand to make sure the resident was swallowing his food or in case something happens such as choking. CNA F stated, if a resident who required assistance with feeding was eating in the dining room she would sometimes sit but she felt more comfortable standing. CNA F stated she had heard of feeding residents at eye level which meant sitting while assisting but did not know why that was important.During an interview on 6/25/26 at 2:41 p.m., the DON stated, Resident #1 required total care, including assistance with feeding. The DON stated her expectation was when a resident was assisted with feeding, the staff should be sitting at eye level with the resident because we want the resident to feel comfortable when they are being fed.Record review of the facility's document titled Resident Rights dated April 2008 reflected in part, .Dignity and Respect.You have the right to.be treated with dignity, courtesy, consideration, and respect.Participation in your care.You have the right to.receive all care necessary to have the highest possible level of health.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 6 residents (Resident #17) reviewed for accidents and hazards:The facility failed to ensure Resident #17 did not have disposable razors, a pair of scissors, a can of air freshener, and a one-pound container of disinfectant wipes in her room.These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.The findings included:Record review of Resident #17's face sheet dated 12/4/25 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included severe cognitive impairment and severe intellectual disabilities.Record review of Resident #17's most current quarterly MDS assessment dated [DATE] reflected the resident was visually impaired and was able to see large print, but not regular print such as in newspapers/books, wore corrective lenses, and was cognitively intact for daily decision-making skills.Record review of Resident #17's comprehensive care plan dated 8/23/23 reflected that the resident had a cognitive deficit and impaired decision-making skills related to severe intellectual disabilities with interventions that included to provide a calm, therapeutic environment and structured routine, and avoid changes in the resident's environment.During an observation on 6/23/26 at 10:20 a.m. Resident 17's bedroom revealed a can of aerosol air freshener placed on top of a personal refrigerator and a disposable razor in a plastic bin with toiletries on the resident's nightstand.During an observation and interview on 6/24/26 at 7:59 a.m. Resident #17 was observed sitting up in bed eating breakfast. Resident #17 stated the disposable razors in the plastic bin with her toiletries and the can of aerosol air freshener were her personal items. Resident #17 stated she was able to shower without assistance, and she used the disposable razor to shave. Resident #17 stated the can of aerosol air freshener was used because sometimes her room smelled. Resident #17 stated there were residents in the facility who would often wander into her room and one resident would come into her room looking for snacks.During an observation on 6/24/26 at 3:03 p.m. Resident 17's bedroom revealed a can of aerosol air freshener placed on top of a personal refrigerator and a disposable razor in a plastic bin with toiletries on the resident's nightstand.During an observation and interview on 6/24/26 at 3:46 p.m. CNA F stated there were residents in the facility who wandered into other residents' rooms looking to see what they can find and one resident in particular who went into resident rooms looking for snacks. CNA F stated the residents in the facility were not supposed to have disposable razors in their room because they were dangerous, and they (residents) could cut themselves. CNA F observed two disposable razors in Resident #17's room and then observed a pair of scissors in a cup next to the disposable razors. CNA F stated she was not sure if Resident #17 was allowed to have the can of aerosol air freshener and stated, I have never seen anybody (residents) with the air freshener. CNA F then observed a one-pound container of disinfectant wipes next to the can of aerosol air freshener. CNA F asked Resident #17 where she got the scissors, and the resident stated she had taken them from a family members house and used them to cut tape. Resident #17 stated she used the disinfectant wipes to clean her hands. CNA F stated, the disinfectant wipes were a product used by the facility and not for use on the skin. CNA F stated the disinfectant wipes were not meant to be used on the skin because they could irritate or worse the ingredients could absorb into the blood. CNA F stated that the disinfectant wipes were used to clean bedside tables and wheelchairs and were never used on a resident. During an interview on 6/25/26 at 4:42 p.m. the Administrator stated there were residents in the facility who wandered into other residents' rooms. The Administrator stated items such as disposable razors could not be kept by the residents because the residents using them or other residents could cut themselves. The Administrator stated disinfectant wipes were not for resident use and staff were responsible for routinely monitoring items that residents were not allowed to have.Record review of the facility document titled Policy for Hazardous Items in Resident rooms, undated reflected in part, .Any items that are hazardous or dangerous to the safety of residents, such as razors, wipees (sic), scissors, will be stored in a secure location.Any staff member that finds any of these items will remove them and give them to the charge nurse or to administration.

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 1 Laundry Room reviewed for infection control:The facility failed to ensure the Laundry Room did not have personal employee food items on the clean folding table and clean laundered resident linens were stored uncovered on the clean storage shelf.These failures could place residents at risk for cross-contamination and infection and could result in illness due to improper care practices.The findings included:During an observation and interview on 6/26/26 at 10:51 a.m. during the inspection of the facility Laundry Room, the clean folding table was observed with a biscuit wrapped in wax paper and an empty food bowl with a lid. The shelf above the clean folding table was observed with three packages of pastries and a plastic grocery bag with food items. The Laundry Attendant stated the personal food items observed on the clean folding table belonged to her. The Laundry Attendant stated the biscuit wrapped in wax paper was for her lunch and the empty food bowl had eggs and bacon that she had consumed. The Laundry Attendant stated the food items should not be on the clean folding table because the table was used to fold clean clothes. The Laundry Attendant stated if the biscuit had been unwrapped it would be a problem but since it was wrapped it was not a problem. The Laundry Attendant stated, if she had left the biscuit unwrapped, she ran the chance of flies and lint getting on it and then would not be able to eat it. The Laundry Attendant stated, personal food items were kept in the laundry room but were not consumed in the laundry room. The Laundry Room inspection revealed the clean storage shelves had laundered resident linens stored uncovered. Observation revealed there were clean storage shelves on both sides of the laundry room with linens that had a bed sheet covering most of the shelves, but overflow was stacked on top uncovered. The Laundry Attendant stated she believed the linens should be covered because of the dust that could be emitted from the laundry room and the linens were next to the exit that had a screen door that could also expose the linens to dust. The Laundry Attendant stated she had been employed by the facility for over 3 years and it's always been like that.During an interview on 6/26/26 at 12:59 p.m., the Administrator stated, the laundry staff were allowed to have water in the laundry room because it's hot in the laundry room. The Administrator stated, as far as food items, laundry staff were allowed to have them but not consume them in the laundry room. The Administrator stated personal food items were to be kept in the refrigerator and any uncovered food items in the laundry room could soil the clean clothes. The Administrator stated that clean clothing items and linens were supposed to be covered to protect them from dust and to help the items stay clean. Record review of the facility document titled Laundry Room Food and Clean Clothes Storage Policy, undated reflected in part, .Attention: Laundry Staff.No food items of any kind are allowed in the laundry room, especially on top of the clean clothes folding table.Water bottles can be placed only on the hanger shelf.All clean clothes items stored in the clean storage shelves need to be covered or placed inside storage bags.Water bottles and food can only be stored inside the refrigerator.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 trash disposal areas that was reviewed for disposal of garbage. The dumpster drainage hole did not have a plug. This failure could place residents at risk for exposure to germs and diseases carried by pests and rodents.The findings included: During an observation of the facility dumpster on 6/24/2026 at 11:20 AM, the dumpster drainage hole did not have a plug. During an interview with the Maintenance Director on 6/24/2026 at 3:07 PM, the Maintenance Director stated the facility did not have a plug for the drainage hole and was not sure of the purpose of the plug. The Maintenance Director stated they had to keep the door of the dumpster closed so mosquitos and flies could not get inside. The Maintenance Director stated mosquitos and flies could not enter the drainage hole in the dumpster. During a second interview with the Maintenance Director on 6/24/2026 at 3:21 PM, the Maintenance Director stated he had found and installed the plug on the drainage hole, and he did not know why it was needed or why it had not been on the dumpster. During an interview with the Administrator on 6/24/2026 at 4:41 PM, the Administrator stated the hole at the bottom of the dumpster is for drainage and should be covered with the plug to prevent flies from getting inside. Record review of the facility policy titled Garbage Dumpster Policy, undated, noted the facility will have a plug in the bottom drain at all times to prevent vermin from entering and liquid waste from escaping.

Based on interview and record review, the facility failed to ensure bedrooms measured at least 80 square feet per resident in multiple resident bedrooms for 16 of 32 double occupancy resident rooms (Rooms 5, 15, 16, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31). Rooms 5, 15, 16, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31 did not have the required 80 square feet per resident. This deficient practice could place residents at risk of inadequate space for activities of daily living in their rooms.The findings included: During an interview with the Administrator on 6/25/2026 at 4:39 PM, the Administrator stated the facility had 16 resident rooms with square footage less than the 80 feet per resident required and identified the resident rooms as rooms 5, 15, 16, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31. The Administrator stated there was a room waiver in effect for these rooms and stated the measurements of the rooms had not changed. Review of the dimensions of the 16 rooms revealed they measured as followed:- room [ROOM NUMBER] - 79.3 square feet per resident (3 resident occupancy)- room [ROOM NUMBER] - 77.9 square feet per resident (2 resident occupancy)- room [ROOM NUMBER] - 61.9 square feet per resident (2)- room [ROOM NUMBER] - 72.0 square feet per resident (2)- room [ROOM NUMBER] - 69.6 square feet per resident (2)- room [ROOM NUMBER] - 74.9 square feet per resident (3)- room [ROOM NUMBER] - 72.0 square feet per resident (2)- room [ROOM NUMBER] - 72.0 square feet per resident (3)- room [ROOM NUMBER] - 76.0 square feet per resident (2)- room [ROOM NUMBER] - 69.6 square feet per resident (2)- room [ROOM NUMBER] - 69.6 square feet per resident (2)- room [ROOM NUMBER] - 70.8 square feet per resident (2)- room [ROOM NUMBER] - 72.0 square feet per resident (2)- room [ROOM NUMBER] - 72.0 square feet per resident (2)- room [ROOM NUMBER] - 72.0 square feet per resident (2)- room [ROOM NUMBER] - 72.0 square feet per resident (2) Record review of the document titled Room Size Waiver for Facilities, dated 6/25/2026, documented Rooms 5, 15, 16, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31 met the justification criteria for waiver. Record review of the document titled Resident Master List Report, dated 6/23/2026, documented 21 residents resided in Rooms 5, 15, 16, 17, 19, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31. No residents were residing in room [ROOM NUMBER] during the annual survey.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for incontinence care. When CNA-A was providing incontinent care to Resident #1 on 06/18/2026, CNA-A did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region) and left buttock area. This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included:Record review of Resident #1's face sheet, dated 12/04/2025, revealed Resident #1 was a [AGE] year-old female and admitted to the facility on [DATE] with the diagnoses of Parkinson's disease (disorder of the nervous system that affects movement and gets worse over time), retention of urine (a condition in which unable to empty all the urine from the bladder), and type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels). Record review of Resident #1's quarterly MDS, dated [DATE], revealed the resident's BIMS was 8 out of 15, which indicated the resident had moderate cognitive impairment, the resident was dependent (Helper does all of the effort) for most activities of daily living, such as hygiene and dressing, and the resident was always bladder and bowel incontinent. Record review of Resident #1's comprehensive care plan, dated 05/27/2026, revealed the resident had the care plan of alteration in bladder and bowel elimination - Monitor and clean urine and bowel movement every shift. Observation on 06/18/2026 at 11:06 a.m. revealed CNA-A washed her hands with water, put on gloves, opened the old and dirty brief of Resident #1, then cleaned the resident's genital area with separating labia, and then cleaned the resident's left and right groin area. CNA-A did not clean the resident's suprapubic area and turned the resident to side. When CNA-A turned Resident #1 to side, the resident had bowel movement. CNA-A cleaned the resident's rectum and right buttock area, then put the new brief under the resident after changing gloves and closed the new brief without cleaning the resident's left buttock area. Interview on 06/18/2026 at 11:22 a.m. with CNA-A stated she did not clean Resident #1's suprapubic area and left buttock area because those areas were visually clean. CNA-A said she should have cleaned the resident's suprapubic area and left buttock area even though those areas were visually clean to prevent possible infection and to keep dry and clean the resident's suprapubic area because that area was folded with belly fat. Interview on 06/19/2026 at 1:40 p.m. with DON stated CNA-A did not clean Resident #1's suprapubic area and left buttock area, but this one was just one isolated event, and those areas were visually clean, so DON questioned if CNAs should clean those areas or not. Interview with the Administrator on 6/19/2026 at 1:41 pm revealed the Administrator said CNA-A should have cleaned the resident's suprapubic area and left buttock area even though those areas were visually clean because germs were invisible to the naked eye and to prevent possible infection. Record review of the facility policy, titled Perineal Care/Incontinent Care - Female with or without catheter, undated, revealed . 9. First separates labia and gently washes, rinse, and dry, as appropriate, the urethral area, wiping from front to back and avoiding the rectum. 10. Then washes, rinses and dries, as appropriate, the remaining perineal area wiping from front to back and working outward to thighs. 11. Turns resident on side and appropriately and gently washes, rinse and dries the remaining area including the rectum and buttocks without returning to the urethral area. 12. Appropriately and gently washes, rinses and dries from clean to dirty area leaving entire area clean and dry.

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. The facility failed to serve the cold chicken penne pasta salad and the mechanical vegetable mixture at 41 F or below for the evening meal service. This failure could place residents at risk for food borne illness. The findings were: In an interview on 04/11/2025 at 5:00 PM, [NAME] A reported the evening meal consisted of a cold plate of a chicken penne pasta salad and soup. [NAME] A stated she had cooked the chicken and pasta earlier in the afternoon for the evening meal and placed them in the refrigerator to cool down, then placed the chicken penne pasta salad on ice on the steamtable. Observation on 04/11/2025 at 5:01 PM reveaked [NAME] A took the temperatures of the food on the steamtable with a thermometer. The temperature of the chicken penne pasta salad was 62 degrees F and the mechanical vegetable mixture of cooked broccoli, cauliflower, and carrots was 70 degrees F. The chicken penne pasta salad and the mechanical vegetable mixture were in steamtable pans with ice under the pans. In an interview on 04/11/2025 at 5:02 PM, [NAME] A stated the vegetable mixture of cooked broccoli, cauliflower, and carrots were for residents who received a mechanical soft diet, and was to be served as a cold dish. In a further interview on 04/11/2025 at 5:08 PM, [NAME] A stated the temperature of the cold food (chicken penne pasta salad and the cooked mechanical vegetable mixture) should be 40 degrees F or below when served. In an interview on 04/11/2025 from 5:11 PM to 5:13 PM, the FSS stated the temperature of the chicken penne pasta salad should be 40 degrees F to 45 degrees F when served, and the harm of not serving it below 41 degrees F was the food product could go bad and the residents could get sick. The FSS stated the chicken penne pasta salad was prepared the afternoon of 04/11/2025. Observation on 04/11/2025 at 5:15 PM of the menu board on the wall across from the kitchen revealed the evening menu was soup, crackers, chicken penne pasta salad, tomato/cucumber salad and spice cake. Observation on 04/11/2025 from 5:17 PM to 5:36 PM revealed [NAME] A served the chicken penne pasta salad, that was above 41 degrees F, to residents who received a regular diet and mechanical soft diet; and served the mechanical vegetable mixture, that was above 41 degrees F, to residents who received a mechanical soft diet. In an interview on 04/11/2025 at 5:38 PM, the FSS stated she had assisted [NAME] A prepare the chicken penne pasta salad earlier around 3 PM when the pasta was cooked and the FSS had grilled chicken thighs for the salad which was why the FSS thought the salad was still warm by the evening meal service time despite being placed in the refrigerator prior to the meal service. In a joint interview on 04/11/2025 at 6:55 PM with the Administrator and Assistant Administrator, the Administrator stated the cold food served at the evening meal (the chicken penne pasta salad and the mechanical vegetable mixture) should have been served at a temperature of 41 degrees or below. The Assistant Administrator stated previously when a pasta meat salad was on the menu, the salad would be made the day before so the salad would be cold enough to serve the next day. Record review of the FDA Food Code 2022, Chapter 3-501.16(A)(2), pages 75-76, revealed Except during preparation, cooking or cooling, time/temperature control for safety food [sic] shall be maintained: (2) at 5 degrees Celsius (41 degrees F) or less. Record review of the facility's undated Dietary Policy on Preparation and Service of Food revealed Food shall be prepared by methods which insure (sic) retention of flavor, appearance, quality and nutrients. The food service supervisor and cooks will be responsible for quality of food .7. Hot foods will be served at a minimum temperature of 140 degrees F. and cold foods will be served as a maximum of 45 degrees F.

Based on observation, interview and record review the menus were not followed, were not updated periodically and were not reviewed by the facility's dietician in 1 of 1 kitchen. 1. Dietary Staff failed to follow the menu on 04/08/25 for 1 of 1 meal; lunch meal. 2. The facility failed to ensure the Dietician reviewed the updated facility menus at the time the menus were made available. for about 5 months These deficient practices could affect all residents and could contribute to residents not being satisfied with their meal options. The findings were: 1. Observation on 04/08/25 at 09:15 AM revealed the monthly menu at a glance for April 2025 was not posted outside the kitchen or around the dining room. Observation on 04/08/25 at 12:18 PM revealed Dietary Staff serving baked ham, pinto beans, mixed vegetables, canned fruit and tea/water. Review of the menu (followed for 04/08/25 included baked ham, pirogues, mixed vegetables, canned fruit and tea/water. Interview on 04/08/25 at 2:45 PM with the FSS revealed she did not post the monthly menu at a glance for April 2025. She stated she did not know if they had one and stated she followed the extended menu dated June 2024. The FSS stated this was the only monthly menu she had available. She stated the lunch menu on, 04/08/25, called for baked ham, mixed vegetables and pirogues (filled dumpling) She stated she served pinto beans instead of pirogues because she did not believe the residents would like them. She stated she did not know what it was and did not try to find out what they were. She stated the Dietician told her it was ok to make changes as long as she added it to the substitution log. The FSS stated she had not kept a substitution log in months. Interview on 04/10/25 at 03:21 PM with the DON and FSS revealed they used a company that provided the facility with menus. The DON stated they should provide updated menus but the Assistant ADM was the FSS's direct supervisor and would have more information. Interview on 04/10/25 at 03:30 PM with the Assistant ADM and the FSS revealed the facility received updated menus from a food company including monthly meals at a glance and extended menus. She stated the menu at a glance was usually posted by the kitchen window. The FSS stated she did not know what happened to them and it had been some time since she had seen one posted She stated she had been using the extended menu's dated June 2024. The Assistant ADM stated the food company provided new menus every 6 months. The FSS again stated she would change the menu if she did not believe the residents liked specific food items. She stated, at times, she would let the Assistant ADM know about the changes. The Assistant ADM stated she would remind the FSS to add the changes to the substitution log. The FSS stated she had not been keeping a substitution log. She further stated she did not discuss changes with the Dietician prior to changing the menu. The Assistant ADM stated administrative staff would meet weekly and she would remind the FSS to follow the menu. She stated she did not have a copy of the most recent menus and had not looked to see if the menu at a glance was posted 2. Review of the current menus were presented for the months of February 2025 through September 2025. Interview on 04/10/25 at 4:00 PM with the ADM revealed the updated menus were sent to their sister facility instead of to them. He stated he knew they would send updated menus every 6 months or so but had not looked or called to find out about the most recent menus. Interview on 04/11/25 at 10:12 AM with the Dietician Consultant revealed she had been asking the ADM for about 5 months if he had printed the menus sent by the food company. She stated she told the ADM she had not reviewed or signed them. The Dietician stated the menus at a glance were not posted so the residents had no idea what they would be served. They only had the menu the dietary staff posted the day of. The Dietician stated dietary staff had been serving meals based on last years menu's; using the extension menu. She stated they did not have menu recipes, substitution options and the purchase guide used to help dietary staff plan their meals. The Dietician stated she believed the new menus came out during August 2024. She stated she understood the FSS was out intermittently last year due to illness and she learned most recently she was exchanging out food items. The Dietician stated she had told the FSS to change out meat for meat, starch for starch etc if she was going to make changes. Review of facility policy, PURPOSE OF DIETARY DEPARTMENT, undated, revealed; The purpose of the Food service Department is to prepare and serve meals in a safe, effective and pleasingly manner and under the standards of sanitation. The meals are prepared in accordance with physician's orders and to meet as far as possible the recommended dietary allowances of the Food and Nutrition. I. The Food Service Supervisor will be responsible for the total operation of the Department. The duties are: A. The supervision of all food service personnel. B. Participation in meeting of heads of department. C. Planning of general diets (Dietitian will approve menus),, and preparation and serving of all diets. II. A qualified dietary consultation will serve as consultation to the Administrator and Food Service Supervisor. 3. To provide guidance to the Food Service Supervisor and staff regarding all procedures and problems in the department. 4. To approve all menus. 11. MENUS AND NUTRITIONAL ADEQUACY. a. Menus shall be planned and followed to meet nutritional needs in accordance with the attending physician's orders and the National Research Council recommended dietary allowances.

Based on interview and record review the facility based on a comprehensive assessment of a resident failed to ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 2 of 7 Residents (Resident #4 and Resident #35) whose records were reviewed for psychotropic medications. 1. Nursing staff failed to ensure Resident #4's informed consent for Haldol (anti-psychotic medication) included the psychiatric condition, assessment for the use of the medication, the risks and benefits and the need for the use of the medication. 2. Nursing staff failed to ensure Resident #35's informed consent for Seroquel (antipsychotic medication), failed to identify the condition being treated and the potential beneficial side effects of the use of the medication. These deficient practices could affect residents who were receiving psychoactive medications and contribute to the administration of unnecessary antipsychotic medications. The findings were: 1. Review of Resident #4's annual MDS assessment, dated 2/6/25, revealed he was admitted to the facility on [DATE]. His BIMS score was 2 of 15 reflective of severe cognitive impairment; diagnoses included Dementia, Depression and Psychotic Disorder and it reflected he was receiving antipsychotic medication on a routine basis. Review of Resident #4's Care Plan, revised 4/9/25, revealed he was receiving psychotropic medication and one of the interventions included to administer medication as ordered. Review of Resident #4's consolidated physician's orders, dated April 2025, revealed an order for Haldol 1 mg. 1.5 tablets equals 1.5 mg, PO 2 x daily, DX: Mood Disorder unspecified. Review of Resident #4's consent for antipsychotic medication treatment, signed by Resident #4's representative on 2/23/23, revealed an order for Haldol one 5 mg tablet tablet by mouth BID for agitation. Further review revealed the physician did not sign the consent. There was no indication of the psychiatric condition, assessment for the use of the medication, the risks and benefits and the need for the use of the medication. Review of Resident #4's MAR for April 2025 revealed he was receiving Haldol per physician's orders. Interview on 04/11/25 at 01:54 PM with the DON revealed she did not believe Resident #4 had a psychiatric condition. She reviewed the diagnosis from a psychiatric provider which revealed a diagnosis of persistent mood disorder unspecified and MDD recurrent and moderate. She also reviewed Resident #4's physician's orders for April 2025 and the consent for Haldol. She stated the consent should be completely filled out to reflect why the resident was receiving the medication. Nursing staff who completed the consent should explain to the resident why the medication was prescribed and the benefits versus the risks. The DON stated not following procedures could result in residents taking medications that were not needed and adverse side effects. 2. Review of Resident #35's face sheet, dated 3/31/25, revealed she was admitted to the facility on [DATE], with diagnoses including Dementia and agitation. Review of Resident #35's quarterly MDS assessment, dated 1/20/25, revealed her BIMS score was 10 of 15 reflective of moderate cognitive impairment. Her diagnosis included Depression and she received antipsychotic medication on a routine basis. Review of Resident #35's Care Plan, dated 10/8/24, revealed she was receiving psychotropic medication and one of the interventions included to administer medication as ordered. Review of Resident #35's consolidated physician's orders for April 2025 revealed an order for Seroquel 25 mg, 1 tablet PO 8 PM. used for agitation. Review of Resident #35's MAR for April 2025 revealed Resident #35 was receiving Seroquel per physician orders. Review of Resident #35's informed consent for Seroquel (antipsychotic medication) signed by Resident's Guardian revealed it did not identify the condition being treated and the potential beneficial side effects of the use of the medication. Interview on 04/11/25 at 06:51 PM with the DON revealed Resident #35's consent should have been completely filled out to reflect why the Resident was receiving the medication. She stated it was important to be in compliance with the regulation. The DON stated not following procedures could result in residents taking medications that were not needed and adverse side affects. Review of a facility policy tilted, USE OF PSYCHOTROPIC MEDICATIONS, undated, revealed: Psychotropic medications must be ordered by a Physician and must have a Diagnosis for the use of the medication. A consent form explaining the use, benefits and adverse reaction of the medication, must be signed by the Responsible person or Guardian of the resident, if resident cannot fully comprehend what he is signing. Nurses must inform resident's Physician if there is a problem associated with the use of the medication.

Based on observation, interview and record review, the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail and review the risks and benefits of bed rails with the resident or resident representative for 4 of 7 Residents (Resident #4, Resident #14, Resident #17 and Resident #27) whose records were reviewed. 1. Nursing staff failed to attempt to use the least restrictive alternatives before using a ,d+[DATE] SR for Resident #4. They also failed to indicate the benefits and risks for using a ,d+[DATE] SR or to assess Resident #4 for its use. 2. Nursing staff failed to obtain a consent for the use of ,d+[DATE] SR for Resident #14 and failed to assess her once a ,d+[DATE] SR was implemented. 3. Nursing staff failed to obtain a consent or to assess Resident #17 for the use of ,d+[DATE] SR. 4. Nursing staff failed to attempt to use least restrictive alternatives before using ,d+[DATE] SR for Resident #27, to indicate the benefits and risks for using ,d+[DATE] SR and failed to assess him for use. These deficient practices could affect residents who used side rails and could result in avoidable accidents and or injuries. The findings were: 1. Review of Resident #4's annual MDS assessment, dated [DATE], revealed he was admitted to the facility on [DATE]. He had a BIMS score of 2 out of 15 reflective of severe cognitive impairment. He had impaired vision and he required partial to moderate assistance for bed mobility (rolling left and right). Review of Resident #4's Care Plan, dated [DATE], revealed problem: ,d+[DATE] SR to bed., Goal Resident will be able to assist with transfers, repositioning and bed mobility. Interventions: Instruct resident on techniques of how to use ,d+[DATE] side rails to change position while in bed. Show resident how to use ,d+[DATE] side rails to assist with transferring. Review of Resident #4's, Informed Consent for Restraint Use, dated [DATE], revealed The facility, with a physician order may need to use a restraining device after a trial of less restrictive measures have failed, at it has been determined through consultation with appropriate health team professional that it may be used for specific time periods to enable and promote great functional independence. (The definition of a restraint is any device from which the resident is able to free self). Further review revealed there was no indication of the risks and benefits or the less restrictive alternatives that had been used. Further review revealed the physician did not sign the consent. Observation and interview on [DATE] at 10:15 AM revealed Resident #4 lying in bed with one ,d+[DATE] SR up on right side of the bed by the wall. Attempted interview with Resident #4 revealed he was alert to self. Resident #4 was asked if was able to lower the SR. He was not able to answer the question. Resident #4 had a blank stare. Interview on [DATE] at 01:54 PM with the DON revealed she reviewed Resident #4's side rail consent, dated [DATE]. The DON stated nursing staff should reassess Resident #4 periodically to determine if he could still use the SR safely, to ensure he would not get stuck or have other accidents. The DON stated the consent did not reflect the benefits, risks or devices used prior to using the SR. The DON stated not following procedure could result in resident's getting injured or worse. 2. Review of Resident #14's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses including Senile Dementia with cognitive impairment, Mood Disorder unspecified, Psychosis/Confusion NOS and Anxiety State NOS. Review of Resident #14's MDS assessment revealed her BIMS was 9 of 15 reflective of moderate cognitive impairment. Review of Resident #14's Care Plan, dated [DATE], revealed problem: ,d+[DATE] SR to bed., Goal Resident will be able to assist with transfers, repositioning and bed mobility, Interventions Instruct resident on techniques of how to use ,d+[DATE] side rails to change position while in bed. Show resident how to use ,d+[DATE] side rails to assist with transferring. Review of Resident #14's consolidated physician's orders, dated [DATE], revealed an order ,d+[DATE] side rails to bed to assist with repositioning and mobility when in bed Q shift, dated [DATE]. Review of Resident #14's consents revealed there was not a consent for SR use. Review of Resident #14's assessments revealed a Side Rail Assessment, last reviewed on [DATE] read no SR in use. Interview on [DATE] at 01:54 PM with the DON revealed the use of SR's required nursing staff to obtain physician's order, consent which included risks and benefits and other interventions used prior to using SR's, complete an assessment, re-assessment periodically and to include in the care plan. The DON reviewed Resident #14's medical chart related to SR use and stated a physician's order and care plan were the only documents in place for Resident #14. She stated a SR should not be used until at a minimum a consent was obtained and the resident was assessed for safety to avoid accidents and the resident getting injured. 3. Review of Resident #17's quarterly MDS, dated [DATE], revealed she was admitted to the facility on [DATE]. Her BIMS score was 9 of 15 reflective of moderate cognitive impairment. Her diagnoses included Cerebral Palsy and Seizure Disorder or Epilepsy. She had functional limited range of motion on one side on her upper extremity and on both sides on her lower extremities, she was dependent on staff for bed mobility; rolling left to right. Review of Resident #17's Care Plan, revived [DATE], revealed she used SR as an enabler and safety device r/t confusion, weakness, forgetful, s/p CVA, hemiplegia, paraplegia and seizure d/o. Interventions: Assess for use of SR, notify family, get consent, apply ,d+[DATE] SR as indicated, make sure mattress fits snuggly against SR to avoid gap. for entrapment. Maintenance and nursing staff to monitor daily. SR to help avoid injury when necessary. Reassess SR use every 90 days. Reduce/remove SR only if indicated no longer needed. Review of Resident #17's consolidated physician's orders for [DATE] revealed an order ,d+[DATE] side rails to bed to assist with repositioning and mobility when in bed Q shift. Review of Resident #17's medical chart revealed there was not a consent for the use of ,d+[DATE] SR. Review of Resident #17's assessments revealed she was not assessed for the use of ,d+[DATE] SR. Interview on [DATE] at 01:54 PM with the DON revealed the use of SR's required nursing staff to obtain a physician's order, consent which included risks and benefits and other interventions used prior to using SR's, to complete an assessment, re-assessment periodically and to include in the care plan. The DON reviewed Resident #17's medical chart related to SR use. She stated nursing staff obtained a physician's order and included the use of SR's in Resident #17's Care Plan. She stated a SR should not be used until at a minimum a consent was obtained and the resident was assessed for safety to avoid accidents and injuries. 4. Review of Resident #27's face sheet, dated [DATE], revealed he was admitted to the facility on [DATE] with diagnoses including Vascular Dementia and Depressive Disorder. Review of Resident #27's quarterly MDS assessment, dated [DATE], revealed his BIMS score was 15 of 15 reflective of no cognitive impairment. He had functional limitation of range of motion on both lower extremities and he required set up assistance from staff for bed mobility; rolling left and right. Review of Resident #27's Care Plan, dated [DATE], revealed Problem: ,d+[DATE] SR to bed. Goal revealed Resident will be able to assist with transfers, repositioning and bed mobility. Interventions: Instruct resident on techniques of how to use ,d+[DATE] side rails to change position while in bed. Show resident how to use ,d+[DATE] side rails to assist with transferring. Review of Resident 27's consolidated physician's orders for [DATE] revealed an order May have ,d+[DATE] side rails on bed for mobility and repositioning Q shift. Review of Resident #27's informed consent for restraint use, dated [DATE], revealed it did not reflect the benefits and risks for using ,d+[DATE] side rail and there was no indication a least restrictive alternative was used. Review of Resident #27's Side Rail Assessment, dated [DATE], revealed he was not using a SR at the time. Further review revealed there was not a current reassessment for Resident #27. Observation and interview on [DATE] at 03:06 PM revealed Resident #27 sitting in a wheelchair. He stated he used the side rail while in bed. He would use it to turn during care or to sit up in bed. He stated he was not able to release the side rail, but was not able to get out of bed on his own related to both his legs being amputated. Interview on [DATE] at 03:32 PM with the ADON revealed Resident #27 started using a SR when his left leg was amputated over 1 year ago. She stated in reviewing Resident #27's consent in his chart, dated [DATE], it did not reflect the benefits and risks involved. She stated the assessment completed on [DATE], reflected he was not using SR's at the time. The ADON stated the use of SR's required a physician's order, a consent, an assessment and it should be included in the care plan. She stated residents who used SR's should also be reassessed periodically to determine if the SR's were benefiting the resident and to ensure the resident was using safely otherwise the resident could sustain injuries. Review of facility policy, SideRails Policy, undated, revealed Residents using siderails for bed mobility or transfer. will get an order from their Physician so they can use the siderails. Staff will instruct the resident on how to use them as indicated in the residents' care plans.

Based on interview and record review, the facility failed to revise residents comprehensive care plan for 4 of 12 Residents (Resident #4, Resident #19, Resident #27 and Resident #30) reviewed for Comprehensive Resident Centered Care Plan. 1. The facility failed to revise Resident #4's Care Plan for the use of 1/2 SR and to provide timeframe's for the review period. 2. The facility failed to revise Resident #19's care plan for diet and care plan interventions after weight loss. 3. The facility failed to revise Resident #27's Care Plan for the use of 1/2 SR. 4. The facility failed to revise Resident #30's care plan interventions for physical restraint. These deficient practices could affect any resident and could contribute to resident's not receiving needed care and services as identified in the residents medical record and or MDS. The findings were: 1. Review of Resident #4's annual MDS assessment, dated 2/6/25, revealed he was admitted to the facility on [DATE]. His BIMS score was 2 of 15 reflective of severe cognitive impairment. His diagnoses included Hypertension (high blood pressure), Dementia, Depression and Psychotic Disorder. He had functional limitation in range of motion on one side on upper extremity and on both sides on lower extremities and he required partial to moderate assistance from staff for bed mobility; rolling left and right. Review of Resident #4's Care Plan revised on 3/28/25 revealed problem: 1/2 SideRail to bed; Goal: Resident will be able to assist with transfers, repositioning and bed mobility; Interventions: Instruct resident on techniques on how to use 1/2 SideRail to change position while in bed and Show resident how to use 1/2 SideRail to assist with transferring. Further review revealed the Care Plan did not reflect Resident #4's medical condition for the use of the Side Rail, it did not include measurable timeframe's and interventions and it did not reflect Resident #4 should be reassessed for the use of the 1/2 Side Rail to ensure he used it safely. Interview on 04/11/25 at 01:54 PM with the DON revealed she and staff had worked with Resident #4 for years and knew him well. She stated Resident #4's condition had not changed and although she understood the requirement for the Care Plan to reflect the Resident's current condition, care and services needed. The DON stated she did not believe not updating the Care Plan would negatively impact Resident #4 in any way. 2. Record review of Resident #19's face sheet dated 3/31/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included dementia with behavioral disturbances (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life with behavior changes), diabetes (chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces), and vitamin D deficiency (the level of vitamin D in the blood is insufficient to maintain proper health). Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated the resident had a BIMS score of 99 indicating the resident was unable to complete the assessment and staff assessment of the resident's cognitive daily decision making indicated the resident was severely impaired cognitively. The resident had a poor appetite or overeating 7 - 11 days (more than half of the days), and the resident had weight loss of 5% or more in the past month or 10% in the last 6 months. Record review of Resident #19's care plan revised on 4/3/25 revealed a problem for dehydration and handwritten next to it was weight loss, last date on this problem was handwritten 10/3/23. On the problem column included the resident did not like nectar or honey thick liquids. Interventions included mechanical soft diet handwritten with no date, other interventions included to assist the resident to drink 8 ounces of honey or nectar thick liquids with each medication pass. A dietary care plan date initialed 6/20/19 with a problem of mechanically altered diet with interventions for diet as ordered and to monitor intake. There were no measurable timeframe's for any goals on the care plan. Record review of Resident #19's consolidated physician orders dated 4/1/25 revealed a diet order of Pureed no concentrated sweets with thin liquids and diabetic shakes dated 7/30/24. Record review of Resident #19's nutritional assessment dated [DATE] indicated the resident was on a pureed diet and may have mechanical soft snacks. 3. Review of Resident #27's face sheet, dated 3/31/25, revealed he was admitted to the facility on [DATE] with diagnoses including Vascular Dementia and Depressive Disorder. Review of Resident #27's quarterly MDS assessment, dated 2/27/25, revealed his BIMS score was 15 of 15 reflective of no cognitive impairment. He had functional limitation of range of motion on both lower extremities and he required set up assistance from staff for bed mobility; rolling left and right. Review of Resident #27's Care Plan revised on 3/28/25 revealed problem: 1/2 SideRail to bed; Goal: Resident will be able to assist with transfers, repositioning and bed mobility; Interventions: Instruct resident on techniques on how to use 1/2 SideRail to change position while in bed and Show resident how to use 1/2 SideRail to assist with transferring. Further review revealed the Care Plan did not reflect Resident #27's medical condition for the use of the Side Rail and it did not include measurable timeframe's and interventions did not reflect Resident #27 should be reassessed for the use of the 1/2 Side Rail to ensure he used it safely. Interview on 04/11/25 at 03:32 PM with the ADON revealed Resident #27 started using a 1/2 SR since his left leg was amputated over 1 year ago. She stated Resident #27's Care Plan did not include the Resident's medical condition to reflect why he was using a SR and timeframe's for using the SR. She stated there was no indication Resident #27 should be reassessed for the use of a SR. The ADON stated the Care Plan should be an accurate representation of Resident #27's medical condition and necessary care and services needed. She stated nursing staff should use the Care Plan as a guide when providing care and if not current, then staff may not provide Resident #27 with the care and services identified. 4. Record review of Resident #30's face sheet dated 3/31/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hypertension (elevated blood pressure), and diabetes (chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). Record review of Resident #30's quarterly MDS assessment dated [DATE] indicated the resident's BIMS was 99 indicating she was unable to complete the assessment. Staff assessment of the resident's cognitive daily decision making indicated the resident was severely impaired cognitively. The resident did not use any mobility devices including a wheelchair and no physical restraints or alarms were used and chair prevents rising was not used. Record review of Resident #30's undated care plan revealed a problem dated 9/15/23 for Geri-chair with or without tabletop and under this problem in the same column was Resident #30's name cannot walk and will try to get out of the Geri-chair. Tabletop is used to prevent a fall and to serve as a table for activities with a goal of resident safety will be maintained. Interventions included to check with the resident frequently to ascertain needs, toilet the resident per schedule and request, provide verbal reminder to the resident to call when needing assistance. (There were no interventions for removing the tabletop or assessing the continued need for the restraint.). There were no measurable time frames for care plan goals. Record review of Resident #30's physician orders dated 3/31/25 revealed an order for a Geri-chair with or without tabletop PRN (as needed) safety device to decrease falls with a date next to it for 9/1/23. In an observation and interview on 4/8/25 at 1:30 p.m., Resident #30 was in the lobby-common area among other residents sitting on couches or in wheelchairs watching television. Resident #30 was seated upright in a Geri-chair with a tray table attached to the chair. Resident #30 was at the edge of the seat and had both her hands on the sides of the tray table and was periodically, vigorously shaking the tray table back and forth and looking around. The ADON was sitting at the nursing station facing the residents and stated the resident was always up in the Geri-chair with the tabletop when out of bed. The ADON stated the resident was not trying to remove the tray table but was restless. The ADON stated the resident would try to get up if the tray table was not attached and the resident was unable to walk. In an observation and interview on 4/9/25 at 2:00 p.m. Resident #30 was in the lobby-common area among other residents sitting on couches or in wheelchairs. Resident #30 was seated upright in a Geri-chair with a tray table attached to the chair. Resident #30 was in the middle of the seat and would periodically grab the tray table sides with both her hands and shake it side to side and would look around. The resident was able to move her upper body and trunk without difficulty and was seated upright without leaning to the side. The resident smiled when greeted but was unable to answer my questions. Resident #30 would attempt to speak but only unintelligible sounds would come out. In an observation on 4/10/25 at 2:30 p.m. Resident #30 was in the lobby-common area alone without any other residents or staff present. Resident #30 was seated in an upright Geri-chair with a tray table attached to it. The resident was seated in the middle of the seat with her upper back leaned back against the chair and had her hands on top of the tray table and would occasionally push against the tray table side closet to her. In an observation on 4/11/25 at 12:30 p.m. Resident #30 was in the dining room sitting upright in an upright Geri-chair with the tray table attached and the tray table was pushed under the half-moon feeding assistance table. In an observation on 4/11/25 at 2:00 p.m. Resident #30 was in the lobby-common area among other residents. Resident #30 was seated upright in a Geri-chair with a tray table attached and was moving around large adult Lego like blocks with her right hand. The resident was not pushing or shaking the tray table. In an observation on 4/11/25 at 4:00 p.m. Resident #30 was seated in a wheelchair at a table in the dining room without any physical restraint and was lifting items from the table during an activity and staff were supervising. Resident #30 was not attempting to get up out of the wheelchair. In an interview on 4/11/25 at 4:35 p.m., the ADON stated the DON was responsible for revising all the resident care plans and the ADON did not participate in care planning. In an interview on 4/11/25 at 5:30 p.m., the DON stated she was responsible for care plan interventions and the care plans were updated and new interventions might be handwritten. A request was made for a Care Plan policy multiple times on 4/11/25 and it was not provided before exit. 42031

Based on observation, interview and record review, the facility failed to maintain safe environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 7 Residents (Resident #17) who were observed for wheelchair use. The facility failed to ensure Resident #17's wheelchair armrest were in good repair. Both armrests were cracked and torn. This deficient practice could affect residents who used a wheelchair and could contribute to injuries; skin tears. The findings were: Review of Resident #17's annual MDS assessment, dated 3/6/25, revealed she was admitted to the facility on [DATE] with diagnosis of Cerebral Palsy. Her BIMS score was 9, reflective of moderate cognitive impairment, she had impaired range of motion on both lower extremities and she used a wheelchair for mobility. Review of Resident #17's Care Plan, revised 3/6/25, revealed Resident #17 had self-care deficit r/t cognitive deficit. Observation on 04/09/25 at 12:06 PM revealed Resident #17 sitting in a wheelchair. Both armrests were cracked and torn. Observation on 04/10/25 at 04:00 PM revealed Resident #17 sitting in a wheelchair in the dining room. Further observation revealed both armrests were cracked and torn exposing the padding. Interview on 04/10/25 at 05:00 PM with the Maintenance worker revealed he was in charge of replacing the armrests on the Resident's wheelchairs when torn. He stated he had not checked them in some time and staff had not reported there was a problem with Resident #17's wheelchair. Observation and interview on 04/10/25 05:05 PM revealed both armrests on Resident #17's wheelchair were cracked and torn. Interview with the Maintenance worker revealed Resident #17's wheelchair armrests were torn. He stated it was important to replace the torn armrests to ensure Resident #17 did not scratch her arms. Interview on 04/11/25 at 3:00 PM with the DON revealed the Maintenance worker would periodically check the Resident's wheelchairs to make sure they were functional and the armrests were not torn. The DON stated the Maintenance worker should replace any torn armrests because the Resident's could get skin tears. Requested a policy for maintaining resident equipment in good working order multiple times on 04/11/2025. A policy was not provided before exit.

Based on observation, interview, and record review, the facility failed to ensure the resident's 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 for 1 of 6 residents (Resident #26), reviewed for resident rights. Resident #26's call light was on the floor and not within reach of the resident. This failure could place residents at risk of not receiving needed care and services in a timely manner. The findings were: Record review of Resident #26's face sheet dated 3/31/25 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease (general term for memory loss and other cognitive abilities serious enough to interfere with daily life), dementia, unspecified (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and muscular Atrophy not otherwise specified (weakening, shrinking, and decreasing of muscle mass). Record review of Resident #26's quarterly MDS assessment dated [DATE] indicated the resident was unable complete the BIMS, and staff assessment of the resident's cognitive daily decision making indicated the resident was severely impaired cognitively. The resident required partial-moderate assistance for rolling left and right. The resident used a manual wheelchair, was impaired on one side of her upper body and both of her lower extremities, and the resident was always incontinent of bowel and bladder. Record review of Resident #26's undated care plan revealed a problem for urinary incontinence and interventions included to keep the call light within the resident's reach and to remind the resident to call for assistance. In an observation on 4/8/25 at 10:55 a.m. a facility maintenance staff member was in the hallway working on the call light for Resident #26's room. An unknown staff member had entered Resident #26's room at this time and exited within 30 seconds. In an observation and interview on 4/8/25 at 11:00 a.m., the maintenance staff member was no longer present. Resident #26 was in bed making a moaning noise when breathing but the resident appeared unaware of the moaning. The resident was able to answer a few questions appropriately but her speech was garbled and then the resident stated, I'm Good, thank you. The call light was plugged in to the wall and the cord was caught in the nightstand drawer and the end for the resident to press was on the floor next to the nightstand. The resident was able to lift her left arm and grab my hand with hers when I extended it in greeting . I was unable to understand the resident's answer when asked if she could use her call light as her speech remained garbled. In an observation and interview on 4/08/25 at 11:23 a.m., the call light remained on the floor in Resident #26's room. The DON stated the call light should not be on the floor. The DON stated the resident was able to talk and let the staff know if she needed assistance. The DON stated the consequences of the resident not having her call light in reach could be the resident would not receive the assistance she needed. In an interview on 4/11/25 at 4:35 p.m., the ADON stated Resident #30 could use the call light if given verbal reminders. The ADON stated the possible consequences of the resident not having her call light within reach could be the resident could fall trying to reach it. In an interview on 4/11/25 at 5:00 p.m., the DON stated maintenance had been working on Resident #26's call light and she was unsure what the issue had been but it had been fixed that same day. Review of the facility policy for ADL undated indicated Certified Nurse Aides (CNAs) must attend to the needs of all residents and provide the care that residents need at all times.

Based on observations and interviews the facility failed to ensure each resident has a right to personal privacy and confidentiality of their personal and medical records. The facility failed to ensure the MAR binder (a binder with a list of residents' prescribed medications and when the medications were administered) on the west wing medication cart was kept confidential when it was left open and facing the hallway unattended while visitors and staff walked by. This could place residents at risk for private health information being viewed by unauthorized individuals. The findings were: In an observation on 4/8/25 at 9:25 a.m. in the hallway on the west wing slightly to the left of the entrance to the west wing hall there was a medication cart against the wall with the MAR binder open and facing the hallway, unattended. The MAR binder contained information on residents' medications. Multiple staff and visitors passed by the open binder on their way down the hallway. In an observation and interview on 4/8/25 at 9:26 a.m. revealed LVN D returned to the medication cart and stated she had just stepped away to put some laundry away. LVN D stated the MAR binder should not have been left open or unattended because unauthorized people could have access but she had stepped away briefly. In an interview on 4/8/25 at 4:45 p.m. the DON stated the MAR binder should not be left open and unattended to keep the resident information private. Medical records policy was requested and not received by time of exit.

Based on observation, interview, and record review the facility failed to ensure the resident was free from physical restraints imposed for purposes of convenience that are not required to treat the resident's medical symptoms for the least amount of time and document ongoing re-evaluation of the need for restraints for 4 of 4 days during the survey period (4/8/25, 4/9/25, 4/10/25, and 4/11/25) reviewed for freedom from abuse. Resident #30 was seated in a Geri-chair with a tray table on 4/8/25, 4/9/25, 4/10/25, and 4/11/25 . The tray table was always present when the resident was out of bed and not removed for meals, or activities. And there was no documentation of ongoing re-evaluation of the need for restraints. This failure could place residents at risk for feelings of frustration, anger, humiliation, and could result in the residents being unnecessarily restrained in violation of their rights. The findings were: Record review of Resident #30's face sheet dated 3/31/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hypertension (elevated blood pressure), and diabetes (chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). Record review of Resident #30's quarterly MDS assessment dated [DATE] indicated the resident's BIMS was 99 indicating she was unable to complete the assessment. Staff assessment of the resident's cognitive daily decision making indicated the resident was severely impaired cognitively. The resident did not use any mobility devices including a wheelchair and no physical restraints or alarms were used and chair prevents rising was not used. Record review of Resident #30's undated care plan revealed a problem dated 9/15/23 for Geri-chair with or without tabletop and under this problem in the same column was Resident #30's name cannot walk and will try to get out of the Geri-chair. Tabletop is used to prevent a fall and to serve as a table for activities with a goal of resident safety will be maintained. Interventions included to check with the resident frequently to ascertain needs, toilet the resident per schedule and request, provide verbal reminder to the resident to call when needing assistance. (There were no interventions for removing the tabletop or assessing the continued need for the restraint.) Record review of Resident #30's physician orders dated 3/31/25 revealed an order for a Geri-chair with or without tabletop PRN (as needed) safety device to decrease falls with a date next to it for 9/1/23. Record review of Resident #30's informed consent for restraint use signed on 8/30/23 revealed Geri-chair was checked and under other was handwritten with or without tabletop. Under benefits of using this type of restraint was handwritten preventing potential life-threatening fall and initialed by the DON. Under the DON's initials were handwritten dates 2/5/24, and 4/9/25. Under less restrictive alternatives that had been used was handwritten wheelchair without tabletop. Record review of Resident #30's Treatment Administration Record for March 2025 revealed up in Geri-chair with or without tabletop for positioning comfort PRN with a start date of 9/1/23 and documented by unknown staff the resident only used this on 3/1/25, 3/4/25, 3/9/25, 3/13/25, 3/15/25, and 3/18/25. Record review of Resident #30's Treatment Administration Record for April 2025 revealed up in Geri-chair with or without tabletop for positioning comfort PRN with a start date of 9/1/23 and documented by unknown staff the resident only used this on 4/9/25, and 4/10/25. Record review of Resident #30's physical restraint elimination assessment form were the dates 1/5/24, 2/5/24, and 4/9/25 with no date for the 3rd column. All four columns were completed and were the exact same and had the score of 23 (21-35 indicating the resident was a good candidate for restraint elimination). On the 2nd page of the assessment for the dates 1/5/24, 2/5/24, and 4/9/25. Under item 1. there was a check mark for the resident being a good candidate. 2. Was the resident a candidate for restraint reduction or elimination was checked no. Under action plan was handwritten no restraint elimination at this time. Under additional comments was handwritten and signed by the DON the resident was unable to walk and tries to stand and walk if the tabletop is not on the Geri-chair. Under less restrictive measures to be used for 1/5/24 was handwritten fall risk, for 2/5/24 and 4/9/25 was left blank. For specific reason, medical symptom, or targeted behavior was blank for 1/5/24, and on 2/5/24, and 4/9/25 was handwritten fall risk. Record review of Resident #30's hospice addendum plan of care review/recert note dated 4/9/25 under interactivity was handwritten Tries to engage, in Geri-chair all day. On the 2nd page under Musculoskeletal was handwritten In Geri-chair all day, no falls reported. Record review of Resident #30's hospice plan of care review dated 3/26/25 under musculoskeletal was handwritten sits in Geri chair, does not ambulate. In an observation and interview on 4/8/25 at 1:30 p.m., Resident #30 was in the lobby-common area among other residents sitting on couches or in wheelchairs watching television. Resident #30 was seated upright in a Geri-chair with a tray table attached to the chair. Resident #30 was at the edge of the seat and had both her hands on the sides of the tray table and was periodically, vigorously shaking the tray table back and forth and looking around. The ADON was sitting at the nursing station facing the residents and stated the resident was always up in the Geri-chair with the tabletop when out of bed. The ADON stated the resident was not trying to remove the tray table but was restless. The ADON stated the resident would try to get up if the tray table was not attached and the resident was unable to walk. In an observation and interview on 4/9/25 at 2:00 p.m. Resident #30 was in the lobby-common area among other residents sitting on couches or in wheelchairs. Resident #30 was seated upright in a Geri-chair with a tray table attached to the chair. Resident #30 was in the middle of the seat and would periodically grab the tray table sides with both her hands and shake it side to side and would look around. The resident was able to move her upper body and trunk without difficulty and was seated upright without leaning to the side. The resident smiled when greeted but was unable to answer my questions. Resident #30 would attempt to speak but only unintelligible sounds would come out. In an observation on 4/10/25 at 2:30 p.m. Resident #30 was in the lobby-common area alone without any other residents or staff present. Resident #30 was seated in an upright Geri-chair with a tray table attached to it. The resident was seated in the middle of the seat with her upper back leaned back against the chair and had her hands on top of the tray table and would occasionally push against the tray table side closet to her. In an observation on 4/11/25 at 12:30 p.m. Resident #30 was in the dining room sitting upright in an upright Geri-chair with the tray table attached and the tray table was pushed under the half-moon feeding assistance table. In an observation on 4/11/25 at 2:00 p.m. Resident #30 was in the lobby-common area among other residents. Resident #30 was seated upright in a Geri-chair with a tray table attached and was moving around large adult Lego like blocks with her right hand. The resident was not pushing or shaking the tray table. In an observation on 4/11/25 at 4:00 p.m. Resident #30 was seated in a wheelchair at a table in the dining room without any physical restraint and was lifting items from the table during an activity and staff were supervising. Resident #30 was not attempting to get up out of the wheelchair. In an interview on 4/8/25 at 2:30 p.m. the DON stated the tray table attached to the Geri-chair was not a restraint and she had to mark it on the MDS. but the DON stated it was not a restraint due to the resident being unable to walk, and it was for her safety because the resident would get up and fall if the tray table was not attached. The DON stated it was also used for activities. In an interview on 4/11/25 at 4:35 p.m., the ADON stated she was unaware of any other interventions that were attempted for Resident #30 prior to or after Geri-chair with tray table use. In an interview on 4/11/25 at 5:30 p.m., the DON stated the RP for Resident #30 had come in and seen that the resident was not in a Geri-chair with the tray table for safety, and the RP was not pleased and was afraid Resident #30 would fall and get hurt. The DON stated the RP stated she would write a letter. The DON stated previous interventions attempted prior to the tray table were wheelchair alarms but the resident fell . The DON stated the resident's family suggested the tray table and it was used for activities, eating, and fall prevention. Review of the facility restraint policy undated indicated It is the practice of our facility to comply with federal and state laws governing the emergency use of restraints. In the absence of the law, our facility shall employ the following policy: Physical restraints may be used based on professional judgement to prevent harm to a resident or others, or to provide medical treatment to proceed unless the facility has notice that the resident has previously made a valid refusal of the treatment in question.

Based on observation, interview, and record review, Administration failed to administer resources to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #1) reviewed for administration in that: The DON confirmed she wrote the policy and had instructed the CNAs to wet residents clothing with water if they refused to shower. The Administrator should have been aware of the policy which constituted the abuse Resident #1 endured as a result of the DON's instruction. The Administrator failed to adequately supervise the DON and nursing staff to ensure residents were free from abuse. This failure resulted in identification of an Immediate Jeopardy (IJ) on 09/23/2021 at 5:12 p.m. While the IJ was removed on 09/27/2021, the facility remained out of compliance at a severity of no actual harm, but with potential for more than minimal harm that is not IJ with a scope identified as isolated due to the facility requiring more time to monitor and assess the plan of removal for effectiveness to ensure the safety of the residents from physical, verbal, and psychosocial harm. This deficient practice could place residents at risk for physical, verbal, and/or psychosocial harm. The findings were: Record review of Resident #1's face sheet dated 7/13/2021 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Annual MDS, dated [DATE], revealed no BIMS score as the Cognitive assessment was not completed with the resident. Further review revealed a staff assessment for mental status had been completed that revealed short-term and long-term memory problems. Memory/Recall ability indicated resident unable to recall current season, location of own room, staff names and faces, that she is in a nursing home and noted residents' cognitive skills to be severely impaired. No behavior issues, such as refusal of care were identified on MDS. Record review of Resident #1's Care Plan, dated 05/11/2021, revealed a problem area: Bathing. Further review revealed Goals: resident will bathe 3x per week, resident will wash upper extremities, resident will wash face and hands, resident will accept assistance with bathing. Further review revealed Interventions: encourage resident to participate in bathing, and praise accomplishments, allow sufficient time for bathing and break tasks down into manageable segments. Record review of Resident #1's Care Plan, revealed no problem areas with resident refusing bathing or behaviors. Record review of Resident #1's Care Plan, revealed a problem area dated 05/11/2021, Carries her babies (2) dolls and a problem area dated 07/08/2021, May refuse care, labs, Tx secondary to confusion, disorientation. Further review revealed Goals: Will have good care to promote good quality of life and well-being. Further review revealed Interventions: Reapproach when refusing, notify RP, Dr when refusing. Document/explain, praise when good. Record review of the facility's provider investigation report, completed by the administrator, dated 07/13/2021, revealed an employee counseling record for CNA A dated 07/07/2021, with date of occurrence 07/06/2021, which stated, Reason for counseling, Employee used inappropriate approach to solving a problem she had why showering a resident who had refused to shower. Employee told resident I'll take your babies away when she could have showered resident with the dolls in her hand. Remarks by counselor, The resident began to yell when employee proceeded to wet resident's clothes in an effort to have resident to agree to remove clothes and take the shower. Employee's Remarks, Employee had been informed by the DON as to how to bathe someone who is offensive with body odor and needs to be bathed. This included wetting the clothes in hopes that the resident will agree to remove clothing and shower. Action to be taken, Suspension x3 days pending the investigation of incident that may have been reported erroneously by other employees who overheard the incident. Record review of CNA A's personnel file revealed an additional employee counseling record dated 08/09/2019, with date of occurrence 08/05/2019, which stated, Reason for counseling, Employee speaks in a loud voice and can be heard by other employees, residents and family members. Remarks by Counselor, Employee has been informed to speak to residents in a calm and low tone. Employee has been informed not to speak in a loud voice and use a relaxing voice. Employee's remarks, Mi vos es Aci no Tengo otra Marera de avtar voi a Trator de Modificor Mi vos [NAME] Aci avto losiento. [This is my voice; I don't have any other way of speaking. I will try to modify my voice. Sorry, but this is the way I speak.] Action to be taken, Employee has been placed on a 90-day probation, any further violation can result in suspension or termination. Record review of the facility's a policy titled, Policy for providing care to difficult residents when refusing nursing care, dated 11/04/2020, revealed When residents are refusing to bathe, and they are offensive to others, with body odor, will be taken to the shower by two CNA's, and showered. This may involve wetting the clothing gently, with desired temperature of the water, as this procedure usually prompts the resident to want to change clothes because they are wet, and while removing the wet clothing, the bathing can begin at the same time, and the resident will participate more willingly. Explaining, and reassuring them all the while, will make it easier to accept the process, even with the most demented or confused resident. An interview on 9/22/2021 at 9:45 am, Laundry Aide F stated she reported the incident of CNA A wetting Resident #1, that occurred on 07/06/2021, to my supervisor, the Assistant Administrator, because didn't feel comfortable, didn't think it's the right way to talk to a resident. Laundry Aide F added she was in the hallway on her break and CNA A took Resident #1's babies away and then she could hear Resident #1 yelling in the shower. In an interview on 09/22/2021 at 10:18 am the DON confirmed she wrote the policy Policy for providing care to difficult residents when refusing nursing care. She states she learned the process working at the state hospital and it works well when you have people who won't shower. Their odor becomes offensive to others and you can't let that happen. We just wet their clothes with a little water and that usually makes them want to remove their clothes. No one wants to be in wet clothes, like the feeling if you peed your pants. In an interview on 9/22/2021 at 4:15 pm, utilizing the RN Consultant as a Spanish interpreter, CNA A stated she gave Resident #1 a shower the way she has been told to by the DON. When CNA A was asked if she was aware of the policy allowing to wet clothing she stated yes, that is how we do it. CNA A stated she took Resident #1's dolls from her and walked into the shower with them. CNA A stated she placed them on the ledge in the shower until shower was completed. CNA A confirms Resident #1 did not want to undress for her shower so she wet her clothes so she would want to take them off. An interview on 09/23/2021 at 11:00 am, with the RN Consultant revealed she was unaware of the bathing policy. She states it is very controversial, felt the DON to be old school and she will be changing the policy immediately. She further added that herself and the GM held a meeting early this morning with the Administrator and DON to inform them that before implementing a new policy and procedure it will be reviewed and approved by administration committee, which includes the Administrator, DON, RN consultant and General Manager. Record review on 09/23/21 of Resident #1's medical record revealed a progress note dated 07/08/2021 written by the DON, that stated the RP had been informed the resident was OK and had no mental disturbance or physical injury from being bathed against her wishes. The DON's progress notes also stated, I also told [RP] there is a way the staff handles a situation like that and the [RP] understood. Stated 'OK as long as [Resident #1] is OK. In an interview on 9/23/21 at 12:55 p.m., Resident #1's RP stated the DON contacted (RP) and stated there had been an issue with [Resident #1's] shower and that they are supposed to have 2 staff assist and only had one staff present and Resident #1 had become very upset. RP stated she was told in the past [Resident #1] refuses showers at times so they leave her alone and try again later. RP was unaware of the policy of wetting a resident's clothes and stated she did not approve of this process. Record review on 09/23/2021 for abuse training revealed 08/20/2019 to be the last staff in-service for abuse and neglect. In an interview on 09/23/2021 at 4:15 p.m., the Administrator, who is the abuse coordinator, stated, I am sure we have had something more current. Administrative staff was unable to provide any documentation of additional in-service training for abuse and neglect. In an interview on 9/23/21 at 2:47 p.m. MA B revealed on 7/6/21 she heard Resident #1 yelling in the shower room with CNA A. Revealed she reported the incident to Administration immediately. MA B revealed it has been a while, more than 5 months since she had been trained in abuse, neglect, or exploitation in the facility. In an interview on 9/24/21 at 10:50 a.m., the Assistant Administrator confirmed Laundry Aide F came to me to report what had happened and we went to [Administrator] because he is the administrator and the abuse coordinator. She further added that Laundry Aide reported being in the hallway and seeing CNA A take the 2 dolls (babies) away from Resident #1. The Assistant Administrator states we started investigating then and the only one I remember saying they saw CNA A wet Resident #1's clothes was CNA I. In an interview on 9/25/21 at 9:13 a.m., the Administrator confirmed the facility had not reported Resident #1's incident to HHSC until 07/08/2021 as he stated there was confusion on which resident had been involved in the incident and he had to initiate an investigation to obtain more information. He further added that as part of the investigation, the administrator, the assistant administrator and the DON had spoken with several staff on duty including [CNA A] and obtained statements from two of them. The administrator added but the girl who first came to us wouldn't write a statement. A counseling record was completed, CNA A was placed on 3 days suspension, and we reported it to the state. the administrator stated. In an interview on 09/25/2021 at 10:15 am, the DON stated it's not so much a policy as a procedure, a way to help the staff know how to get these people clean. You know we get a lot of people in here from APS with feces and dirt on them and I'm not going to tell you how they treat them at the State hospital. I didn't tell them to spray her with a hose but you have to get them clean and if starting with their clothes on is how you have to do it, they don't remember (as she points to her head) but they are ok. The DON added but the girl (CNA G) that is here today will do her best and she (Resident #1) will probably refuse and so she won't get a bath today and that will be the way it is today In an interview on 9/25/21 at 2:20 p.m. the DON stated CNA A is a good CNA and the DON's teaching must have been misinterpreted. The DON stated Resident #1's babies should not have been taken away and instead found another way. The DON further stated she felt CNA A was appropriate in wetting the resident to get her to take her clothes off and emphasized Gently wetting the resident. The DON further stated, you do what you have to do, the state hospital does it, the police, the fire department. The DON confirmed the facility is not any of those entities. The DON denied wetting the resident against her will to get her to take her clothes off was abuse and stated she won't remember it due to her dementia and emphasized her point by pointing to her head and stated they don't remember anything, and are not harmed. The DON then reported CNA A will be working nights now because there are no showers on nights and there is an LVN to supervise CNA A. The DON confirmed there were 4 nurses and herself on duty when the incident happened. Record review of the facility's policy titled, Abuse Policy, dated 03/2004, revealed, Abuse Prohibition Regulations: F-223- The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Record review of the document used as the facility's policy, according to the RN Consultant, titled, Resident Rights, from the Nursing Facility Requirements for Licensure and Medicaid Certification, dated April 2008, revealed, Dignity and Respect: You have the right to . be free from abuse, neglect, and exploitation, be treated with dignity, courtesy, consideration and respect. Freedom of Choice: You have the right to .make your own choices regarding personal affairs, care, benefits, and services. The facility Administrator was notified an IJ had been identified on 09/23/21 at 5:51 p.m. The IJ template was provided, and a plan of removal was requested. The facility's Plan of Removal was accepted on 06/05/2021 at 4:59 p.m. and included: This is our letter for San [NAME] Nursing Center plan of removal for IJ component Noncompliance dated 9/23/21. Supervisory staff will be in-servicing on all components of the IJ. In services began at 6:00Pm and are ongoing until all staff members are in-serviced. Component one: Noncompliance 1. The policy that was shown to the surveyor has been cancelled and a new policy Bathing Policy for Residents was implemented as of 9/23/21. [CNA A] was in-serviced on 9/23/21 on ANE policy, new protocol dated 9/23/21 Bathing Policy for Residents who refuse showers, and the Director of Nurses, Assistant Director of Nurses and the Assistant Administrator trained [CNA A] on the facility policies completed a Nurse Aide Performance Review. On 9/23/21 the facility started in-servicing all staff members on the ANE policy, nursing staff is being in-serviced on bathing policy for residents, and competency evaluations are being conducted. On 9/23/21 all staff members were in-service on the ANE policy. In addition, the new bathing policy and procedure was started on 9/23/21; Coupled with the Nurse Aide Performance Reviews. The new bathing policy includes if a resident refuses a shower the resident will be offered a bed bath. If the resident refused the bed bath they will be asked as resident if they prefer the bed bath at a different time, If the resident still refuses will stop and informed the charge nurse. The Administrator and Assistant Administrator are conducting the Abuse, Neglect, and Exploitation and the Nurse Supervisor, Director of Nurses and the Assistant Director of Nurses are conducting the in-service for the Bathing Policy for Residents who refuse showers and the Nurse Aide Performance Reviews. C,N,A.'s are being monitored by charge nurses and treatment nurses every shift on a continuous bases the bathing procedures They are also being monitored by DON and ADON on a daily basis Monday through Friday and the weekend RN on weekends. 2. This incident was reported to the Assistant Administrator on 7/7/21 at around 1:00PM the allegation for resident for [Resident #5]. [Laundry Aide F] stated that the incident had happened the previous day on 7/6/21 and that she had witness it. When asked to write a statement she refused. On 7/7/21, the facility immediately initiated an investigation and on 7/8/21, the facility determined through interviews that correct resident was [Resident #1] and not [Resident #5]. On 7/8/21, it was called through HHSC website TULIP. 3. On 7/23/21 The Administrator and Assistant Administrator are currently conducting the Abuse, Neglect, and Exploitation and the Register Nurse Consultant, Director of Nurses and the Assistant Director of Nurses are conducting the in-service for the Bathing Policy for Residents who refuse showers and the Nurse Aide Performance Reviews. Component two: Serious injury, serious harm, serious impairment or death: C.N.A. will not shower a resident who refuses to be showered; a bed bath will be offered instead, as per protocol, Bathing residents who refuse shower or baths dated 9/23/21. C.N.A.'s will be in-serviced about conducting water temperatures before beginning to shower a resident, to ensure that the water temperature (not too hot or cold). Component three: Need for Immediate Action: The facility will ensure that staff is trained on abuse and neglect to include reporting and ensuring their understanding. This training is currently in progress. The facility will ensure that Nursing Staff is trained on proper showering and bathing techniques when dealing with residents with memory problems (Bath Policy for residents who refuse to be showered) or those refusing care and ensuring their understanding. The new bathing policy includes when a resident refused a shower a bed bath will be offered. If the resident refused a bed bath the C.N.A. will stop and notify the charge nurse who will then communicate with the resident about possible alternative bathing times and methods. The training is currently in progress. The training of all nursing staff on bathing procedures are currently being conducted by the D.O.N. and the A.D.O.N. The RN Consultant will monitor on a weekly basis, the new bathing policy and procedure. On 9/24/21 a copy of the new bathing policy and procedures were provided to the surveyor. The DON was trained by the RN consultant on the new bathing policies and procedures. All new policies and procedures will be reviewed by the Administration Committee composed of Administrator, RN Consultant, DON, and General Manager before they are implemented. The new bathing policy and procedures we reviewed and on 9/23/21 and 9/24/21 and approved by the Administration Committee and a copy was given to the surveyor. The new bathing policy's and the policy and procedure will be reviewed by the Quality Assurance Committee on a quarterly basis. STAFF MEMBERS WHO ARE ON VACATION, SICK, OR UNABLE TO BE REACHED, WILL NOT BE ALLOWED TO BACK TO WORK UNTILL IN-SERVICED ON THE ABOVE SUBJECT MATTERS. INSERVICE STARTED ON 9/23/21 AT AROUND 6:00PM. The survey team confirmed the plan of removal had been implemented sufficiently to remove the IJ by: Observation and interview on 9/25/21 at 2:30 p.m. CNA K reported she has been here for 6 days and denied any knowledge of abuse or neglect at the facility. CNA K further stated the staff are very helpful and kind. CNA K offered a shower to Resident #3 and resident refused and stated through a Spanish interpreter that CNA A had showered her yesterday and she did not need another one. The Resident #3 then agreed to let CNA K wash her face and stated that her [family member] was coming to see her. CNA K gathered her equipment and basin of warm water and wash cloths. CNA K spoke slowly and asked permission and kept the resident informed of what she was doing. Resident #3 was asked if she was doing ok and nodded her head yes. CNA K washed, rinsed and dried residents face and neck with no concerns observed. CNA K stated if a resident refused a shower, she will notify the nurse and try other times or in this case washing at least the resident's face or whatever they will allow. CNA K reported it would not be okay to wet a resident's clothing against their wishes. Observation and interview on 9/25/21 at 3:15 p.m., CNA E and CNA G knocked and entered Resident # 4's room. Resident #4 was lying in bed and staff explained they were going to shower resident. Resident #4 was irritated slightly but agreed. Surveyor introduced self to Resident #4 and resident stated, uh oh and smiled. Resident #4 gave permission for surveyor to watch her shower and laughed. Staff turned resident and removed her brief and rolled her on to a lift sling. Resident #4's brief was clean and dry when removed and no skin issues observed. Resident moaned a couple of times, but staff was gentle and slow with resident and spoke to her and kept her informed of what they were doing, and the next steps and resident would state ok. Mechanical lift transfer to shower chair by two staff without incident. Resident smiled at surveyor throughout and appeared comfortable. Resident was completely covered and taken to the shower room. One CNA showered Resident #4 while the other CNA prepped the room and handed soap and other items to the one showering the resident. CNA E checked the water temperature with her gloved hand and on her arm before placing it on resident and tested it on resident's feet and legs before moving to resident's upper body. Resident #4 yelled out and staff immediately removed and tested the water again and asked resident what was wrong. Resident #4 did not answer, and staff started showering resident again and resident stated she wanted the water warmer and staff adjusted the water and resident was satisfied. Staff spoke to resident calmly and informed of each step prior to doing it. Staff spoke to resident about things in general during her shower as well. Resident#4 was in good spirits throughout. Shower was completed without issues or concerns; the resident was rinsed, and towel dried by staff. CNA E and CNA G denied any knowledge of abuse or neglect and denied being instructed to wet a resident's clothing to get them to take a shower and both reported that would not be okay to do. Both staff further reported if a resident refused a shower, the nurse would be notified, and staff would try again later, or the nurse would try to talk to the resident but stated a resident would not be forced. Observation and interview on 9/25/21 at 4:03 p.m. Resident #1 in bed awake and her two dolls (her babies) on the resident's left side with the blanket not covering the dolls but the dolls were wrapped in a towel. Resident #1's speech was jumbled and unable to make out most words. I introduced myself and asked permission to come further into her room. Once I reached the middle of the room the resident reached out to surveyor with her hand and as I approached resident grabbed surveyor's hand and gently squeezed it in greeting and then let go. Resident #1's speech is jumbled but would speak each time surveyor asked a question. When asked about her babies resident's facial expression changed, and Resident #1 reached over and pulled her babies closer to her side and back and Resident #1 then just stared at surveyor and kept her hand on her babies. I assured Resident #1 that I was only mentioning her babies because they were pretty babies and I was not going to touch them. Resident #1 immediately released her dolls and began with jumbled speech. I then asked Resident #1 if her babies were a boy and a girl and resident motioned towards her babies and continued with jumbled speech but was able to understand the word girl in her speech. I thank the resident for letting me talk to her and see her babies and resident grabbed surveyor's hand and gently squeezed in a goodbye gesture and waved at me as I was exiting the room. In an interview on 9/26/2021 at 3:00 pm the RN Consultant revealed CNA A had been terminated from the facility. She added, she and the GM discussed the incident and that even though the DON had moved her to nights where there were no showers, she (CNA) could go anywhere and do anything at night. She then said, I just can't have that feeling that someone like that could be here. Further interview revealed the RN Consultant had researched additional information on the types of abuse and posted flyers in the facility. She stated new training had been initiated as of that morning and all staff would be re-trained. In an interview on 9/26/21 at 3:00 p.m., the RN Consultant revealed she had provided the DON with training on the facility's new showering policy and that all but 3 direct care staff, who were scheduled to come in the following day had completed the training. In an interview on 9/26/21 at 3:30 p.m. the DON confirmed she had been trained on the new showering protocol and demonstrated knowledge of residents' right to refuse and residents not being wet in the shower with their clothes on. Further interview and record review revealed direct care staff had completed nurse aide performance reviews (including the showering/ bathing tasks). In an interview on 9/27/21 at 1: 00 p.m. CNA G was able to demonstrate knowledge of treating residents with dignity and respect, the process for caring for residents who refused showers/ bed baths (including nurse notification). CNA G demonstrated knowledge of abuse/ neglect prohibition, identification, and reporting concerns for actual or suspected abuse or neglect. In an interview on 9/27/21 at 1:03 p.m. CNA H demonstrate knowledge of treating residents with dignity and respect, the process for caring for residents who refused showers/ bed baths (including nurse notification). CNA H demonstrated knowledge of abuse/ neglect prohibition, identification, and reporting concerns for actual or suspected abuse or neglect. An observation on 9/27/21 at 1:10 p.m. revealed CNA G and CNA H perform hand hygiene and began the process of asking Resident #1 if she was ready to take a shower. CNA G asked Resident #1 if she was ready for her shower and Resident #1 stated No, I'll shower tomorrow. CNA H asked if she wanted to shower/bed bath, Resident #1 held her baby dolls close and said, I'm no doing anything, because I'm sleeping with my babies. Resident #1 appeared in bed with 2 baby dolls she referred to as her babies, she appeared clean and well groomed, room was clean and in good repair, no foul odors detected. Demonstrated knowledge of checking the water temperatures prior to showering residents to ensure it was warm. In an interview on 9/27/21 at 1:15 p.m. LVN C revealed the staff were to offer residents a shower and if they refused, they were to offer a bed bath, if refused the aide should notify the charge nurse, who will try again and notify the resident's family the resident refused. Demonstrated knowledge of checking the water temperatures prior to showering residents to ensure it was warm. LVN C demonstrated knowledge of abuse/ neglect prohibition, identification, and reporting concerns for actual or suspected abuse or neglect. In an interview on 9/27/21 at 3:20 p.m. the DON revealed nursing staff were being in-serviced on monitoring resident showers daily to ensure proper technique and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of in-service logs provided by the DON confirmed training. In an interview on 9/27/21 at 3:38 p.m. LVN C and LVN D confirmed they had been in-serviced on monitoring resident showers every shift according to the shower schedule and to document in the binder at the nurse's station. Record review of in-service logs provided by the DON and RN Consultant confirmed 34 of 36 direct care staff completed training on updated showering/bathing policy. Verification interviews for 25 of 36 direct care staff from 1st, 2nd, and 3rd shifts completed. Record review of in-service logs provided by the Administrator and RN Consultant confirmed 52 of 52 staff members completed training on abuse, neglect and exploitation for all staff. Verification interviews for 36 of 52 staff members completed. On 09/27/21 at 6:30 p.m. the Administrator was notified the immediacy was lifted. The facility remained out of compliance at a potential for more than minimal harm with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on observation, interview, and record review the facility failed to ensure the resident's right to be free from abuse for 1 of 7 residents (Resident #1) reviewed for abuse in that: CNA A placed Resident #1 in the shower while clothed, intentionally wet her clothes to encourage her to remove them, and Resident #1 was made to shower against her will. The DON developed/wrote a policy directing staff to wet residents clothings when they refuse to bathe to get them to shower. Resident #1's comfort items (baby dolls) were taken away from her against her will and over her stated objection. This failure resulted in identification of an Immediate Jeopardy (IJ) on 09/23/2021 at 5:12 p.m. While the IJ was removed on 09/27/2021, the facility remained out of compliance at a severity of no actual harm, but with potential for more than minimal harm that is not IJ with a scope identified as isolated due to the facility requiring more time to monitor and assess the plan of removal for effectiveness to ensure the safety of the residents from physical, verbal, and psychosocial harm. This deficient practice could place residents at risk for physical, verbal, and/or psychosocial harm. The findings were: Record review of Resident #1's face sheet dated 7/13/2021 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Annual MDS, dated [DATE], revealed no BIMS score as the Cognitive assessment was not completed with the resident. Further review revealed a staff assessment for mental status had been completed that revealed short-term and long-term memory problems. Memory/Recall ability indicated resident unable to recall current season, location of own room, staff names and faces, that she is in a nursing home and noted residents' cognitive skills to be severely impaired. No behavior issues, such as refusal of care were identified on MDS. Record review of Resident #1's Care Plan, dated 05/11/2021, revealed a problem area: Bathing. Further review revealed Goals: resident will bathe 3x per week, resident will wash upper extremities, resident will wash face and hands, resident will accept assistance with bathing. Further review revealed Interventions: encourage resident to participate in bathing, and praise accomplishments, allow sufficient time for bathing and break tasks down into manageable segments. Record review of Resident #1's Care Plan, revealed no problem areas with resident refusing bathing or behaviors. Record review of Resident #1's Care Plan, revealed a problem area dated 05/11/2021, Carries her babies (2) dolls and a problem area dated 07/08/2021, May refuse care, labs, Tx secondary to confusion, disorientation. Further review revealed Goals: Will have good care to promote good quality of life and well-being. Further review revealed Interventions: Reapproach when refusing, notify RP, Dr when refusing. Document/explain, praise when good. Record review of the facility's provider investigation report, completed by the administrator, dated 07/13/2021, revealed an employee counseling record for CNA A dated 07/07/2021, with date of occurrence 07/06/2021, which stated, Reason for counseling, Employee used inappropriate approach to solving a problem she had why showering a resident who had refused to shower. Employee told resident I'll take your babies away when she could have showered resident with the dolls in her hand. Remarks by counselor, The resident began to yell when employee proceeded to wet resident's clothes in an effort to have resident to agree to remove clothes and take the shower. Employee's Remarks, Employee had been informed by the DON as to how to bathe someone who is offensive with body odor and needs to be bathed. This included wetting the clothes in hopes that the resident will agree to remove clothing and shower. Action to be taken, Suspension x3 days pending the investigation of incident that may have been reported erroneously by other employees who overheard the incident. Record review of CNA A's personnel file revealed an additional employee counseling record dated 08/09/2019, with date of occurrence 08/05/2019, which stated, Reason for counseling, Employee speaks in a loud voice and can be heard by other employees, residents and family members. Remarks by Counselor, Employee has been informed to speak to residents in a calm and low tone. Employee has been informed not to speak in a loud voice and use a relaxing voice. Employee's remarks, Mi vos es Aci no Tengo otra Marera de avtar voi a Trator de Modificor Mi vos [NAME] Aci avto losiento. [This is my voice; I don't have any other way of speaking. I will try to modify my voice. Sorry, but this is the way I speak.] Action to be taken, Employee has been placed on a 90-day probation, any further violation can result in suspension or termination. Record review of the facility's a policy titled, Policy for providing care to difficult residents when refusing nursing care, dated 11/04/2020, revealed When residents are refusing to bathe, and they are offensive to others, with body odor, will be taken to the shower by two CNA's, and showered. This may involve wetting the clothing gently, with desired temperature of the water, as this procedure usually prompts the resident to want to change clothes because they are wet, and while removing the wet clothing, the bathing can begin at the same time, and the resident will participate more willingly. Explaining, and reassuring them all the while, will make it easier to accept the process, even with the most demented or confused resident. Record review of the facility's policy titled, Abuse Policy, dated 03/2004, revealed, Abuse Prohibition Regulations: F-223- The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Record review of the document used as the facility's policy, according to the RN Consultant, titled, Resident Rights, from the Nursing Facility Requirements for Licensure and Medicaid Certification, dated April 2008, revealed, Dignity and Respect: You have the right to . be free from abuse, neglect, and exploitation, be treated with dignity, courtesy, consideration and respect. Freedom of Choice: You have the right to .make your own choices regarding personal affairs, care, benefits, and services. An interview on 9/22/2021 at 9:45 am, Laundry Aide F stated she reported the incident of CNA A wetting Resident #1, that occurred on 07/06/2021, to my supervisor, the Assistant Administrator, because didn't feel comfortable, didn't think it's the right way to talk to a resident. Laundry Aide F added she was in the hallway on her break and CNA A took Resident #1's babies away and then she could hear Resident #1 yelling in the shower. In an interview on 09/22/2021 at 10:18 am, the DON confirmed she wrote the policy, Policy for providing care to difficult residents when refusing nursing care. She states she learned the process working at the state hospital and it works well when you have people who won't shower. Their odor becomes offensive to others and you can't let that happen. We just wet their clothes with a little water and that usually makes them want to remove their clothes. No one wants to be in wet clothes, like the feeling if you peed your pants. Observation on 09/22/2021 at 10:25 a.m. revealed Resident #1 was walking in the hallway. Further observation revealed her holding 2 dolls closely with a small blanket wrapped around them. In an interview with MA B on 09/22/2021 at 10:28 a.m., MA B stated that's her [Resident #1] babies, she's very protective of them In an interview on 9/22/2021 at 4:15 pm, utilizing the RN Consultant as a Spanish interpreter, CNA A stated she gave Resident #1 a shower the way she has been told to by the DON. When CNA A was asked if she was aware of the policy allowing to wet clothing she stated yes, that is how we do it. CNA A stated she took Resident #1's dolls from her and walked into the shower with them. CNA A stated she placed them on the ledge in the shower until shower was completed. CNA A confirms Resident #1 did not want to undress for her shower so she wet her clothes so she would want to take them off. An interview on 09/23/2021 at 11:00 am, with the RN Consultant revealed she was unaware of the bathing policy prior to the interview with CNA A. She states it is very controversial, felt the DON to be old school and she will be changing the policy immediately. She further added that herself and the GM held a meeting early this morning with the Administrator and DON to inform them that before implementing a new policy and procedure it will be reviewed and approved by administration committee, which includes the Administrator, DON, RN Consultant and General Manager. Record review on 09/23/21 of Resident #1's medical record revealed a progress note dated 07/08/2021 written by the DON, that stated the RP had been informed the resident was OK and had no mental disturbance or physical injury from being bathed against her wishes. The DON's progress notes also stated, I also told [RP] there is a way the staff handles a situation like that and the [RP] understood. States 'OK as long as [Resident #1] is OK. In an interview on 9/23/21 at 12:55 p.m., Resident #1's RP stated the DON contacted (RP) and stated there had been an issue with [Resident #1's] shower in that they are supposed to have 2 staff assist and only had one staff present and Resident #1 had become very upset. RP stated she was told in the past [Resident #1] refused showers at times so they leave [Resident #1] alone and try again later. RP was unaware of the policy of wetting a resident's clothes and stated she did not approve of this process. In interviews on 9/23/2021 between 1:10 pm and 2:25 pm, MA B, the ADON, CNA I, CNA G, and LVN J all confirmed they were unaware of the bathing policy that included wetting residents as a method for them to use for residents who refused to bathe. In an interview on 9/23/21 at 2:47 p.m. MA B revealed on 7/6/21 she heard Resident #1 yelling in the shower room with CNA A. Revealed she reported the incident to Administration immediately. MA B revealed it has been a while, more than 5 months since she had been trained in abuse, neglect, or exploitation in the facility. In an interview on 9/23/21 at 2:55 p.m., Laundry Aide F revealed on 7/6/21 she was sitting across from the nurse's station when she saw CNA A using Resident #1's dolls to get her to go into the shower. Laundry Aide F revealed she heard CNA A tell Resident #1 I'm not going to give you your babies if you don't shower. Laundry Aide F revealed she reported the incident to the Assistant administrator on or about a day later, and she had not removed Resident #1 from the situation on 7/6/21 when it happened but stated It [the incident] really bothered me. Laundry Aide F revealed she had no recent training from the facility on abuse, neglect, or exploitation, but she knew if staff witnessed any abuse or suspected abuse they were expected to remove the resident as soon as possible and report any incidents to Administration immediately. Laundry Aide F was not able to state why she had not reported Resident #1's incident with CNA A to Administration immediately. Record review of nurse aid competencies revealed several CNA's were not current. In an interview at the same time with the ADON, she stated, she was attempting to catch up but had not been able to get them done due to COVID. Further record review for abuse training revealed 08/20/2019 to be the last staff in-service for abuse and neglect. In an interview on 09/23/2021 at 4:15 p.m., the Administrator, who is the abuse coordinator, stated, I am sure we have had something more current. Administrative staff was unable to provide any documentation of additional in-service training for abuse and neglect. In an interview on 9/24/21 at 10:50 a.m., the Assistant Administrator confirmed Laundry Aide F came to me to report what had happened and we went to [Administrator] because he is the administrator and the abuse coordinator. She further added that Laundry Aide reported being in the hallway and seeing CNA A take the 2 dolls (babies) away from Resident #1. The Assistant Administrator stated we started investigating then and the only one I remember saying they saw CNA A wet Resident #1's clothes was CNA I. In an interview on 9/24/21 at 12:40 p.m., Resident #2 stated I have heard [Resident #1] yelling in the shower, she doesn't like the water they say but she is fine when she comes out. They have to get her clean or she will start to smell. In interviews on 9/24/2021 between 12:45 pm and 1:20 pm, Resident #2, Resident #3, Resident #4, Resident #6, Resident #8 and Resident #9 all confirmed they were unaware of the bathing policy that included wetting residents who refused to bathe. Resident #9 added of course we wouldn't know about something like it because we could speak up for ourselves, so no one is going to do something like that to someone like me. In an interview on 9/24/21 at 2:30 p.m., MA B provided a witness statement, I [MA B] hear [CNA A] tell [Resident #1] time for her shower Went to [Resident #1] room to grab her clothes come out out room [Resident #1] did not went to go with her, [CNA A] took her dolls away from [Resident #1], [Resident #1] follow her saying she went her baby, so [Resident #1] went into the shower, because [CNA A] put her baby in the shower room shelve. In an interview on 9/24/21 at 2:45 p.m., Laundry Aide F provided a witness statement, I [Laundry Aide F] saw. I was sitting at a chair on East on my break 15 min. What I heard [CNA A] telling the resident, hurry hurry if not I am not going to give you your baby's back [CNA I] went to the shower room where [Resident #1] (the resident and [CNA A] were. [CNA I] asked her why she was wetting her with her clothes on? In an interview on 9/25/21 at 9:13 a.m. the Administrator confirmed the facility's new showering policy had been updated according to the process put in place by the General Manager and RN Consultant, the direct care staff had been in-serviced and remaining staff will be in-serviced before they can return to work. Further interview confirmed the facility had trained CNA A on the abuse, neglect, and exploitation policy and the new protocol, and CNA A had a nurse aide performance review completed. In this same interview on 9/25/21, the Administrator confirmed the facility had not reported Resident #1's incident to HHSC until 7/8/21 as he stated there was confusion on which resident had been involved in the incident and he had initiated the investigation to obtain more information. He further added that as part of the investigation, the administrator, the assistant administrator and the DON had spoken with several staff on duty including [CNA A] and obtained statements from two of them. The administrator added but the girl who first came to us wouldn't write a statement. A counseling record was completed, CNA A was placed on 3 days suspension, and we reported it to the state. the administrator stated. In an interview on 09/25/2021 at 10:15 am, the DON, stated about the previous policy, it's not so much a policy as a procedure, a way to help the staff know how to get these people clean. You know we get a lot of people in here from APS with feces and dirt on them and I'm not going to tell you how they treat them at the State hospital. I didn't tell them to spray her with a hose but you have to get them clean and if starting with their clothes on is how you have to do it, they don't remember (as she points to her head) but they are ok. The DON added but the girl (CNA G) that is here today will do her best and [Resident #1] will probably refuse and so [Resident #1] won't get a bath today and that will be the way it is today In an interview on 9/25/21 at 2:20 p.m. the DON stated CNA A is a good CNA and the DON's teaching must have been misinterpreted. The DON stated Resident #1's babies should not have been taken away and instead found another way. The DON further stated she felt CNA A was appropriate in wetting the resident to get her to take her clothes off and emphasized Gently wetting the resident. The DON further stated, you do what you have to do, the state hospital does it, the police, the fire department. The DON confirmed the facility is not any of those entities. The DON denied wetting the resident against her will to get her to take her clothes off was abuse and stated she won't remember it due to her dementia and emphasized her point by pointing to her head and stated they don't remember anything, and are not harmed. The DON then reported CNA A will be working nights now because there are no showers on nights and there is an LVN to supervise CNA A. The DON confirmed there were 4 nurses and herself on duty when the incident happened. In an interview on 9/27/21 at 1:30 p.m., CNA I provided a witness statement, I [CNA I] was walking to answer a call light, when I saw [CNA A] was walking with [Resident #1] then took the dolls from her arms. So [CNA A] said 'Let's go shower' and [Resident #1] said 'no.' I told [CNA A] let me try to get her shower room. So [Resident #1] walk in to change her brief. She agreed me and [Resident #1] went into shower room. [Resident #1] sat down on shower chair then [CNA A] came in. I told [CNA A] do you need help. She said no, I got from here. I walk out to wash hands from around corner then I heard yelling, [Resident #1] saying 'don't wet me stupied', I walked into shower room and [CNA A] was lightly wetting her. I told don't do that get help. [Resident #1] had a dress on. Then she [CNA A] stopped the water and I went to tell nurse. The facility Administrator was notified an IJ had been identified on 09/23/21 at 5:51 p.m. The IJ template was provided, and a plan of removal was requested. Plan of Removal for Immediate Jeopardy (quoted as written in Administrator's format and wording). This is our letter for San [NAME] Nursing Center plan of removal for IJ component Noncompliance dated 9/23/21. Supervisory staff will be in-servicing on all components of the IJ. In services began at 6:00Pm and are ongoing until all staff members are in-serviced. Component one: Noncompliance 1. The policy that was shown to the surveyor has been cancelled and a new policy Bathing Policy for Residents was implemented as of 9/23/21. [CNA A] was in-serviced on 9/23/21 on ANE policy, new protocol dated 9/23/21 Bathing Policy for Residents who refuse showers, and the Director of Nurses, Assistant Director of Nurses and the Assistant Administrator trained [CNA A] on the facility policies completed a Nurse Aide Performance Review. On 9/23/21 the facility started in-servicing all staff members on the ANE policy, nursing staff is being in-serviced on bathing policy for residents, and competency evaluations are being conducted. On 9/23/21 all staff members were in-service on the ANE policy. In addition, the new bathing policy and procedure was started on 9/23/21; Coupled with the Nurse Aide Performance Reviews. The new bathing policy includes if a resident refuses a shower the resident will be offered a bed bath. If the resident refused the bed bath they will be asked as resident if they prefer the bed bath at a different time, If the resident still refuses will stop and informed the charge nurse. The Administrator and Assistant Administrator are conducting the Abuse, Neglect, and Exploitation and the Nurse Supervisor, Director of Nurses and the Assistant Director of Nurses are conducting the in-service for the Bathing Policy for Residents who refuse showers and the Nurse Aide Performance Reviews. C,N,A.'s are being monitored by charge nurses and treatment nurses every shift on a continuous bases the bathing procedures They are also being monitored by DON and ADON on a daily basis Monday through Friday and the weekend RN on weekends. 2. This incident was reported to the Assistant Administrator on 7/7/21 at around 1:00PM the allegation for resident for [Resident #5]. [Laundry Aide F] stated that the incident had happened the previous day on 7/6/21 and that she had witness it. When asked to write a statement she refused. On 7/7/21, the facility immediately initiated an investigation and on 7/8/21, the facility determined through interviews that correct resident was [Resident #1] and not [Resident #5]. On 7/8/21, it was called through HHSC website TULIP. 3. On 7/23/21 The Administrator and Assistant Administrator are currently conducting the Abuse, Neglect, and Exploitation and the Register Nurse Consultant, Director of Nurses and the Assistant Director of Nurses are conducting the in-service for the Bathing Policy for Residents who refuse showers and the Nurse Aide Performance Reviews. Component two: Serious injury, serious harm, serious impairment or death: C.N.A. will not shower a resident who refuses to be showered; a bed bath will be offered instead, as per protocol, Bathing residents who refuse shower or baths dated 9/23/21. C.N.A.'s will be in-serviced about conducting water temperatures before beginning to shower a resident, to ensure that the water temperature (not too hot or cold). Component three: Need for Immediate Action: The facility will ensure that staff is trained on abuse and neglect to include reporting and ensuring their understanding. This training is currently in progress. The facility will ensure that Nursing Staff is trained on proper showering and bathing techniques when dealing with residents with memory problems (Bath Policy for residents who refuse to be showered) or those refusing care and ensuring their understanding. The new bathing policy includes when a resident refused a shower a bed bath will be offered. If the resident refused a bed bath the C.N.A. will stop and notify the charge nurse who will then communicate with the resident about possible alternative bathing times and methods. The training is currently in progress. The training of all nursing staff on bathing procedures are currently being conducted by the D.O.N. and the A.D.O.N. The RN Consultant will monitor on a weekly basis, the new bathing policy and procedure. On 9/24/21 a copy of the new bathing policy and procedures were provided to the surveyor. The DON was trained by the RN consultant on the new bathing policies and procedures. All new policies and procedures will be reviewed by the Administration Committee composed of Administrator, RN Consultant, DON, and General Manager before they are implemented. The new bathing policy and procedures we reviewed and on 9/23/21 and 9/24/21 and approved by the Administration Committee and a copy was given to the surveyor. The new bathing policy's and the policy and procedure will be reviewed by the Quality Assurance Committee on a quarterly basis. STAFF MEMBERS WHO ARE ON VACATION, SICK, OR UNABLE TO BE REACHED, WILL NOT BE ALLOWED TO BACK TO WORK UNTILL IN-SERVICED ON THE ABOVE SUBJECT MATTERS. INSERVICE STARTED ON 9/23/21 AT AROUND 6:00PM. Surveyor Verification of Plan of Removal was as follows: Observation and interview on 9/25/21 at 2:30 p.m. CNA K reported she has been here for 6 days and denied any knowledge of abuse or neglect at the facility. CNA K further stated the staff are very helpful and kind. CNA K offered a shower to Resident #3 and resident refused and stated through a Spanish interpreter that CNA A had showered her yesterday and she did not need another one. The Resident #3 then agreed to let CNA K wash her face and stated that her [family member] was coming to see her. CNA K gathered her equipment and basin of warm water and wash cloths. CNA K spoke slowly and asked permission and kept the resident informed of what she was doing. Resident #3 was asked if she was doing ok and nodded her head yes. CNA K washed, rinsed and dried residents face and neck with no concerns observed. CNA K stated if a resident refused a shower, she will notify the nurse and try other times or in this case washing at least the resident's face or whatever they will allow. CNA K reported it would not be okay to wet a resident's clothing against their wishes. Observation and interview on 9/25/21 at 3:15 p.m., CNA E and CNA G knocked and entered Resident # 4's room. Resident #4 was lying in bed and staff explained they were going to shower resident. Resident #4 was irritated slightly but agreed. Surveyor introduced self to Resident #4 and resident stated, uh oh and smiled. Resident #4 gave permission for surveyor to watch her shower and laughed. Staff turned resident and removed her brief and rolled her on to a lift sling. Resident #4's brief was clean and dry when removed and no skin issues observed. Resident moaned a couple of times, but staff was gentle and slow with resident and spoke to her and kept her informed of what they were doing, and the next steps and resident would state ok. Mechanical lift transfer to shower chair by two staff without incident. Resident smiled at surveyor throughout and appeared comfortable. Resident was completely covered and taken to the shower room. One CNA showered Resident #4 while the other CNA prepped the room and handed soap and other items to the one showering the resident. CNA E checked the water temperature with her gloved hand and on her arm before placing it on resident and tested it on resident's feet and legs before moving to resident's upper body. Resident #4 yelled out and staff immediately removed and tested the water again and asked resident what was wrong. Resident #4 did not answer, and staff started showering resident again and resident stated she wanted the water warmer and staff adjusted the water and resident was satisfied. Staff spoke to resident calmly and informed of each step prior to doing it. Staff spoke to resident about things in general during her shower as well. Resident#4 was in good spirits throughout. Shower was completed without issues or concerns; the resident was rinsed, and towel dried by staff. CNA E and CNA G denied any knowledge of abuse or neglect and denied being instructed to wet a resident's clothing to get them to take a shower and both reported that would not be okay to do. Both staff further reported if a resident refused a shower, the nurse would be notified, and staff would try again later, or the nurse would try to talk to the resident but stated a resident would not be forced. Observation and interview on 9/25/21 at 4:03 p.m. Resident #1 in bed awake and her two dolls (her babies) on the resident's left side with the blanket not covering the dolls but the dolls were wrapped in a towel. Resident #1's speech was jumbled and unable to make out most words. I introduced myself and asked permission to come further into her room. Once I reached the middle of the room the resident reached out to surveyor with her hand and as I approached resident grabbed surveyor's hand and gently squeezed it in greeting and then let go. Resident #1's speech is jumbled but would speak each time surveyor asked a question. When asked about her babies resident's facial expression changed, and Resident #1 reached over and pulled her babies closer to her side and back and Resident #1 then just stared at surveyor and kept her hand on her babies. I assured Resident #1 that I was only mentioning her babies because they were pretty babies and I was not going to touch them. Resident #1 immediately released her dolls and began with jumbled speech. I then asked Resident #1 if her babies were a boy and a girl and resident motioned towards her babies and continued with jumbled speech but was able to understand the word girl in her speech. I thank the resident for letting me talk to her and see her babies and resident grabbed surveyor's hand and gently squeezed in a goodbye gesture and waved at me as I was exiting the room. In an interview on 9/26/2021 at 3:00 pm, the RN Consultant revealed CNA A had been terminated from the facility. She added, she and the GM discussed the incident and that even though the DON had moved her to nights where there were no showers, she (CNA A) could go anywhere and do anything at night. She then said, I just can't have that feeling that someone like that could be here. Further interview revealed the RN Consultant had researched additional information on the types of abuse and posted flyers in the facility. She stated new training had been initiated as of that morning and all staff would be re-trained. In an interview on 9/26/21 at 3:00 p.m., the RN Consultant revealed she had provided the DON with training on the facility's new showering policy and that all but 3 direct care staff, who were scheduled to come in the following day had completed the training. In an interview on 9/26/21 at 3:30 p.m. the DON confirmed she had been trained on the new showering protocol and demonstrated knowledge of residents' right to refuse and residents not being wet in the shower with their clothes on. Further interview and record review revealed direct care staff had completed nurse aide performance reviews (including the showering/ bathing tasks). In an interview on 9/27/21 at 1: 00 p.m. CNA G was able to demonstrate knowledge of treating residents with dignity and respect, the process for caring for residents who refused showers/ bed baths (including nurse notification). CNA G demonstrated knowledge of abuse/ neglect prohibition, identification, and reporting concerns for actual or suspected abuse or neglect. In an interview on 9/27/21 at 1:03 p.m. CNA H demonstrate knowledge of treating residents with dignity and respect, the process for caring for residents who refused showers/ bed baths (including nurse notification). [NAME] demonstrated knowledge of abuse/neglect prohibition, identification, and reporting concerns for actual or suspected abuse or neglect. An observation on 9/27/21 at 1:10 p.m. revealed CNA G and CNA H perform hand hygiene and began the process of asking Resident #1 if she was ready to take a shower. CNA G asked Resident #1 if she was ready for her shower and Resident #1 stated No, I'll shower tomorrow. CNA H asked if she wanted to shower/bed bath, Resident #1 held her baby dolls close and said, I'm not doing anything, because I'm sleeping with my babies. Resident #1 appeared in bed with 2 baby dolls she referred to as her babies, she appeared clean and well groomed, room was clean and in good repair, no foul odors detected. Demonstrated knowledge of checking the water temperatures prior to showering residents to ensure it was warm. An observation on 9/27/21 at 1:15 p.m. revealed CNA G informed LVN C Resident #1 refused her shower and was told staff would return later. In an interview on 9/27/21 at 1:15 p.m. LVN C revealed the staff were to offer residents a shower and if they refused, they were to offer a bed bath, if refused the aide should notify the charge nurse, who will try again and notify the resident's family the resident refused. Demonstrated knowledge of checking the water temperatures prior to showering residents to ensure it was warm. LVN C demonstrated knowledge of abuse/ neglect prohibition, identification, and reporting concerns for actual or suspected abuse or neglect. In an interview on 9/27/21 at 3:20 p.m. the DON revealed nursing staff were being in-serviced on monitoring resident showers daily to ensure proper technique and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of in-service logs provided by the DON confirmed training. In an interview on 9/27/21 at 3:38 p.m. LVN C and LVN D confirmed they had been in-serviced on monitoring resident showers every shift according to the shower schedule and to document in the binder at the nurse's station. Record review of in-service logs provided by the DON and RN Consultant confirmed 34 of 36 direct care staff completed training on updated showering/bathing policy. Verification interviews for 25 of 36 direct [TRUNCATED]

Based on observation, interview and record review the facility failed to establish infection control measures to help prevent the transmission of infection and disease by bloodborne pathogens for 4 of 4 residents (#3,15,16 and 21) observed for blood sugar testing. 1. LVN E used the same lancet pen device on multiple residents to obtain blood for blood glucose tests. 2. LVN J failed to sanitize the glucometer after a blood glucose test on Resident #21. 3. CNA G failed to remove soiled gloves before using a clean cloth during perineal care on Resident #3. An Immediate Jeopardy (IJ) was identified on 04/14/2015. While the IJ was removed on 04/14/2015 prior to exit the facility remained out of compliance at a severity level of potential for more than minimal harm that is not Immediate Jeopardy and a scope of Pattern due to the plan of removal was still being monitored for compliance. This deficient practice placed 25 residents who required the use of a glucometer and a lancing device to obtain blood by fingerstick for blood glucose testing at risk of bloodborne infections; and placed 20 residents who were incontinent on the West wing at risk for transmission of infections. The Findings include: A. During observation of medication pass on 04/14/2015 at 7:00 a.m. LVN E was observed performing a fingerstick for blood glucose testing on Resident #16, using a lancing device (pen device used to obtain a blood sample). LVN E went back to the Nurse's cart, removed the lancet inside the pen, then reloaded the lancet pen with a new lancet, carried the items needed for testing the blood glucose to Resident #15's room. LVN E laid the glucometer and the loaded lancet pen on Resident #15's over bed table and picked up the loaded lancet pen and obtained a blood sample which she placed on the glucometer test strip (measures the blood sugar). LVN E picked up the items (glucometer and lancet pen) and took them back to the nurse's cart then removed the lancet from the pen and discarded the lancet into a sharps container (container used to dispose of used needles and sharp objects). She then placed the lancet pen and the glucometer back into the Nurse's cart without cleaning the items. Review of the face sheet, dated 03/26/2013, for Resident #15 revealed she was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #15's Consolidated physician's orders [REDACTED].#15 received blood glucose testing three times a day before meals and at night (HS). Review of the box for the Adjustable Lancing Device with Ejector revealed on the box the fourth bullet down Single patient use and on the brochure insert as statement that reads in part, CAUTION: SINGLE PATIENT USE ONLY. This device should not be used for assisted blood draws be healthcare providers in settings such as long term care, ., and should not be shared with anyone. Interview with LVN E on 04/14/2015 at 7:15 a.m., she confirmed she had not cleaned the glucometer and lancet device and they were to clean the glucometer and lancet device between residents and after use. Interview with LVN N on 04/14/2015 at 10:05 a.m. revealed an invoice receipt number , dated 09/05/2014 for the lancet pen. The facility began to use the lancet pen device the same day received around 09/05/2014. LVN N confirmed the lancet pen device was the only device used for all the residents that have blood sugar checks. These failures resulted in the identification of an IJ of which the facility General Manager, DON, and RN M were informed on 04/14/2015 at 10:10 a.m. During an interview with the General Manager, RN M, and DON on 4/14/15 at 10:15 a.m. revealed they were not aware of the CMS letter concerning the lancet pens. The surveyor explained that CMS had issued a S&C letter in August 27, 2010, which included as a directive that fingerstick devices must never be used for more than one resident. Interview with the RN M, on 4/14/15 at 10:15 a.m. revealed it was the facility's policy to disinfect the lancet pen between use and confirmed LVN E had not sanitized the lancet pen between use on residents. Further interview with RN M on 4/14/15 at 2:37 p.m. revealed she was not aware the lancet pen could not be used on more than one resident. Information posted by the Center of Disease Control, updated 2/9/11, at website http://www.cdc.gov/injectionsafety/Fingerstick-DevicesBGM.html contained the following in part: The shared use of fingerstick devices is one of the common root causes of exposure and infection in settings such as long-term care (LTC) facilities, where multiple persons require assistance with blood glucose monitoring. Risk for transmission of bloodborne pathogens is not limited to LTC settings but can exist anywhere multiple persons are undergoing fingerstick procedures for blood sampling . Recommendations Anyone performing fingerstick procedures should review the following recommendations to ensure that they are not placing persons in their care at risk for infection. Fingerstick devices should never be used for more than one person. Auto-disabling single-use fingerstick devices should be used for assisted monitoring of blood glucose. These recommendations apply not only to licensed healthcare facilities but also to any setting where fingerstick procedures are performed, . skilled nursing facilities, . Protection from infections, including bloodborne pathogens, is a basic requirement and expectation anywhere healthcare is provided. The facility submitted an action plan to remove the immediacy dated 04/14/2015 at 12:42 p.m. consisting of the following actions: 1. Nursing staff was in-serviced on proper procedure for infection control related to diabetes services. Content included glucometers which must be cleaned between residents, do not reuse lancets (discard in approved sharps container), no reusing finger stick devices (pen like devices) for more than one resident, finger stick devices that are non-disposable are not to be used on multiple residents (the device is to be used on one resident only), Completion date 04/14/2015 2. Diabetic residents who require blood glucose monitoring via finger stick use may be affected. 3. All nurses present in the facility have been in-serviced to use Single Use Lancets only on all residents. All other nurses are presently being called to the facility to be in-serviced on the policy and no nurse will be allowed to work until they are in-serviced. Completion date: 04/14/2015 4. All Adjustable Lancing Devices have been removed from all treatment carts and nurses station. Completion date 04/14/2015 5. Facility purchasing finger sticks will be single use only devices. Residents who purchase pen like devices will not be used on any other residents. Completion date: 04/14/2015 Verification of Plan: 1. One time use disposable lancing devices were purchased and were being used during observations of resident blood glucose testing. 2. No lancet pen devices were found in the medication cart or medication room. In an interview with the DON she stated all the lancet pen devices had been removed. 3. In services were conducted with the facility nurses on 04/14/2015 regarding the use of single stick lancing devices and cross contamination of resident to resident on blood related pathogens. In-services have also been conducted on 04/14/2015 regarding the cleaning of the glucometer before and after use on a resident and between residents. Completion date: 04/14/2015 4. Interviews conducted on 04/14/2015 and 04/15/2015 with the facility nurses to confirm in services were conducted. The Administrator, Nursing Supervisor and Director of Nurses was informed the IJ was removed on 04/14/2015 at 2:55 p.m. The facility remained out of compliance at a severity level of potential for more than minimal harm that is not Immediate Jeopardy and a scope of Pattern. A list provided by the RN M on 04/14/2015 at 10:59 a.m. revealed 25 residents received blood glucose testing. B. Observation on 4/14/15 at 11:32 a.m. of blood sugar checks performed by LVN J on Resident # 21, revealed she placed the glucometer in the medication cart drawer without sanitizing it after checking Resident # 21's Blood glucose level. During an interview on 4/14/15 at 11:35 a.m. LVN J confirmed that she did not wipe the glucometer down before placing it in the drawer, she stated she was going to sanitize it before the next blood sugar check. She confirmed that should have sanitized the glucometer before and after performing the blood sugar check. Record Review of Resident # 21's face sheet, undated, revealed a [DIAGNOSES REDACTED]. Review of the policy titled Cleaning of Glucometers , dated 10/27/10, revealed Glucometers wills be cleaned before and after use with disinfecting wipes to help prevent the spread of infectious material and other contaminants. C. Observation of CNA G on 4/13/15 at 3:02 p.m. revealed during perineal care on Resident #3 the CNA did not change her gloves after she wiped the resident ' s right soiled buttock with an incontinent wipe before she grabbed a clean wash cloth. With the same soiled gloves, CNA G repositioned the resident and placed the bedspread over the resident. Interview with CNA G on 4/13/15 at 3:15 p.m. confirmed she did not change her gloves after she handled the soiled wipe. The Resident Face Sheets, MAR's and Physician's Consolidated Orders were provided by the Doircetor of Nurses revealing there were 25 residents residing in the facility receiving glucose checks and a list was provided by the facility revealing there were 20 residents on the West wing who were incontinent.