Every finding on record at Schulenburg Regency Nursing Center

Based on interviews and record reviews, the facility failed to develop and implement a person-centered comprehensive care plan, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, physical, mental, and psychosocial needs for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement a care plan for Resident #1 that was individualized to her care needs, which included ADLs, activities, specialized diet, dementia and related behaviors.This deficient practice could place residents at risk of not having their needs met to attain their highest practicable well-being.Findings included: Record review of Resident #1's Face Sheet dated [DATE] reflected a [AGE] year-old female with an admitted to facility on [DATE] and discharged on [DATE]. Resident #1 had diagnoses included acute pulmonary edema(life threatening medical emergency where excess fluid rapidly accumulates in the lungs air sacs), heart failure, unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety ( a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and does not have any behaviors associated with unspecified dementia), muscle weakness ( a feeling or objective observation that reduced effort, such as attempting to lift or move, fails to produce normal muscle contraction), and coronavirus infection. Record review of Resident #1's admission MDS dated [DATE] reflected Resident #1 had a BIMS of 04, indicating severe cognitive impairment. The MDS also reflected Resident #1 had Dementia, Malnutrition, Therapy Services, Mechanically Altered Diet, and she required substantial / maximal assistance (helper does more than half the effort) with eating, oral hygiene, and toileting. Resident #1 was dependent on staff with showers and lower body dressing. Record review of Resident #1's Comprehensive Care Plan, reviewed on [DATE], with a start date of [DATE] reflected only 2 problem areas. Resident #1's Diet, Malnutrition, Dementia, Therapy, and ADLs were not documented on the comprehensive care plan.Interview conducted on [DATE] at 4:13PM, the Social Worker stated she has been employed at the facility for almost two years. She stated the MDS nurses place information on the comprehensive care plans. She stated the facility previously had another individual assist with developing the care plans; however, that person was no longer employed with the facility. The Social Worker stated that residents' activities of daily living (ADLs), diet, dementia, and behaviors are important areas that should be included in the comprehensive care plan. She stated the potential harm to residents is that staff may not be aware of the resident's goals, needs, and planned interventions if this information was not included in the comprehensive care plan.Interview conducted on [DATE] at 4:35 PM, the MDS Nurse A stated she had worked at the facility for one year. She stated the MDS nurses were currently responsible for developing and maintaining comprehensive care plans. She stated the facility previously had a dedicated care plan coordinator; however, that individual was terminated approximately one week after the facility's full book survey. She stated the MDS department assumed responsibility for the care plans again. The MDS Nurse A stated a comprehensive care plan should include essentially everything related to the resident's care. She stated areas such as ADLs, diet, activities, and treatments should be included in the care plan. She stated that when she completed Resident #1's last revision on [DATE], she probably entered enough information to clear the electronic alert. She stated she did not recall noticing that no additional care plan information had been entered. The MDS Nurse A stated the potential effect of an incomplete comprehensive care plan is that a resident may not receive the care and services needed.Interview conducted on [DATE] at 4:53 PM, the DON stated the facility identified in March during the annual recertification (full book) survey that resident care plans were not being completed as required. The DON stated the facility had hired an employee whose responsibility was to complete the resident care plans; however, the employee was terminated shortly after the full-book survey. The DON stated Resident #1's comprehensive care plan was in the process of being updated following completion of the resident's last MDS assessment. However, the resident expired before the care plan revision was completed. The DON stated the MDS nurse should have corrected the resident's care plan when it was last revised on [DATE]. The DON stated the potential outcome of an inaccurate care plan could lead to a resident receiving the wrong care.Record review of the facility's Care Plans, Comprehensive Person-Centered Policy, dated 2001, revised [DATE] reflected: Policy StatementA comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.Policy Interpretation and ImplementationI. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to:a. participate in the planning process;b. identify individuals or roles to be included;c. request meetings;d. request revisions to the plan of care;e. participate in establishing the expected goals and outcomes of care;f. participate in determining the type, amount, frequency and duration of care;g. receive the services and/or items included in the plan of care; andh. see the care plan and sign it after significant changes are made. 7. The comprehensive, person-centered care plan:includes measurable objectives and timeframes.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.any specialized services to be provided as a result of PASARR recommendations; andwhich professional services are responsible for each element of care.includes the resident's stated goals upon admission and desired outcomes.builds on the residents' strengths; andreflects currently recognized standards of practice for problem areas and conditions.

Based on observations, interviews, and record review the facility failed to ensure to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.The facility failed to ensure that the medications stored in the medication storage room [ROOM NUMBER] were not expired.This deficient practice could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment.The findings included:During an observation in medication room [ROOM NUMBER] on 3/9/2026 at 10:30am it was revealed that the following medications and other items were expired:Two bottles of Pro - Stat Concentrated Liquid Protein 30 fluid ounces. The date of expiry printed on it was January 21, 2026. One Miconazole Nitrate Vaginal Cream 4% vaginal antifungal with 2 applications in the box. The expiry date printed on it was September 2025.Two dressing change kit with Stat Lock. The expiry date printed on it was 08/20/2025.Eight sterile saline syringes. The expiry date printed on them was 10/2025.One bottle of Chardonnay contains approx. 1/2 bottle of wine, stored in the residents' refrigerator in the medication room. The opened date written on it was 5/18/2025.During an interview on 03/11/26 at 09:21 a.m., RN J stated that she was new to the facility and understood that the nurse in charge was responsible for removing expired items from the medication room. She added that the last time the medication room was checked for expired medications was on 03/04/26. She stated she did not know why expired medications were still present among the medications. When asked about the procedure for adding new items to residents' refrigerators in the medication room, RN J explained that all items should be labeled with the resident's name, the item, and the date it was opened. She stated that all open, unused items were discarded after three days. She also mentioned that the shelf life of white wine in the refrigerator was one week after opening. RN J stated that consuming expired medications and food items poses health hazards for residents.In an interview on 03/11/26 at 10:00 a.m., RN K identified himself as the charge nurse on that day. When the investigator inquired about who was responsible for removing expired items from the medication room, RN K responded that everyone was responsible for maintaining the medication room. He stated that staff check for expired items whenever a new shipment arrives, which occurs every Tuesday, and he was confident the room had been checked for expired items the previous Tuesday (03/03/26). RN K explained that expired items were stored in a designated, locked cabinet for destruction and the expired medications should not have been among the active medications . Regarding the procedure for adding new items to residents' refrigerators in the medication room, he stated they are labeled with the resident's name and the date, and that such items are generally good for 72 hours. He said that the consumption of expired food could cause gastrointestinal upset, nausea, and vomiting, and that using expired medications could compromise therapeutic effects or cause serious side effects.A phone call was placed to the facility pharmacist on 03/11/26 at 12:13 p.m., leaving a voice message requesting a callback. As of 05:00 p.m. on the same day, there had been no response.In an interview on 3/11/26 at 12:55pm with ADON A, she stated that she served as both the Assistant Director of Nursing and the Infection Preventionist. She stated that maintaining the medication room was everyone's responsibility. She explained that the medication room was updated on order days, which were typically Monday or Tuesday, and that expired items were stored in a locked cabinet designated for destruction. She described the process for storing items in the refrigerator as labeling them with the resident's name and date, with a shelf life of 72 hours once opened. When asked about the potential negative outcomes of consuming expired items, she stated that it could result in illness like stomach viruses, nausea, and vomiting. ADON A stated there were in-services conducted very often and she needed to see when an in service was conducted on medication storage recently.Record review of in-services files from September 2025 to 03/11/26 revealed there were no in-services on labelling , storage and destruction of expired medications.Review of the facility policy titled Storage of Medications revised November 2020 reflected : .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident# 17, and Resident #92) reviewed for ADL care.The facility failed to ensure Resident #17's and Resident #91's nails were cleaned and did not have any rough edges.This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem. Findings included: Record review of Resident #17's face sheet, dated 03/10/2026, reflected a [AGE] year-old male, admitted [DATE], with diagnoses: type 2 diabetes mellitus without complications ( a chronic metabolic disorder where the body develops insulin resistance and fails to use insulin properly without any complications), muscle weakness (a decrease in the ability to exert force with your muscles, meaning they do not contract or move as expected), cognitive communication deficit ( an impairment in communications skills- such as speaking, listening, or organizing thoughts), and lack of coordination (an inability to produce smooth, precise, and voluntary muscle movements).Record review of Resident #17's admission MDS, dated [DATE] reflected it was in progress. Record review of Resident #17's Baseline Care Plan, dated 03/02/2026, reflected Resident #17 required one person assist with personal hygiene, eating, toileting, dressing, bathing, and transfers.Observation and interview on 03/09/2026 at 10:25 am, revealed Resident #17 was sitting in his specialty chair in the common area near the lobby. He had a blackish/ brownish substance underneath the middle and ring fingernails on his right hand. Resident #17's middle fingernail on his right hand was uneven around the edges. Resident #17 did not respond to questions or conversation about his nails. He was not interview able.Record review of Resident #91's face sheet, dated 03/10/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: unspecified osteoarthritis, unspecified site (joint disease when the specific joints had stiffness without specifying if it is in the knees, hips, hands or other locations), muscle weakness (a decrease in the ability to exert force with your muscles, meaning they do not contract or move as expected), need for assistance in personal care ( help with bathing, dressing, grooming, toileting, meal preparation, mobility, medication management, and housekeeping), and stiffness in left and right shoulder ( a limitation in range of motion, often caused by inflammation, injury, or tightness in the muscles).Record review of Resident #91's Quarterly MDS Assessment, dated 01/22/2026, reflected Resident #91 had a BIMS score of 15 indication cognition was intact. Resident #91 required assistance with personal hygiene ( supervision or touching assistance- helper provides verbal cues and /or touching assistance). She required substantial/maximal assistance ( helper does more than half the effort) with the following: toileting hygiene, showers, and lower body dressing. Record review of Resident #92's Comprehensive Care Plan, dated 01/28/2026, reflected Resident #92 had an ADL self-care performance deficit. Interventions: bathing/showering: check Resident #92's nail length and clean on bath day and as necessary. Report any changes to the nurse. Assist resident with one staff as needed with personal grooming with difficult areas of grooming. Observation and interview on 03/09/2026 at 11:01 a.m., revealed Resident #91was in her wheelchair watching her favorite soap opera on television. She had very long fingernails on both hands. Resident #91's middle ring and fore fingernails on her right hand were rough around the edges. She stated on Saturday (03/07/2026) she asked a staff if she would trim and file her nails. Resident #91 did not recall the employee's name or their position. Resident #91 stated the person stated her nails would be trimmed and filed sometime next week. She stated she did not ask anyone else to assist her with her nails. Resident #91 stated the staff believes I can do my own nails, but I am getting where it is hard for me to file my nails. She stated I have arthritis and it hurts for me to attempt to do my own nails. Resident #91 stated she did not need any medication for her pain. She stated she preferred the staff to trim and file her nails. Resident #91 pointed to a scratch on her left arm approximately 5 inches above her wrist where she scratched herself with one of her fingernails that was rough around the edges. In an interview on 03/11/2026 at 9:30 a.m., LVN L stated the nurses were responsible for residents with diagnosis of diabetes with nail care such as trimming, cleaning, filing. He stated the CNAs were responsible for all other residents' nail care. LVN L stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill such as stomach problems, nausea, and vomiting. LVN L stated if a resident refused any type of care, the nurse would document the refusal in the nurse's notes. He stated Resident #91 and Resident #17 did not refuse nail care. He stated if a resident had uneven fingernails there was a possibility a resident may scratch themselves or someone else and cause a skin tear. He also stated a resident may scratch their eye and cause a tear in the eye. He stated he had been in- serviced on nail care, however, he did not recall the date. In an interview on 03/11/2026 at 10:05 a.m., CNA T stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA T stated the residents' nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill such as vomiting and diarrhea or an infection in their stomach. CNA T stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she was not aware of Resident # 92 or Resident #17 refusing nail care. She stated if any resident refused nail care, she reported it to the nurse. CNA T stated she was not sure where the nurse documented the refusal of nail care. She stated if a resident had long nails with rough edges there was a possibility the resident may scratch themselves and have a skin tear or scratch another resident causing a skin tear. She stated there was a possibility a resident may develop an infection if there were bacteria underneath the nail and the bacteria transferred to the open area on the skin. In an interview on 03/11/2026 at 10:25 a.m., the ADON stated the nurses were responsible to complete nail care such as trimming, filing, and cleaning once a week or as needed on residents with diagnosis of diabetes. The ADON stated the CNAs were responsible for nail care on all other residents (not diabetic) The ADON stated if a CNA noticed any concerns of a resident's nails, the CNA was expected to report any concerns to the nurse. The ADON stated if a resident had blackish substance underneath their nails there was a possibility a resident may become ill such as nausea or diarrhea depending on the type of bacteria. The ADON stated if a resident had rough edges around their nails, it was a possibility the resident may scratch themselves and develop a skin tear. She stated the nurse supervisors were responsible for monitoring the CNAs and nail care. Record review of the facility's policy on nail care, not dated, reflected to ensure residents receive routine nail care to maintain hygiene, comfort, and safety while preventing infection or injury. The facility will provide routine nail care to residents as part of daily personal hygiene and grooming. Nail care will be performed safely and in accordance with infection control standards, resident care plans, and applicable medical considerations. Basic hygiene services including cleaning under nails, filing nails, and trimming nails when appropriate. Routine nail care may include the following:Cleaning under nailsFiling rough edgesTrimming fingernailsApplying lotion to surrounding skin as needed.Routine nail care will be provided during bathing or other personal care activities as needed.

Based on observations, interviews and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of two kitchens reviewed for kitchen sanitation. The facility failed to ensure Dietary Assistant [NAME] D used proper hand hygiene during food preparation. These failures could place residents who ate food from the kitchen at risk for foodborne illness.Findings included: Observation and interview on 03/09/2026 at 12:15 p.m. revealed Dietary Assistant [NAME] D was holding the top of a clip board with both of her bare hands. There was a hard black substance covering the top of the clip board where Dietary Assistant [NAME] D had her fingers on her right and left hand touching the substance. Dietary Assistant [NAME] D placed the clip board on top of a shelf and she touched the right side of her scrub top with fingers on her right and left hand. Dietary Assistant [NAME] D walked to the steam table and picked up a divided plate with her left hand. Her fingers on her left hand were located inside the plate, and she placed food on the area where her fingers had touched the plate. She did this twice on two different plates. Dietary Assistant [NAME] D pulled the aluminum foil away from the chicken spaghetti and her fingers on both hands touched inside of the aluminum foil. Her fingers on her right hand touched the chicken spaghetti in the pan on the steam table. She never washed or sanitized her hands. She was interrupted from serving food and was asked if she washed her hands prior to serving food. Dietary Assistant [NAME] D stated she did not wash or sanitize prior to serving food. She immediately stopped serving food and sanitized her hands. Interview on 03/09/2026 at 12:40 p.m. Dietary Assistant [NAME] D stated the clip board did have black dirty stuff all over it. She stated she did touch the black substance and she did not wash her hands after she placed the clip board on top of the shelf. She stated she did touch her scrub top. She stated it was expected to wash her hands prior to serving food. Dietary Assistant [NAME] D stated the clip board and her scrub top was considered contaminated. She stated there was a possibility a resident may have bacteria on their plate or in their food transferred from her hands. Dietary Assistant [NAME] D stated if a resident swallowed food with bacteria on the food there was a possibility the resident may become physically sick with stomach issues such as vomiting and may need to be hospitalized . She stated she had been in-serviced on hand hygiene in February 2026, but she did not recall the exact date. Interview on 03/11/2026 at 12:05 p.m. The Dietary Supervisor stated all staff were required to wash hands between tasks and whenever they touched anything contaminated. She stated the clip board and clothes were considered contaminated. She stated there was a possibility bacteria moved from Dietary Assistant [NAME] D's hands onto residents' plates and food. She stated she did not recall the date of the in-service. She stated if a resident ingested some type of bacteria the resident may develop a food borne illness and may need to be transferred to the emergency room for evaluation if the resident became severely ill. She stated she in-serviced all staff in February 2026 on hand hygiene when preparing food. Record review of the Facility's Policy on Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, not dated, reflected Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. All employees must wash their hands: during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks and/or after engaging in other activities that contaminate the hands.

Based on observation, interviews, and record review, the facility failed to ensure residents received care, consistent with professional standards of care to prevent development or promote wound healing for one ( Resident # 6 ) of 3 residents reviewed for pressure ulcers. The facility failed to perform Resident #6's thorough skin assessments on Sunday 03/08/2026 new skin issues to right gluteus (buttock), rear left thigh, and right fourth toe. These failures could place residents at risk for worsening skin concerns leading to discomfort, pain, and potential infections. Findings included:Record review of Resident #6's face sheet, dated 3/10/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE], diagnoses included type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic- hyperosmolar coma (extremely high blood sugar (> 600 mg/dL), severe dehydration, and high blood concentration without significant ketone- chemicals produced by the liver from fat breakdown when the body lacks sufficient glucose for energy- production or deep coma), morbid obesity due to excess calories (a chronic disease defined by a body mass index of 40 or higher, or 35-39.9 related to health conditions like diabetes or heart disease), and malignant neoplasm of vulva, unspecified ( a rare, slow-growing cancer found on the external female genitalia, including the labia, clitoris, or perineum).Record review of Resident #6's Quarterly MDS Assessment, dated 02/25/2026, reflected Resident #6 had a BIMS score of 15 which indicated her cognition was intact. Resident #6 received PRN pain medications. She frequently was in pain. Resident #6 was at risk of Pressure ulcer/ injuries. She did not have any unhealed pressure ulcer/ injuries or other skin concerns. Resident #6 had a pressure reducing device for bed. She required substantial/maximal assistance ( helper does more than half the effort) with toileting hygiene, showers, and lower body dressing. Resident #6 required partial/moderate assistance - helper does less than half the effort with roll left to right, sit to lying, and lying to sitting on side of bed.Record review of Resident #6's Care plan revised on 03/09/2026 reflected Resident #6 was at risk for impaired skin integrity. Resident #6 had MASD to the right buttock and left thigh. Wound: Resident #6 had a diabetic ulcer on the 4th toe located on right foot. Interventions: MASD to right buttock and left thigh provide house barrier cream as needed, wound care/ treatments per orders, monitor resident and keep MASD clean and dry. Wound : Right foot- 4th toe- diabetic ulcer provide Corona Ointment every 2 hours or as needed. Wound Care- cleanse, pat dry, calcium alginate and dry dressing. Consult wound, ostomy ( an opening in the abdomen , allowing waste - stool or urine- to exit the body into a wearable, odor proof pouch when the digestive or urinary systems are damaged or diseased.)Evaluate skin for areas of blanching (temporary whitening or [NAME] of the skin that occurs when pressure is applied, displacing blood from the area)or rednessEvaluate skin for redness or excoriation (skin picking or scratching that results in skin damage, such as sores, lesions, or scabs)Provide skin care per facility guidelines as needed.Utilize pressure relieving devices on appropriate surfacesEncourage Resident #6 to frequently shift weightEducate Resident #6 and family on factors to maintain skin integrity. Record review of Resident#6's Weekly Skin Assessment, dated 03/01/2026, reflected the following: Skin color normalTemperature of the skin normalDid not have any of the following: discoloration, skin tear, abrasion, laceration, surgical incision, rash or moisture associated skin damage ( inflammation and erosion of the skin caused by prolonged exposure to moisture, such as urine, stool, sweat, or wound fluid).Did not have pressure, venous- poor drainage, arterial-poor blood flow or diabetic ulcer- from nerve damage.Did have supra pubic catheter and diagnosis of labia cancerThere were not any new areas that have not been communicated to the physician or family. Record review of Resident #6's Weekly Skin Assessment, dated 03/08/2026, reflected the following:Skin color normalTemperature of the skin normalDid not have any of the following: discoloration, skin tear, abrasion, laceration, surgical incision, and rash.Resident #6 did have Moisture Associated Skin DamageResident #6 did have a pressure, venous, arterial or diabetic ulcer.Resident #6 had other skin findings not described above: 2 skin tears, red open areas to buttocks, and 1 open area to right toe. There was not any new areas that have not been communicated to the physician/NP or family. Signed by LVN L.In the skin assessment dated [DATE] did not have the following in the skin assessment: measurement of the areas of skin, did not specify where the areas was on the buttocks, did not specify if there was any drainage, did not specify if Resident #6 was in pain, and did not obtain pictures of the skin concerns.Record review of Resident #6's Skin Issues Assessment completed on 03/09/2026 by Treatment Nurse LVN N, reflected Resident #6 had a new wound. It was in-house acquired. The exact date was on 03/08/2026. There was no signs or symptoms of infection. The skin areas was staged by in-house nursing ( Treatment Nurse LVN N)Record review of Resident #6's Nurses Notes, dated 03/08/2026, reflected LVN L did not document any further information on Resident #6's skin concerns after completing weekly skin assessment on 03/08/2026.Record review of Resident #6's Nurses Notes, dated 03/09/2026 at 9:58 a.m. reflected Resident #6 was given pain medication related to discomfort to right fourth digit (toe).Record review of Resident #6's Nurses Notes, dated 03/09/2026 at 10:04 a.m. reflected LVN M called and asked for a PRN order for corona ointment to Rt foot- 4th digit as a barrier. Physician Assistant gave order to apply corona ointment to the area. LVN M attempted to contact Family member emergency contact #1. She left a voice message and awaiting response from the family member (first emergency contact). LVN M will continue to monitor. Record review of Resident #6's Nurses Notes, dated 03/09/2026 at 10:04 a.m., reflected LVN M noted Resident #6 had a redness on top of the right 4th digit. Resident #6 reported discomfort. LVN M notified wound care nurse to reassess the area. Resident #6 was given pain medication and will continue to monitor. Record review of Resident #6's Nurses Notes, dated 03/09/2026 at 2:51 p.m., reflected LVN M noted Resident #6 received corona ointment to right foot 4th digit every two hours or as needed for redness/irritation and may leave at bedside. Resident #6's initial dose was at 10:04 a.m. on 03/09/2026.Record review of Resident #6's Nurses Notes, dated 03/09/2026 at 2:55 p.m., reflected LVN M noted Resident #6 pain medication was effective and Resident #6's pain was a zero.Record review of Resident # 6's Nurses Notes, dated 03/09/2026, at 4:14 p.m., reflected Treatment Nurse LVN N noted LVN M notified her of Resident #6 had redness and discomfort to the right foot, 4th toe. LVN M reported contacted the PCP, who provided new orders per Resident #6's request for as needed corona ointment as a barrier. Treatment Nurse LVN N documented upon assessment, Resident #6 was noted to have an open area to right 4th toe with 100 percent red granulation tissue (new, highly connective tissue that forms at the base of a wound during the phase of healing)noted with scant serous drainage. Resident #6's peri wound area was noted to have redness without warmth and was tender to touch. Resident #6 wound measuring 0.4 cm x 0.5 cm x 0.1 cm. Resident #6 wound left open to air at this time. Resident #6 noted with moisture associated skin damage to right buttock measuring 3 cm x 1.2 cm x 0.2 cm. Her wound bed noted with 100 percent red granulation tissue with moderate serous drainage noted. Resident #6 treatment initiated to cleanse with wound cleanser, apply calcium alginate, and cover with border foam dressing three times per week. Resident #6 was noted with moisture associated skin damage to left posterior thigh measuring 0.7 cm x 2.3 cm x 0.2 cm. The wound bed was noted with 100 percent dermis ( the thick, middle layer of skin situated between the outer epidermis and inner tissue, often called the true skin) with moderate serous. Resident #6 peri wound noted with normal skin tones and treatment initiated to cleanse with wound cleanser, apply calcium alginate, and cover with border foam three times per week. Resident #6 notified Treatment Nurse LVN N she became aware of open areas to her buttocks and thigh on Sunday 03/08/2026 when a nurse (did not specify what nurse) informed her that a dressing would be applied due to the presence of open areas. Resident #6 reported she had not previously noticed the areas prior to the nurse ( did not specify nurse name). Resident #6 voiced understanding the need for treatment and dressing application. The Physician Assistant verbalized she will notify Primary Care Physician and will follow up with Treatment Nurse LVN N regarding further instructions and wound care orders. Treatment Nurse LVN N awaiting further guidance at this time. Record review of Resident #6's nurses notes dated 03/09/2026 at 4:26 p.m. reflected Treatment Nurse LVN N documented new skin issue located on rear left thigh. Additional location information: left thigh issue type : Moisture Associated Skin Damage. Progress: new wound. Wound acquired in house. The date acquired was on 03/09/2026. There was no signs or symptoms of infection. The area was not painful. It was staged in house by Treatment Nurse LVN N. The measurements : 0.74 width cm, 2.32 depth cm, 0.2 cm area. There was no tunneling(a complication where narrow, channel-like pathways or passageways extend from the main wound bed into surrounding tissue or muscle). Exudate (the liquid that seeps from a wound, containing water, proteins, nutrients, and white blood cells that facilitate healing by keeping the wound bed moist) amount was moderate, and type was serous with clear watery fluid, which is separated from solid elements. There was no odor. Other wound bed information: 100 percent dermis. Peri wound attached. Surrounding tissue: normal in color. No induration (the hardening or thickening of soft tissue, most commonly the skin, caused by inflammation, infection, or disease present. There was no swelling or edema. Peri wound temperature : normal. Dressing appearance: intact. Dressing saturation: Moderate 26- 75 percent. Cleansing solution: Normal saline. Primary dressing: Calcium Alginate. Secondary dressing: foam. Modalities: none. Treatment will be three times per week.Record review of Resident #6's nurses notes dated 03/09/2026 at 4:26 p.m. reflected Treatment Nurse LVN N documented new skin issue on right gluteus ( located outer side of right hip). The issue type was Moisture Associated Skin Damage. This is a new wound associated with incontinence- associated with dermatitis ( moisture associated skin damage). The wound was acquired at the facility. The date the wound was acquired was on 03/08/2026. There is not signs or symptoms of infection. Resident #6 was not exhibiting any pain from the new wound. Treatment Nurse LVN N staged the wound as the following: length - does not give the length of the wound, 2.97 cm width, 1/18 cm depth and 0.2 cm2 ( square centimeter) 2.08. There was no undermining ( tissue destruction occurs under the skin at the wound edge, separating it from the underlying tissue and creating a pocket) or tunneling. Granulation was 100 percent . The Exudate amount was moderate. The exudate type was serous: clear watery fluid, which was separated from solid elements. There was no odor to the area after cleansing. The peri wound was attached. The surround tissue was maceration ( softening, whitening, and breakdown of the skin caused by prolonged exposure to moisture, such as sweat, urine, or wound fluid). The following was not present: induration, edema, peri wound temperature. Resident #6's dressing was intact, and dressing saturation was moderate 26-75 percent. Cleansing solution : normal saline. Primary dressing: calcium alginate. Secondary dressing was foam and three times per week. Record review of Resident #6's nurses notes dated 03/09/2026 at 4:26 p.m., reflected Treatment Nurse LVN N documented Resident #6 had new skin issue located on the right dorsum ( the top or upper surface, extending from the ankle to the toes) 4th toe. Issue type: Diabetic foot ulcer. Progress: new wound. Wound acquired in-house on 03/05/2026. Resident #6 did not have any signs or symptoms of infection. She was not in pain. Treatment Nurse LVN N stated the wound was as follows: Length 0.4 cm, 0.45 cm depth, and area cm2 0.15. There was no tunneling. Granulation was 100 percent. Exudate amount was light. Exudate type; serous with clear watery fluid, which was separated from the solid elements. There was no odor after cleansing. There was no induration or edema. Peri wound was attached, and the surrounding tissue was erythema(a common skin characterized by redness of inflammation, caused by increased blood flow in the dilated capillaries of the skin's lower layers) Dressing saturation was zero percent. Cleansing solution was normal saline and no dressing. There was no modalities (specialized, non-surgical techniques, tools, or technologies used to address specific skin concerns). The frequency of treatment was to leave open to air per Physician Assistant. The Physician Assistant will give further wound care orders when rounding in facility today. Record review of Resident #6's nurses note dated 03/09/2026 at 5:12 p.m. reflected Treatment Nurse LVN N received call from Physician Assistant regarding new open areas on Resident #6. Physician Assistant will see Resident #6 for evaluation of new areas tomorrow (03/10/2026). The Physician Assistant was in agreement with applying calcium alginate and border foam to Resident #6's right buttocks and left posterior thigh. The Physician Assistant ordered for the 4th toe on right foot leave to open air for today and will reevaluate tomorrow (03/10/2026) when she is in facility making her rounds on the residents. Resident #6 was made aware of the new orders. Record review of Resident #6's nurses notes dated 03/10/2026 at 8:04 a.m. reflected Resident #6 was out of the facility for an appointment. Record review of Resident #6's Physician Assistant Progress Note, dated 03/10/2026 reflected Resident #6 had a right foot 4th digit diabetic wound.Interview and Observation of Resident #6 on 03/09/2026 at 12:00 p.m. revealed Resident #6 was in her room lying in bed. She stated her toe did hurt whenever it was touched or she moved her leg, and her toe touched another one of her toes. She stated at this time she was not in pain. The area on her toe was swollen very red and had brownish color draining. Surveyor did obtain a picture of her toe. Resident #6 stated the area on her toe began last Thursday 03/05/2026. She stated it was a red and pinkish color. Resident #6 stated she was getting a shower from the best CNA in the facility ( CNA O). She stated CNA O was giving her a shower and when she began to wash her feet the small red /pinkish area began to bleed , however, you could barely see any blood. Resident #6 stated a person could barely see the red/ pinkish area on her toe. Resident #6 stated when CNA O finished her shower she reported to LVN M. She heard CNA O report this information to LVN Min the hallway and she was in her room. Resident #6 stated she heard LVN M state she would assess the toe on Resident #6 sometime today ( 03/05/2026). Resident #6 stated LVN M came to her room and put some ointment on her toe. She stated her toe was not red or pinkish when the nurse (LVN M) came to her room. Resident #6 stated on Thursday (03/5/2026) the toe on her right foot was fine there was not any pain, no open area, it was a little pink at first and she said by end of day on Thursday (03/05/2026) it looked normal. She stated she did not voice any concerns about her toe from Thursday 03/05/2026 until Sunday 03/08/2026 when the nurse came to her room to complete her skin assessment. She stated a nurse came in her room on Sunday (03/08/2026) and looked at her skin. Resident #6 stated this is when the nurse found the area on her bottom. She stated she was not in pain with the area on her bottom and did not realize it was there until Sunday. She stated it was not there when she received a shower on Thursday 03/05/2026 and when staff had changed her prior to Sunday (03/08/2026). Resident #6 stated the nurse on Sunday (03/08/2026) never mentioned an area on her thigh. She stated the nurse told her the treatment nurse would be in her room on Monday (03/09/2026) morning to reassess her toe and the area on her buttocks. Resident #6 stated she agreed with the plan. She stated she did receive pain medications as needed. She stated she woke up on Sunday morning (03/08/2026) and moved her right leg and noticed her toe was red and swollen. Resident #6 repeated on Sunday (03/08/2026) was when the toe began to swell and have some drainage. Resident #6 stated she had not experienced any pain with her bottom and she had received a shower in the past few days, and it was not there when she had her shower and when staff changed her clothes. In an interview on 03/09/2026 at 1:55 p.m. Treatment Nurse LVN N stated she received a message from LVN M close to lunch time about Resident #6 having a new area on the 4th toe on her right foot. She stated she was going to assess the area on the 4th toe on her right foot today (03/09/2026). She stated Resident #6 did not have any other skin concerns. Treatment Nurse LVN N and surveyor reviewed Resident #6's skin assessment together dated 03/08/2026. Resident #6's skin assessment revealed Resident #6 had 2 skin tears (did not specify location), red open areas to buttocks (did not specify measurements or how many open areas) and 1 open area to right toe ( did not specify measurements, location of the open area). The Treatment Nurse LVN N stated she was not notified of the new skin concerns on Resident #6 except for the area on Resident #6's toe. She stated LVN M had notified her today about the open area on the toe but did not mention anything of other skin concerns. Treatment Nurse LVN N stated the nurse completed the skin assessment on Sunday 03/08/2026 and was expected to contact her, contact the physician and the family. She stated anytime there is a new skin concern she was to be notified. Treatment Nurse LVN N viewed the facility phone in her possession and stated there was no message from the nurse on Sunday 03/08/2026 about Resident #6's new skin concerns. She reviewed the nurses notes and stated there were no nurses notes from the nurse who worked on Sunday. Treatment Nurse LVN N stated LVN L was the nurse who completed the skin assessment on 03/08/2026. She stated there was no other documentation in the electronic medical record related to Resident #6's new skin concerns. She stated she would be going to Resident #6's room and would complete a skin assessment. She stated LVN L did not follow the expectations of communicating and following reporting new skin concerns at the facility. Treatment Nurse LVN N stated when there was a new skin condition this was considered a change of condition. In an interview on 03/09/2026 at 2:40 p.m. The Director of Nurses stated anytime there was a new skin concern the physician and treatment nurse were to be notified immediately the day the new skin concern was discovered. She stated the nurse on duty Sunday 03/08/2026 who completed Resident #6's weekly skin assessment needed to measure the new skin concerns and if there was any existing skin concerns, observe any discoloration of the skin, if Resident #6 was in pain, take pictures if needed, document any drainage, and document where the skin concerns were located on Resident #6's body. The Director of Nurses stated she expected a nurses note to be completed with full assessment information in the nurses note and to document on the communication board for the next shift to know about new concerns with Resident #6. She stated if the area was on Resident #6 toe on 03/05/2026 and a nurse knew about the area, the nurse was expected to report it to the treatment nurse and call the physician. The Director of Nurses stated the Treatment Nurse LVN N was informed today about the area on Resident #6's toe from the nurse working with Resident #6 (LVN M). She stated she would need to do some investigation with this incident with Resident #6 before responding to any further questions.In an interview on 03/09/2026 at 3:15 p.m. LVN M stated last Thursday (03/05/2026) CNA O reported to her of Resident #6 had a small red/ pinkish area and could barely see it on her toe on her right foot. She stated CNA O reported when she was giving Resident #6 a shower and she was washing her feet she noticed after she washed her right foot there was a little blood coming from the reddish/pinkish area on her toe. LVN M stated she did observe Resident #6's toe and put some zinc ointment on the toe but she did not see any open areas, and it was not discolored. LVN M stated she did not document anything about the toe in nurses notes. She stated today was her first day back to work and she reported to the treatment nurse this morning ( 03/09/2026) to look at Resident #6's toe on her right foot. LVN M stated she did observe it earlier today and she did apply ointment approved from Physician Assistant on Resident #6's toe. She stated there was some drainage coming from the area. LVN M stated there was no information reported to her in morning report from the night shift about any skin concerns of Resident #6. She stated CNA O reported to her today (03/09/2026) of Resident #6 having new areas on her buttocks. She stated she was not aware of the new skin concerns until today. LVN M stated there was not any information about Resident #6 documented on the communication board in the electronic medical records. She stated anytime there was a change of condition including new skin concerns the nurse was expected to document it on the communication board for all staff in the facility to view the changes of a resident. CNA O stated she did not report to the treatment nurse about the new areas on Resident #6's buttocks and when she contacted the Physician Assistant concerning Resident #6's area on her toe she did not report about the area on Resident #6's buttocks due to not knowing a lot of information about the area. She stated she did not assess Resident #6's buttocks. LVN M stated she was expected to report new concern to the Physician and ensure the resident's family was aware of new concern. Resident #6 is her own responsible party and she has a family takes care of finances and both was notified. She stated she did not report to anyone about the small red area and it had a small amount of bleeding when it was reported to her on Thursday 03/05/2026 and she was expected to report this to the treatment nurse and document it in the nurses notes.In an interview on 03/10/2026 at 9:05 a.m. CNA O stated she worked with Resident #6 on 03/05/2026 and was off work on 03/06/2026, 03/07/2026 , and 03/08/2026. She stated on 03/05/2026 Resident #6 had a small reddish pink area on her toe on her right foot. She stated she thought it was her fourth toe. CNA O stated she gave Resident #6 a shower and when they were in the shower she noticed a very small pinkish area on Resident #6's toe on her right foot. CNA O stated she was not able to leave Resident #6 alone and she was finished with the shower. She stated she assisted Resident #6 to her room and assisted her to bed. She stated LVN M was standing in the hall near Resident #6's room and she went in the hall and reported to LVN M about Resident # 6 having a very small pinkish spot on her toe on her right foot. She stated LVN M stated she would assess the area on Resident #6's toe sometime that day ( 03/05/2026). CNA O stated she did not discuss the area on Resident #6's toe anymore with LVN M. She stated once she reported the concern about Resident #6's toe to the nurse she did what she was supposed to do when there was a new condition with a resident. CNA O stated she was talking to Resident #6 yesterday (03/09/2026) about if she wanted to be assisted out of bed and Resident #6 stated I want to stay in bed a nurse is supposed to come and check my bottom and my toe. The nurse yesterday (03/08/2026) found a new skin problem on my bottom. CNA O stated there was not any skin concerns to Resident #6's thigh area or her buttocks on 03/05/2026 when she gave her a shower. CNA O reported Resident #6 stated I did not know I had any problems on my bottom until I was told yesterday (03/08/2026)- (this was the first time the staff noticed of skin condition on resident bottom was 03/08/2026 and Resident #6 was notified immediately when the nurse assessed her during weekly skin assessment). She stated I have not had any pain or issues on my bottom and there was not any issues I felt, and the nurse told me immediately what she found when she did my skin assessment on 03/08/2026 prior to this date I did not have any concerns on my bottom. I am not in pain except my toe hurts a little and the nurse already gave me some medicine for the pain, and it is a lot better. CNA O stated she reported the areas on Resident #6's bottom to LVN M yesterday (03/09/2026) right after breakfast around 9:00 a.m. She stated LVN M reported she would notify the treatment nurse.In an attempted interview on 03/10/2026 at 9:46 a.m. LVN M did not answer the phone and left voice message to return phone call and sent a text message with surveyor's phone number.In an interview on 03/10/2026 at 9:56 a.m. LVN L stated she worked at this facility on 03/08/2026 on the 600 hall. She stated she did complete skin assessment on Resident #6 on 03/08/2026. LVN L stated Resident #6 had 2 pressure areas on her buttocks and both of them were opened. She stated she did look at Resident #6's toe on her right foot. LVN L stated she documented on the skin assessment but was expected to complete a nurses note and to document more information. She stated I know I did not complete the skin assessment correctly and that is nursing 101 on how to assess a skin concern. She stated she needed to measure the areas on Resident #6's buttocks and her toe, note any discoloration of Resident #6's skin concerns, touch for any heat from the toe area, note any drainage from the skin concerns, and document the color of the drainage. She stated I was to document a nurses notes, take pictures to send to the treatment nurse on 03/08/2026 , contact the physician and family. She stated she did not do any of this and did not report the new skin concerns on Resident #6 to anyone in the facility or document it on the communication board in the electronic medical record to alert all staff of change of condition with Resident #6. She stated she was expected to document all the information she was expected to gather when assessing skin concerns and document it in a nurses note and she stated she did not complete a nurses note. LVN L stated I did not do anything correct when assessing Resident #6's new skin concerns. She stated she did not notice any areas on Resident #6 thighs only on her buttocks and toe on right foot. She stated she forgot to report to the oncoming nurses of the changes with Resident #6 skin concerns.In an interview on 03/10/2026 at 10:15 a.m. RN P stated she worked on Friday 03/06/2026 from 6:00 a.m. to 6:00 p.m. She stated she was assigned on the hall where Resident #6 resides. She stated she had checked Resident #6's catheter and Resident #6 did not report any concerns to her ( RN P). She stated Resident #6 does not hesitate to report any health concerns or any concerns to anyone. RN P stated Resident #6 had her TED hose (specialized medical compression stockings designed for non-ambulatory residents to prevent blood clots on both feet. She did not see her feet. RN P stated Resident #6 did not complain about being in pain when she was in her room. RN P stated Resident #6 denied being in pain. She stated anytime a resident has a new skin concern a complete skin assessment was expected to be completed and a nurses note. RN P stated the nurse was expected to do the following with the skin concerns: measure the area, note any drainage, color of the area, take pictures of the skin concern, and document all the information on the skin assessment and the nurses note. She stated the Physician, Family and the treatment nurse were expected to be contacted immediately. She stated the nurse was required to document the change of condition of Resident with new skin concerns on the communication form in the electronic medical record and the nursing staff and administrator would be able to view the changes with any resident. RN P stated also a verbal report was to be given to the oncoming nurses. Interview on 03/10/2026 at 10:30 a.m. The Physician Assistant stated Resident #6 was out of facility to a doctor appointment today (03/10/2026) and she was unable to assess Resident #6. However, she stated she reviewed all of the pictures of Resident #6's wound, skin assessments and nurses documentation. She stated the area on Resident #6's 4th toe on her right foot was a diabetic ulcer. She stated Resident #6 was not in harm or potential harm with any of the new skin concerns. She stated she was contacted on 03/09/2026 about all skin concerns and was provided with pictures. The Physician Assistant stated she felt comfortable with the care the facility was giving Resident #6 with the new skin concerns. She stated a diabetic ulcer anywhere on a resident's body can decline very quickly. The Physician Assistant stated with the areas on Resident's buttocks and toe was not an emergency and it was not an immediacy for the nurse to contact the physician on 03/08/2026 but needed to contact the physician within 24 hours of finding the skin concerns. She stated the staff in the facility did contact her within 24 hours.In an interview on 03/10/2026 at 3:10 p.m. CNA Q stated she worked on 600 hall with Resident #6 on Friday (03/06/2026). She stated Resident #6 did not want to get out of bed on that particular day. She stated it was not unusual for some days Resident #6 preferred to remain in bed. She stated Resident #6 had her hose on her feet and she did not see her toes or feet. CNA Q stated she did not observe any skin issues with Resident #6's bottom or her thigh when she changed her clothes on Friday (03/06/2026). She stated Resident#6 did not complain about being in pain or mention any concerns about her buttocks or her thigh. She stated Resident #6 is very outspoken about her health and everything. CNA Q stated if she was in pain or knew she had concerns on her bottom and thigh she would mention it. She stated Resident #6 did not mention any concerns about her toe. She stated Resident #6 was at her baseline on Friday 03/06/2026. CNA Q stated she would report any change of condition including skin concerns to the nurse supervisor and if she could not find the nurse supervisor she would report to ADON or DON. She stated she had been in serviced on reporting any new change of condition on a resident to the nurse. CNA Q did not recall the date of the in-service.In an interview on 03/10/2026 at 3:20 p.m. CNA R stated she worked on 600 hall and assisted with Resident #6 on Saturday 03/07/2026. She stated she was not assigned to Resident #6, however, she was in Resident #6's room assisting another staff (she did not specify what staff). She stated Resident #6 did not complain about being in pain. CNA R stated she had been assigned to Resident #6 several times a month approximately 5 or 7 times a month. She stated Resident #6 was not shy and always voiced concerns or complaints about her health if she had any and about anything else going on with her especially if she had a new roommate. CNA R stated Resident #6 did not complain about her toe or having any issues with her buttocks or thigh. She stated she did not recall the time she was in Resident #6's room, but she was in there two times on Saturday (03/07/2026) and she does not recall R[TRUNCATED]

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #21 and Resident #87) of four residents reviewed for infection control practices, in that: The facility failed to ensure Med Aide C sanitized the blood pressure monitor before Resident #21, in between Resident #21 and Resident #87 and after Resident # 87 while obtaining blood pressure.This failure could place residents at risk for healthcare associated with cross-contamination and infections.Findings included:Review of Resident #21's face sheet dated 03/09/26 reflected an [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses including unsteadiness on feet, muscle weakness, muscle wasting, lack of coordination , history of falling, and hypertension (high blood pressure).Review of Resident #21's quarterly MDS assessment, dated 01/15/26 revealed her BIMS was 15 indicating that her cognition was intact.Review of Resident #21's care plan dated 08/21/25 reflected she had altered cardiovascular status r/t: HTN and risk for Dehydration. The relevant intervention was evaluating blood pressure and monitoring other vital signs.Review of Resident # 21's medication order revealed: Nebivolol HCl Oral Tablet 5 MG (Nebivolol HCl): Give 1 tablet by mouth one time a day related toessential (primary) hypertension. Hold for Pulse under 50. Record pulse even when held and notify MD. -Start Date-01/13/2026.Review of Resident #87's face sheet dated 03/09/26 reflected an [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses including unsteadiness on feet, muscle weakness, muscle wasting, lack of coordination, cognitive communication deficit, and hypertension.Review of Resident #87's initial MDS assessment, dated 12/22/25 revealed his BIMS was 11 indicating that his cognition was moderately impaired. Review of Resident #87's care plan dated 12/31/25 reflected he had hypertension. The relevant intervention was taking blood pressure except after physical activity or emotional distress and administering blood pressure medications as directed by the physician.Review of Resident # 87's medication order revealed: Norvasc Tablet 10 MG (amlodipine Besylate): Give 1 tablet by mouth one time a day related toessential (primary) hypertension . Hold if SBP is less than 100 or DBP is less than 60.Document B/P even if med is held and notify charge nurse -Start Date- 12/17/2025.During an observation conducted on 03/09/26 at 9:45 a.m., Med Aide C did not sanitize the wrist blood pressure monitor before using it on Resident #21, between Resident #21 and Resident #87, and after Resident #87. Med Aide C measured Resident #21's blood pressure with the wrist monitor without prior sanitization. After administering medications to Resident #21, she proceeded to Resident #87 and used the same monitor without sanitizing it first. She did not sanitize the monitor after the completion of using it on Resident #87 until the investigator pointed out the omission.In an interview on 03/09/26 at 10:35 a.m., Med Aide C stated that she had been employed at the facility for approximately five years and had received in-service training on hand sanitization between residents. However, she indicated that she had not received any training on the importance of sanitizing medical equipment between patients. She said that she had not previously considered the significance of sanitizing medical equipment concurrently with hand sanitization. She stated that, following her current mistake, she had come to recognize the importance of sanitizing blood pressure cuffs between residents, as it helps reduce the risk of transmitting infectious diseases through contamination.During an interview on 03/11/26 at 2:25 p.m., ADON A stated that she also serves as the facility's infection preventionist. She confirmed that her expectation was for all staff to sanitize medical equipment, including blood pressure cuffs, between residents. ADON A reported that she observed deficiencies in infection control practices during routine rounds in the facility. She explained that when deficiencies are identified, staff members are retrained and re-educated accordingly. ADON A further stated on Med Aide C's remark that she had never received training on sanitizing medical equipment during her five years of employment at the facility that sanitizing medical equipment was part of the standard precautions for infection control. She said the facility conducted in-service training on standard precautions at least once a month and Med Aide C attended them most of the time. She indicated she would discuss this matter with the DON, who was on leave that week, and plans to include additional topic of sanitizing medical equipment in the in-service sessions.Review of the in-service records from 10/01/25 to 03/10/26 revealed there were no in-services on cleaning medical equipment .There was one in service on 02/03/26 on 'infection control, universal precautions , hand washing and the review of the sign in sheet revealed Med Aide C had not participated in it.Record review of facility's policy Cleaning and Disinfection of Resident-Care Items and Equipment revised in September 2022 reflected : Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard.Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).

Based on observations, interviews and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of two kitchens reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Assistant [NAME] A used proper hand hygiene during food preparation.2. The facility failed to ensure Dietary Assistant [NAME] A used appropriate oven mitt to remove food from the oven and prevent cross-contamination of the food. These failures could place residents who ate food from the kitchen at risk for foodborne illness.Findings included: 1. Observation on 11/01/2025 at 7:20 AM, reflected Dietary Assistant [NAME] A touched her shirt, the right side of her hair, and touched her face with her right hand. She did not wash or sanitize her hands prior to touching the cereal in bowls on a meal tray. She placed the meal tray full of bowls of cereal in the meal cart to be delivered to the 600-hall kitchenette. Interview on 11/01/2025 at 7:30 AM, Dietary Assistant [NAME] A stated she did not wash her hands, and she did touch her clothes and hair. She stated she did not recall if she touched her face. She stated her clothes, and hair was considered to be contaminated. Dietary Assistant [NAME] A stated she was required to wash her hands anytime she touched anything that was considered to have germs. She stated there was a possibility germs or bacteria may transfer from her hands onto the raisin bran cereal. Dietary Assistant [NAME] A stated if a resident ate the cereal the resident may have stomach issues such as being too sick to eat and have diarrhea. She stated she had been in-service on hand hygiene but did not recall the date of the in-service. 2. Observation on 11/01/2025 at 7:35 AM, Dietary Assistant [NAME] A obtained a dish rag with holes in the rag and brownish color stains laying on top of mop heads in a medium size white container. She held the dish rag and entered the kitchen area and used the dish rag to remove hot pan of bacon from the oven. When she removed the silver pan of bacon the dish rag touched over half of the bacon. The Dietary Assistant [NAME] A placed a lid on the bacon and placed it on the meal cart to be delivered to the kitchenette on 600 hall. She placed the dish rag on the food prep table and had very light scent of disinfectant. Interview on 11/01/2025 at 7:38 AM, the Dietary Assistant [NAME] A stated the dish rag was on the mop heads, and she did not know if the dish rag had been used to clean anything in the kitchen. She stated she was expected to use an oven mitt or potholder to remove food from the oven. She stated the dish rag did have holes in it and was stained. Dietary [NAME] Assistant A stated she did not smell anything on the dish rag when she first picked it up but she did smell something when she placed it on the food prep table. She stated the dish rag did touch the bacon, but it would be ok to serve the bacon. She stated she thought it would be ok to serve the bacon. Interview on 11/01/2025 at 7:42 AM Dietary [NAME] B stated the bacon, and cereal was considered contaminated and was expected to be thrown away and prepare more food for the residents. She stated anytime you touch clothes staff was expected to wash their hands. She stated only an oven mitt, or potholder was to be used to remove anything from the oven. Dietary [NAME] B stated all dietary staff had been in serviced on hand hygiene and preparing food. She did not recall the date of the in-services. Observation on 11/01/2025 7:40 AM Dietary [NAME] B instructed Dietary [NAME] Assistant A to prepare more bacon and cereal for the kitchenette on 600 hall. Dietary [NAME] Assistant A did remove the bacon and cereal from the 600-hall meal cart after Dietary [NAME] B asked her three times to remove the food and prepare more food. Interview with the Dietary Manager on 11/01/2025 at 1:40 PM, the Dietary Manager stated all staff was expected to wash their hands anytime the staff change tasks or touch their clothes or hair. She stated using a dish rag was not appropriate to remove food from the oven. The Dietary Manager stated dish rags was only to be used to clean food prep table and they were not to be stored on top of mop heads. She stated if the dish rag touched the bacon when the Dietary Assistant [NAME] A removed the bacon from the oven, the bacon was contaminated from the dish rag. She stated anytime dietary staff touched food after touching anything considered contaminated the food was expected to be discarded including cereal. She stated if a resident ate bacon or the cereal it was possible a resident may become physically ill with some type of food borne illness such as vomiting and other stomach issues. The Dietary Manager stated she was responsible for monitoring the kitchen policies and protocol. Interview with the Administrator on 11/01/2025 at 2:30 PM, The Administrator stated all dietary staff was required to wash or sanitize hands anytime they touched their clothes, hair, or change tasks. She stated if the dietary staff touched food and did not wash or sanitize their hand, she expected the food to be discarded and prepare the same food. The Administrator stated a dish rag was not appropriate to replace an oven mitt or potholder. She stated a dish rag with holes in it and stained may have been used to clean in the kitchen. The Administrator stated anytime a dish rag touched the food she required for the food to be discarded. She stated if the food was not discarded and a resident did eat the bacon or the cereal there was a potential a resident may become sick with stomach issues with vomiting or some type of food borne illness. The Administrator stated the Dietary Manager was responsible for monitoring the kitchen and she was responsible for monitoring the Dietary Manager. Record review of Dietary Inservice on hand hygiene, do not touch food with bare hands and all foods are required to be covered, dated 08/07/2025, Dietary Assistant [NAME] A and Dietary [NAME] B attended the in-service. Record review of the Facilities Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, revised on November 2022, reflected All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illness. Employees must wash their hands before coming in contact with any food surfaces, during food preparation, as often as necessary to remove soil and contamination and to prevent cross-containment when changing tasks; and/or after engaging in other activities that contaminate the hands.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #109) of 4 residents reviewed for elopement on 10/27/24. The facility failed to put interventions in place to prevent Resident #109 from eloping from the facility when she walked out of the memory care unit and exited the fire alarm gate on 10/27/24. Resident #109 was found by an exit door again on 12/01/24 . Resident has history of opening the doors after pushing on them for 15 seconds allowing the door to open. An IJ was identified on 12/12/24. The IJ template was provided to the facility on [DATE] at 3:30 PM. While the IJ was removed on 12/13/24, the facility remained out of compliance at a scope of isolated and severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for unsafe elopements, injuries, and hospitalization . Findings included: Review of Resident #109's admission record, dated 12/12/24, reflected she was an [AGE] year old female who initially admitted to the facility on [DATE], and had diagnoses including Alzheimer's disease (a brain disorder that causes a gradual decline in memory, thinking, and reasoning skills), Hypokalemia (a condition where the potassium levels in the blood are lower than normal), Hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs), Hyperlipidemia (a condition where there are abnormally high levels of lipids (fats) in the blood), Essential primary hypertension (a type of high blood pressure that develops gradually over time and has no clear cause), Chronic atrial Fibrillation (a type of heart arrhythmia that causes the upper chambers of the heart to beat irregularly and quickly), unspecified atrial fibrillation (a heart condition where the upper chambers of the heart beat irregularly and out of sync with the lower chambers), seasonal allergic rhinitis (an inflammatory condition of the upper airways that occurs when the immune system overreacts to airborne allergens), constipation (a bowel dysfunction that makes it difficult or infrequent to have a bowel movement), primary osteoarthritis (is a type of arthritis that develops in joints over time and has no known cause), abnormalities of gait and mobility (any deviation from a normal walking pattern, which can manifest as difficulties with balance, coordination, or the rhythm of walking, often caused by underlying neurological, musculoskeletal, or sensory issues, leading to symptoms like limping, shuffling, dragging feet, or an unsteady gait), Altered mental status (a general term that describes a change in how well the brain is working) and cognitive communication deficit (a communication difficulty caused by a cognitive impairment). Review of Resident #109's comprehensive MDS assessment, dated 10/16/24, reflected a BIMS of 2 indicated severe cognitive impairment. MDS review reflected wandering - Presence and Frequency: Resident score 1 indicating behavior of this type occurred 1 to 3 days. Review of Resident #109's care plan, dated 10/11/24, reflected Resident #109 has impaired cognitive function with potential for worsening cognition related to progression of disease along with adjusting to new environment. Staff were instructed to keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Resident #109 is an elopement risk/wanderer related to disoriented to place, Impaired safety awareness. Staff were to maintain resident's safety will be maintained through the review date . Review of Resident #109's progress notes, from 10/10/24 through 12/1/24 , reflected, -A note by RN A on 10/10/24 at 5:09 AM, Late entry, which stated, behaviors: Wandering, Chronic. There have not been any recent medication reductions. -A note by LVN I on 10/10/24 at 1:54 PM, stated admission details: Mental Status: Resident is confused. Resident is inattentive. Resident is experiencing signs of short-term memory loss. Resident is disorganized in thinking. Oriented to person. Confused: Chronic. Short term memory loss: Chronic. Safety: Utilizing wander elopement alarm. -A note by LVN T, on 10/11/2024 at 10:54 AM, stated elopement evaluation: history of elopement while at home. Yes. Wandering behavior, a pattern or goal directed. Yes. Wanders aimlessly or non-goal-oriented: No. Wandering behavior likely to affect the safety or well-being of self/others: No. Wandering behavior likely to affect the privacy of others. No. Recently admitted or readmitted (within past 30 days) and has not accepted the situation: No. Elopement Score: 5.0 Score of 5.0 means: High risk of elopement. -A note by LVN E, on 10/13/2024 at 11:10 AM stated, note text: Resident exit seeking currently. Resident pushed on doors until they came open. Resident walked through doors down hall. RN charge and I were able to redirect resident back onto secure unit, with no resistance. Directed resident to her room. - A note by LVN E, on 10/13/2024 at 2:57 PM stated, note text: Resident in exit seeking, in search of her car to go home. Redirected resident to different activities with other residents. Redirection effective currently. Will continue with current plan of care. - A note by LVN E, on 10/13/2024 at 3:52 PM stated, Mood and behavior: Resident is currently experiencing unwanted behaviors. Wandering: Chronic. Mood and behavior note exit seeking. -A note by LVN U, on 10/13/2024 at 8:00 PM stated, note text: Noted with restlessness. Continuously pacing up and down hallway attempting to exit out of locked doors. Has held door long enough to release lock multiple times with staff able to redirect. Continues to state, I need to get to the parking lot and get my grey [NAME]. I am sorry but I am not staying here, especially when I do not belong here. Staff attempt to re-orient resident with no success. Staff continues to redirect currently. Plan of care to continue. - A note by LVN I, on 10/15/2024 at 6:19 PM stated, Behavior notes: Noted with increased restlessness/agitation/exit-seeking - repeatedly ambulating to double doors while stating, I need to go home, I have work to do at home. Initially easily redirected though required x2 staff to redirect from exiting and to dining area for supper. Noted confusion increasing when interacting with peers- staff able to direct to dining area for supper. RP made aware of behaviors. - A note by LVN V, on 10/27/2024 at 1:29 PM stated, note text: Resident was found around back of building approximately at 11:48 am. Resident was redirected back into the building by staff in which she was easily redirected without incidence. Resident assessed and noted no visible injuries, vitals taken 142/76/77, temperature 97.2, respiration rate 18. Skin warm, dry and intact. Resident states she had not been outside today. When question was asked resident stated she followed someone out of the gate and around the building, she also stated she goes out there numerous times. All parties are made aware including, MD, Representative, DON and administration. Resident eats her lunch and remains at table until family arrives. -A note by DON, on 10/27/2024 at 2:55 PM , indicates note strike out reason from resident chart: Incorrect documentation. Note text: After review of camera footage; resident noted to be outside for approximately one hour. Weather noted to be 94 degrees. Notified Medical Director Received new orders for labs to be drawn when resident arrives back at facility for CBC, CMP. Diagnosis: Fatigue. Representative made aware of new orders. -A note by DON on 10/27/2024 at 3:00 PM, stated Note text: after review of the camera footage and time stamp; resident noted to be out of sight for 14 minutes . Medical Director updated. -A note by LVN E on 12/01/2024 at 03:46 PM, stated nurse note: Resident was observed at exit doors. Resident pushed on doors until they came open. Resident came through doors to other side. Nurse intervened and assisted in getting resident back on the other side. Review of Resident #109's admission wandering evaluation, dated 10/11/24, reflected she had a history of wandering/elopement. There were no goals or interventions notated on the evaluation for Resident #109. Review of Resident #1's plan of care, from 10/11/24 through 11/03/24, reflected Resident #109 exhibited Problem: The resident is an elopement risk/wanderer related to disoriented to place, impaired safety awareness. 10/27/2024: Resident found outside back of building with no injuries (resident states she followed someone out of gate). Interventions/Tasks: Resident to reside on secured unit. Staff education regarding elopement/wandering with new policy regarding elopement. Date initiated: 10/27/2024. Wander alert: resident may have wander guard applied to alert staff of attempts to exit to facility; check placement and functioning every shift. Problem: The resident has impaired cognitive function with potential for worsening cognition related to progression of disease along with adjusting to new environment. Interventions/tasks: Administer medications as ordered. Monitor/Document for side effects and effectiveness (Namenda and Aricept). Keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Review of the facility's investigation file for Resident #109's incident on 10/27/24 reflected on 10/27/24, ADM investigation summary indicated review of camera footage. Resident observed exiting back door at 11:33 am. Resident noted exiting gate at 11:33 LVN V, observed walking out to the porch and to gate that is sounding at 11:35 am. Resident was escorted back to memory care wing at 11:49 am. Head to toe assessment performed, no injuries noted. Medical Director notified. Resident family member notified. Received new lab orders from doctor. Residents assessed and note no visible injuries, vitals taken 142/76/77, temperature 97.2, respirations 18. Skin was dry and intact. Resident states she had not been outside today. Resident eats her lunch and remains at table until family arrives as resident was scheduled to go out on pass this day to watch family member's theater performance. Action taken 10/27/24: Dementia training with appropriate interventions. Abuse and Neglect. Elopements. State reportable. 300 hall education: No propping open door, roller shades to be open. 10/28/24 Wander guard system placed for additional monitor placement on exit gate. Created new policy and procedure to follow for when exit alarms sound that include nursing staff conducting a roll call for all residents. During an interview on 12/11/24 at 9:50 AM, LVN H stated Resident #109 was outside in the smoking area. LVN H noticed her outside and realized that she was a little confused and then realized she was a resident from the facility. She was standing outside the gate; the gate was propped open in the smoking rest area for residents. LVN H redirected the resident back inside. LVN H verbalized, I'm not sure how long she was outside, I didn't see her when I passed by the window but when I went outside to take a break, I noticed her outside, it could not have been that long voiced LVN H. During an interview on 12/12/24 at 9:36 AM, LVN V stated she was the charge nurse for the memory unit on 10/27/24. She verbalized that staff were not very familiar with Resident #109 and the resident's family member had called that morning and asked that the staff get the resident ready for an outing. Staff got the resident ready and that morning staff had residents out in the outside area enjoying the weather. LVN V verbalized she is not sure if the resident was with the group but when the staff brought the residents back in shortly after the gate alarm went off outside. LVN V voiced she went out to check the gate and it was closed. She said she did not see anyone outside, so she closed the door that was left propped open during the process of bringing the residents back in that morning. LVN V verbalized she just thought someone pushed up on the gate and that is why the alarm went off. So, she turned the alarm off. LVN V, voiced another nurse came up to her at one point and told her he found one of her residents near the smoking area. LVN V provided a skin assessment on the resident and notified the doctor and family. LVN V, voiced she thinks the resident was gone for about 10 to 15 minutes. LVN V, verbalized that administration came in and re-checked everything to make sure staff complied and provided an in-service on elopements, abuse, and neglect. LVN V was sent home and informed that this was just part of the investigation process. During an interview on 12/12/24 at 10:16 AM, LVN E verbalized Resident #109 can read so she knows that the instructions on the door say to hold for 15 seconds, and it will open. LVN E, verbalized after the 10/27/24 elopement staff have been instructed to see who is at the door if the alarm goes off and do a head count of all the residents. During an interview on 12/12/24 at 10:28 AM, the DON verbalized she was not here the day Resident #109 eloped, but staff informed her of the elopement. DON voiced she is not sure if the resident walked through the grass around the back to reach the other end, or if she walked through the street that is located directly behind the building. DON acknowledged there was a potential for the resident to get hurt when she walked out of the memory care unit gate. DON verbalized that there were no other elopements since 10/27/24. During an interview on 12/12/24 at 11:12 AM the ADM verbalized that the videos show the resident leaving the facility at 10:33 AM but that the video was behind the regular time by one hour. ADM verbalized that the back cameras behind the building were not working. During an observation of the facility video footage on 12/12/2024, it reflected on 10/27/2024 resident exiting the alarm door outside the memory unit. During a telephone interview with Resident #109's family member on 12/12/24 at 1:24pm, she stated they called her about the elopement that she was in their outdoor patio and waited long enough that she stated that they did not tell her about the incident. Resident daughter verbalized she does not have any concerns about her being able to get out she is very normal, and a lot of people do not realize that she belongs there. Daughter verbalized if the resident does get out, she is not going to get hurt and not going to get far and stated with the nature of her disease it will happen from time to time. During an interview on 12/12/24 at 2:11 PM, maintenance employee W, stated that the alarms on the doors are checked monthly and records were provided and reviewed by survey team. During an interview on 12/12/24 at 2:15 PM, ADM verbalized that the back door was propped open for about 15 minutes on 10/27/24 after the residents were brought back into the building that morning. ADM verbalized she is trying to provide video footage, but it keeps freezing on her end. During an interview with DON on 12/12/24 at 3:02 PM, DON stated the nurse that was working on the 300-memory unit hall is was PRN nurse and 2 CNAs, along with an LVN and med aide. DON verbalized, I was not here that day, but I was told she walked outside the side door in front of the day room. The resident walked out the gate to the right, went out that door the blinds were closed in day room. Nurse went outside and she looked but the resident had closed the gate, so she just assumed that one of the residents pushed up on it. She was not gone that long at all. I will be honest less than 30 minutes. I will be honest the time stamp on the video footage is off. I believe when I calculated the time it was less than 30 minutes. Since then, we have done an in-service that includes staff need to make sure they are doing a roll count. Anytime alarms sound if it is not a planned exit, they need to make sure the residents are safe and all in the building. Make sure no doors are propped open. DON verbalized that all staff have been in-serviced and they were informed not to prop doors open, keep blinds open. During an interview on 12/12/24 at 3:15 PM, ADM voiced new policies and procedures to do roll call will, new wander guard ordered to be installed by 12/16/24 . They have increased staffing levels. Staff have dementia training that they must update monthly. During an interview on 12/12/24 at 3:48 PM with Alarm Representative X, the delayed egress should not be used for resident protection. An observation of the outside of the back gate on 12/12/2024 at 11:00 AM where Resident #109 exited to the smoking gate where she was found by LVN H on 10/27/24 reflected approximately 200 - 225 feet of distance that the resident walked. There was a residential road directly behind the facility and a parking lot for employees to park. This was determined to be an Immediate Jeopardy (IJ) on 12/12/24, The Administrator was notified. The Administrator was provided with the IJ template on 12/12/24 at 3:30 PM. The following Plan of Removal submitted by the facility was accepted on 12/13/24 at 11:08 AM Plan of Removal Immediate Threat On 12/12/2024 an abbreviated survey was initiated at facility. On 12/12/2024 the surveyor provided an Immediate Jeopardy that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: state the issue you will find the info on the template you were provided. Action: 1:1 Monitoring; assess staff is required to be always within arm's reach of resident. Start Date: 12/12/2024 at 1:35 PM Completion Date: In progress, will not complete until additional hardware (wander guard is installed on 12/16/2024) Responsible: Facility's staffing nurse, the QM nurse, & Director of Nursing is responsible for ensuring the adequate 1:1 Monitoring of resident. 12-12-24 (Thursday): Staff #1 from 4 till left on bus. Staff #2- while on the bus 12-12-24 (Thursday): staff # 3 from 8P-6A 12-13-24 (Friday): staff #4 from 6A-6P 12-13-24 (Friday): staff #3 from 6P-6A 12-14-24 (Saturday): staff #5 from 6A-6P 12-14-24 (Saturday): staff #6 from 6P-6A 12-15-24 (Sunday): staff #4 from 6A-6P 12-15-24 (Sunday): staff # 7 from 6P-6A 12-16-24 (Monday): staff # 4 from 6A-6P 12-16-24 (Monday): staff # 8 from 6P-6A Action: Door Monitoring Start Date: 12/12/2024 6:00 PM. Completion Date: In progress until new locking mechanisms is installed, date pending. Responsible: Facility's staffing nurse, the QM nurse, & Director of Nursing is responsible for ensuring the adequate 1:1 Monitoring of resident. 12/12/24 7P- 6A Staff member #9 12/13/23 6A-6P Staff member #10 12/13/24 6P- 6A Staff member #10 12./14/24 6A-6P Staff member #9 12/14/24 6P- 6A Staff member #11 12/15/24 6A-6P staff member #9 12/15/24 6P- 6A staff member # 11 12/16/24 6A-6P Staff member #12 12/16/24 6P- 6A Staff member # 13 Action: Training regarding: Abuse/Neglect, 1:1 Monitoring / Guarding of exit Doors, Elopement. A new policy and procedure , initiated on October 28, 2024, this procedure implements a roll call for all residents within the building. Medical Director, Director of Nursing, and Administrator created the policy and procedure 10/28/24. The CNAs receive training from charge nurses or administrative nurse, charge nurses are trained by the administrative nurses, who receive training from the DON, the DON receives training from Administrator; the Administrator receives training from Facility Consultant. Start Date: 12/12/2024. Completion Date: 12/13/2024 Responsible: In-service was conducted by previous ADON on roll call 10/28/2024 & again 12/12/2024 by IP and QM . Agency staff will receive in-services prior to their shift begins by the charge nurse on shift. Staff members who are off shift or PRN will receive in-service training via portal. Action: Door Signage posted as a reminder to staff not to prop the door open. In-service training provided by QM to re-iterate that doors are not to be propped open at any time. The CNAs receive training from charge nurses or administrative nurse, charge nurses are trained by the administrative nurses, who receive training from the DON, the DON receives training from Administrator; the Administrator receives training from Facility Consultant . Start Date: 12/12/2024. Completion Date: 12/12/2024 6:30 PM Responsible: QM Admin Nurse Action: Elopement Assessments Completed monthly and Care plans Updated as needed. Findings will be reported monthly to QA committee for review, with changes made to the plan as required. Start Date: 12/12/2024 5:30 PM Completion Date: 12/12/2024 09:30 Responsible: Assessments Charge Nurse #1, Care plans updated by designated MDS administrative nurse Action: The facility will conduct monthly audits to ensure that all assess Start Date: 12/12/2024 5:30 PM Completion Date: 12/12/2024 09:30 Responsible: Assessments Charge Nurse #1, Care plans updated by designated MDS administrative nurse. QAPI attendees include Facility Consultant, Administrator, Medical Director, Director of Nursing, and all administrative nursing personnel. The Administrator receives training from facility consultant. The Survey Team monitored the Plan of Removal on 12/13/24: Observation on 12/13/2024 at 8:30 and 11:15am staff member sitting by the door . Observation on 12/13/2024 at 11:15am revealed a staff member was in arm reach of Resident #1 . Further observation revealed that door signage was posted on both doors . Observation on 12/13/2024 at 1:27pm revealed a staff member was sitting by the door . Observation on 12/13/2024 at 1:28pm revealed a staff member was in arm reach of Resident #1 . During an Interview on 12/13/2024 at 2:27 pm, LVN I stated and confirmed she took the training this month. LVN A stated that she was trained on one-on-one monitoring, Resident #109 is within arm's length and to always know the resident's location, and to keep the resident distracted. LVN, I stated she has been trained on monitoring the exit doors and she took all the training today. LVN, I stated when the alarm sounds, we must do a head count on all residents, monitor the doors, and keep them closed, do not leave them open. LVN, I stated she took the elopement training today, and to keep the door closed, perform head counts if the alarm goes off, and to always know the locations of all residents. LVN, I stated if a resident elopes, I must notify the ADM and DON, call 9-1-1, and to notify staff and attempt to locate the resident. LVN, I stated if the alarm goes off, I go to the location of the alarm, investigate what is going on, if I see a resident by the door I redirect the resident, I conduct a head count on the residents, and notify the ADM and DON. LVN I stated when completed the Charge nurse will ensure each resident is accounted for and after roll call, I keep a mental note of the findings and I then review our wander guard list and ADL list. During an interview on 12/13/2024 at 2:37 pm, CNA M stated she took the in-service yesterday (12/12/2024), she has been educated on resident rights, she has been in-serviced on one-on-one monitoring. CNA M stated the training covered on how not to leave the resident's (Resident #109) side, and that a staff must be always at their side. CNA M stated he has been trained on monitoring exit doors, and that if the alarm goes off, we look at the surrounding area and ensure no resident got out, we do a head count and we can reset the alarm. CNA M stated that she has been trained on elopement procedures and that if a resident elopes or even steps on the other side of the door we must intervene and report to the charge nurse on duty, the charge nurse then reports the elopement up the chain of command, the goal is ensure no residents eloped. CNA M stated if a resident attempts to elope we must act, we redirect the resident and have them come back inside, we make sure there are no other residents out, we immediately notify the charge nurse on duty and we do a head count. CNA M added that we (staff) are all responsible that each resident is accounted for, one of us goes down the hall, another staff goes to the day area, and a third staff check the other doors, and that after the roll call we notify the nurses where all the residents were located, and we make a mental note on the residents and we communicate with all staff to assure all residents are accounted for. During an interview on 12/13/2024 at 2:52 pm, CNA L stated she has been in-serviced on one-on-one monitoring on residents, and that we must keep residents safe, keep them from falling, assure residents are taken care of, and assure residents are within arm's reach. CNA L stated that she was trained on monitoring the exit doors and that she took the training today. CNA L stated the training covered the importance of watching and monitoring the doors, calling the ADM for all elopements, and the importance on all staff locating the residents. CNA L stated we immediately notify the charge nurse if a resident elopes, and if I hear an alarm I get up and check what set the alarm off; I see who went in our out, who is close to the door, I check outside to assure no residents are outside. CNA L stated that all staff are responsible for assuring each resident is accounted for, and that after roll call I confirm findings with nurse. CNA L stated that after our roll call we are checking all residents are accounted for, we are checking the number of residents locations and his or her ADL sheets. During an interview on 12/13/2024 at 2:58 pm, CNA K stated she has taken the training, she has been trained on one-on-one monitoring. CNA K stated that she was in-serviced on having the resident stay within arm's reach, and if the resident (Resident #109) attempts to leave outside we must redirect the resident and have them come back inside, we were educated on redirecting the resident, keeping the resident busy by communicating with the resident. CNA K stated she was in-serviced on monitoring the exit doors, and we cannot leave doors cracked or propped open, we cannot let residents leave unsupervised. CNA K stated she was trained on elopement procedures, CNA K added if I see a resident g out , I intervene, I notify the nurse on duty, I tell the charge nurse, I start looking for the residents, and we notify the ADM and DON. CNA K stated if an alarm goes off, I will run and investigate who is going out of the door, I investigate if it was a resident or if a resident is outside the door. CNA K stated all staff, the charge nurse, everyone is responsible on assuring all residents are accounted for, and that after we complete our roll call for residents we communicated with the nurse on findings. CNA K stated that during the roll call, we confirm all residents, we count and make sure all residents are here and we review the ADL sheet for the residents. During an interview on 12/13/2024 at 3:20 pm, LVN J she took trainings today, she has been trained on one-on-one monitoring and that we always have eyes on resident, within arm's reach, and if a staff member needs to go on break, we notify another staff to assure we are always doing these things. LVN J stated if an alarm goes off, we act, we do a head count, then a roll call to account all residents are here. LVN J confirmed she has taken the elopement trainings today, and added that if an alarm goes off, we act, the system will inform us what number band (wander guard) set off the alarm, and we follow the location of residents and roll call procedures. LVN J stated we must report all elopements to the DON, and if an alarm goes off, we find out if a resident went out of the building, we check outside the surrounding areas for any residents, and that we are all responsible that each and all residents are accounted for. After the roll call, I would take a mental note and recall each resident, if a resident is missing or not accounted for, I check our computer (records) and review who has been checked out (signed out on pass, appointment, et all) of the facility and reference that for all residents that should be present in the facility. During an interview on 12/13/2024 at 3:22 pm, DON stated training was completed today, on the importance of one-on-one monitoring, how residents must be within arms always reach and for staff to communicate if they need a break, staff must assure another staff takes over the important duties until they return. DON stated we had education on guarding or monitoring the doors today and that staff should be at the door 24/7 and that the elopement training was done this morning. DON stated the training covered what to do if there is an elopement; there needs to be a roll call and if it is in the secured unit, we need to do an elopement assessment to determine who is at risk of an elopement, we always respond to alarms or if a resident elopes. DON also stated if nursing staff will assure the roll calls are completed for the whole facility, I (DON) will notify ADM and do a self-reported incident to HHSC . DON stated staff are to respond immediately, to get our residents to safety, staff need to communicate and get in touch with the charge nurses to do a roll call of the entire facility, charge nurses will use a printed midnight census to assure all residents are in the building and after the roll call staff are to huddle, assure all is clear on resident head counts and locations and to report all findings to myself and ADM. During an interview on 12/13/2024 at 3:29 pm, ADM stated we must report all findings of abuse, we have trained staff on one-on-one monitoring, we educated staff that one-on-one is defined as you (staff) stay within arm's reach of the resident that needs the monitoring and to communicate and call if they (staff) need a break so one-on-one can continue. ADM stated I have been trained on monitoring exit doors, and that guarding or monitoring the exit doors mean to redirect or ask for additional staff to assist with residents who are trying to enter or exit. ADM confirmed the elopement training education conducted today, this morning, that in the elopement training we check for resident's safety, staff must notify us, administration, the residents RPs and Doctors. ADM added that we placed interventions to keep our residents safe and from further elopement. ADM added we have been trained in an elopement situation staff are to perform if an alarm goes off, even if it is just a fire alarm, all residents must be accounted for, we look around the premises, we locate the residents, we call local law enforcement advise of a silver alert, we notify doctors or nurse practitioners, we were trained on the importance of a roll call being completed and that we can just clear or turn off the alarm, all residents must be accounted for prior to resetting any alarm. ADM stated that the charge nurses for each hallway are responsible for assuring the residents are accounted for by matching face to name on the midnight census, after the roll call this will be submitted to the nursing office. Record Review of In-Services for 1:1, door monitoring, door propping, elopement, abuse, and neglect, exit alarm sounding and Dementia revealed that 110 out of 129 staff have been in serviced. Staff interviews revealed staff have been trained on 1:1, door monitoring, exit door alarm, elopement, and roll call. Record reviewed revealed 110 out of 129 staff have been in-serviced on propping the door open . Record Review of all residents on memory care's medical records revealed that residents who were higher risk of elopement have been updated and their care plans h [TRUNCATED]

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan with resident rights, which included measurable objectives and time frames to meet the resident's mental and psychosocial needs for 3 of 10 residents (Residents #17, #41 and #98) reviewed for care plans. 1. The facility failed to update Resident #17's care plan to reflect current needs for suprapubic catheter care. 2. The facility failed to update Resident #17's care plan to reflect current needs with transfers. 3. The facility failed to update Resident #41's care plan to reflect current diet consistency orders. 4. The facility failed to update Resident #98's care plan to reflect current needs with transfers. This failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being. Findings included: Record Review of Resident #17's admission record dated 12/11/24 revealed an [AGE] year-old male admitted on [DATE]. Resident #17's diagnoses include benign neoplasm of prostate (an abnormal growth near the prostate), hematuria (blood in the urine), obstructive and reflux uropathy (urine cannot flow in through the urinary system due to an obstruction), need for assistance with personal care, and ankylosing spondylitis (an inflammatory disease that can cause back pain, stiffness, and hunched posture). Record Review of Resident #17's quarterly MDS dated [DATE] revealed resident was unable to complete a BIMS assessment that indicated severe cognitive impairment. The MDS revealed Resident #17 required substantial/maximal assistance to complete dependence on staff for all the assessment under functional abilities. The quarterly MDS revealed an Indwelling catheter under the section labeled Bladder and Bowel. Record review of Resident #17's physician order summary dated 12/11/2024 revealed Resident #17 had orders as follows: 1. Catheter: Catheter care with Incontinent Wipes Every Shift with a start date of 7/11/2024 2. Catheter: Change Foley Catheter or Supra-pubic Catheter [a tube inserted directly into the bladder through the abdominal wall to drain urine] as indicated for infection, obstruction, or when closed system is compromised as needed with a start date of 12/4/2024. 3. Catheter: Change Foley Catheter or Supra-pubic Catheter as indicated for infection, obstruction or when closed system is compromised everyday shift on the 4th for 1 day with a start date of 12/4/2024 4. Catheter: Change leg strap or stat lock with each foley change and prn as needed 5. Catheter: Ensure Catheter is draining properly to bedside privacy bag and leg strap is in place every shift. 6. Catheter: Monitor for signs/symptoms of infection with a start date of 7/11/2024 7. Catheter: Monitor Output Every Shift 8. Irrigate Foley with 500 ml's distilled water-push 100 ml's in and pull out and repeat until clear as needed for hematuria with a start date of 10/29/2024. 9. May use [mechanical] lift and x 2 assist to transfer safely. Record review of Resident #17's Care Plan dated 9/5/2023 and revised on 3/25/24 revealed The resident has an ADL self-care performance deficit. Interventions included Transfer: The resident requires assist x one staff member to move between surfaces. Further review revealed no mention of Suprapubic Catheter throughout the plan. Review of Resident #41 face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of heart failure, disturbances of salivary secretion, and dysphagia. Review of Resident #41 care plan with revision date of 03/10/2022 revealed resident was at risk for weight loss and interventions included diet of mechanical soft texture with regular consistency liquids with date of 10/17/2022 with additional interventions listed on 04/20/2024 of mechanical soft texture and regular consistency liquids with date per resident request. Review of Resident #41 nursing progress note dated 11/07/2024 revealed hospice nurse gave new order per hospice physician to change diet consistency to regular texture. Review of physician's telephone orders for Resident #41 dated 11/07/2024, revealed change diet consistency to regular texture. Review of Resident #41 physician order dated 11/07/2024 revealed reduced concentrated sweets diet, regular texture, regular consistency. Record Review of Resident #98's admission record dated 12/10/24 revealed a [AGE] year-old female with an admitted [DATE]. Resident #98's diagnoses included Chronic pain, fatigue, repeated falls, lack of coordination, muscle weakness, reduced mobility, need for assistance with personal care, and unspecified dementia (a disease that affects the short- and long-term memory). Record Review of Resident #98's quarterly MDS dated [DATE] revealed a BIMS score could not be assessed due to severe cognitive impairment. The MDS revealed Resident #98 was substantial/maximal assistance to dependence on staff for all assessment under the self-care functional abilities section. Record Review of Resident #98's Care Plan dated 3/15/2024 and revised on 7/9/2024 revealed The resident has an ADL self-care performance deficit. Interventions included Transfers: The resident requires assistance x one with transfers, providing weight bearing assistance, guidance as needed. Record Review of Resident #98's Order Summary Report dated 10/10/24 revealed an order stated, May use [mechanical] lift and x 2 assist to transfer safely. During an interview on 12/12/24 at 9:28 AM, LVN E stated she had worked at the facility about a year. She stated Resident #17 and Resident #98 require a [mechanical] lift and assistance x 2 staff for a safe transfer. She stated the DON and management are responsible for updating care plans for residents during the resident's care plan meeting or as changes occur. LVN E stated that the CNAs look at ADL sheets, which are provided when they sign in for the day, to determine care for each resident. She stated she was not sure who used the care plan. During an interview on 12/12/24 at 9:53 AM, LVN F stated she had worked at the facility about 4 years. She stated MDSN, activities, therapy and ADM was responsible for updating all care plans. LVN F stated the care plans are updated every Wednesday during their meeting. She stated she was not sure who used the care plans for the residents. During an interview on 12/12/24 at 2:18 PM, MDSN stated she was responsible for completing and updating care plans. She stated that care plans should be updated for falls, skin issues, changes in medications and any significant event. MDSN stated that care plans should be updated for new catheters and for changes in requirement for transfers. She stated that nursing staff, activities staff and dietary staff all utilized the care plan when they provide care to the resident and not updating the care plans could affect how they provide the care. During an interview on 12/12/24 at 2:39 PM, the DON stated MDSN was responsible for updating the care plans and they should have been updated quarterly, with any significant change in care, and/or new preferences identified by staff. She stated that she expected care plans to be updated when a resident had a new order for a catheter or when the resident's need changes for how care is provided. She stated if diet orders were changed then the care plan should be updated too. The DON stated the care plans are reviewed by MDSN, DON and during the quarterly meetings. She stated that floor staff used the MAR and NMAR and ADL sheets for daily care instructions. During an interview on 12/12/24 at 3:04 PM, the ADM stated MDSN was responsible for updating the care plans quarterly, annually and with any significant change, incident/accident, or new preference. She stated that care plans should have been updated when a diet order changes, when a resident's requirements for transfers and when a resident had a new order for a catheter. The ADM stated the care plans are used by the interdisciplinary team and if they were not updated correctly then it could cause the team to provide care incorrectly. Review of policy titled Resident Assessments and dated 2001 and revised in 2022 revealed. Policy statement A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements. Policy Interpretation and Implementation 1) The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessment and reviews according to the following requirements: 4. Significant Change in status assessment 3) A comprehensive assessment includes: a. completion of the MDS. b. completion of the care is assessment process and c. development of the comprehensive care plan. 50872

Based on interviews and record review, the facility failed to ensure the residents rights to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 5 residents (Resident #26) reviewed for advanced directives. The facility failed to ensure Resident #26's out of hospital do-not-resuscitate (OOH-DNR) order form was signed by a physician. These failures could place residents at-risk of having their wishes dishonored or delay necessary medical treatment or intervention due to confusion. Finding included: Review of Resident #26 face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, altered mental status, cognitive communication deficit, hypertensive heart disease with heart failure, and unspecified diastolic (congestive) heart failure. Review of Resident #26 physician orders dated [DATE] reflected an order for do not resuscitate. Review of Resident #26 care plan dated [DATE] revealed resident or family requested to be DNR. Interventions included chart to have proper documentation of DNR status and goals included resident decision to be honored through review date. Review of Resident#26's out-of-hospital do-not-resuscitate (ooh-dnr) order form revealed no physician signature in the physician statement section. Further review revealed there was no physician signature in the section all persons who have signed above must sign below, acknowledging that this document has been properly completed. During an interview on [DATE] at 3:17 PM, LVN C stated that she knew what a resident's code status was by a list provided by the ADON/DON. She stated that the list is updated often and that it was also in their chart. She stated that she verified an OOH-DNR was complete and valid because it was in the resident's chart and uploaded into the document section. LVN C stated that you had to make sure there were signatures on the OOH-DNR. LVN C stated an OOH-DNR is not considered valid if it did not have physician signature. LVN C reviewed Resident #26's OOH-DNR and stated that it did not have any physician signature. LVN C stated that because the OOH-DNR did not have a physician signature the resident would have to be a full code and it was not valid. She stated that unfortunately the resident's wishes may not be met if they had an OOH-DNR and are put as a full code. During an interview on [DATE] at 3:22 PM, LVN D stated that she knew a resident's code status because it was in their chart on their face sheet and as an order. She stated she verified that an OOH-DNR is complete and valid by the physician signature. LVN D stated that if an OOH-DNR did not have a physician signature it was not considered valid. LVN D viewed Resident #26's DNR and stated that it did not have physician signatures and it should have them. During an interview on [DATE] at 3:56 PM, SW stated that she knew a resident's code status was because she participated in getting signatures for OOH-DNRs. SW stated their code status is also in the system on their face sheet and there were copies of the OOH-DNRs. She stated that she verified that an OOH-DNR is valid by when she witnessed the resident or representative sign it and then it was sent to the doctor. SW stated it was incomplete until doctor signed it. SW stated she is unsure if there was an audit to see if OOH-DNRs were completed. She stated nurse handles scanning the OOH-DNR into the resident's chart. SW viewed Resident #26's OOH-DNR and stated it was not valid because it did not have physician signature. She stated that if a resident did not have a valid OOH-DNR a medical professional may assume it was valid and the resident may pass and later realize the resident was a full code. She stated that it was not valid, and staff performed CPR it would have also been a major concern. During an interview on [DATE] at 2:54 PM, DON stated that staff knew a resident's code status because it was in PCC and binders were also available with the document. She stated that code status was also posted at the nurses stations. She stated that the SW was supposed to verify if an OOH-DNR was complete or valid. She stated that the SW should audit the document when they initially get the OOH-DNR. DON stated she expected that OOH-DNRs are audited quarterly. DON stated an OOH-DNR was not valid without a physician signature. She stated that the potential harm of an incomplete OOH-DNR was not following the wishes of the family or resident. DON stated that if an OOH-DNR was not valid the facility could potentially perform CPR, and if a resident did not want CPR it may lead to trauma. During an interview on [DATE] at 3:04 PM, ADM stated that audits are completed monthly for advanced directives. She stated during the audit it was reviewed the accuracy of the OOH-DNR and match it to the order in the resident's chart. She stated the SW was responsible for completing OOH-DNR audits, but it has been a collaboration with nursing recently. She stated that an OOH-DNR should include physician signatures. ADM stated that the potential harm was that they may not resuscitate someone if an OOH-DNR was not valid. Review of facility policy Advanced Directives dated [DATE] revealed the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Review of health and safety code 166.083(b)(4)(6) revealed an OOH-DNR order at minimum must contain statement that the physician signing the document is the attending physician of the person and that the physician is directing health care professionals acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue certain life-sustaining treatment on behalf of the person and places for the printed names and signatures of the witnesses or the notary public's acknowledgment and for the printed name and signature of the attending physician of the person and the medical license number of the attending physician Further review of health and safety code 166.089(3) revealed an OOH-DNR order form appears valid when it includes the signature or digital or electronic signature of the declarant or persons executing or issuing the order and the attending physician in the appropriate places designated on the form for indicating that the order form has been properly completed.

Based on interview and record review, the facility failed to ensure the residents had the right to be free from resident neglect for one (Resident #12) out of three residents reviewed for neglect. The facility failed to ensure FTA from ensuring the facility lift was located at the back facility door to transfer Resident #12 off the van onto the lift . Resident #12 fell from the van onto the lift located on the ground on 11/15/2024. This noncompliance was identified as PNC. The deficient practice occurred on 11/15/2024 and in-service was completed on 11/15/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of neglect, injury, and psychosocial harm. Findings included: Record review of Resident # 12's face sheet, dated, 12/11/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #12 had diagnoses which included vascular dementia ( a condition that affects the brain's ability to think, remember, caused by lack of blood flow to the brain), type 2 diabetes with diabetic neuropathy, acute respiratory failure with hypoxia (a medical condition where the body's ability to take in oxygen is suddenly impaired, leading to a dangerously low level of oxygen in the blood. Hypoxia can be life-threatening), muscle weakness ( a lack of muscle strength that makes it difficult to move your body),glaucoma ( buildup fluid in the front of the eye, which increases pressure inside the eye. If left untreated can lead to vision loss and eventually blindness), and type 2 diabetes with diabetic neuropathy ( when nerve damage develops due to long-term high blood sugar levels). Record review of Resident #12's Annual MDS Assessment, dated 10/07/2024, reflected the resident had a BIMS score of 4, which indicated her cognition was severely impaired. Resident #12 required assistance with transfers, dressing, hygiene, and showers. Record review of Resident #12's Comprehensive Care Plan, completed on, 11/18/2024, reflected Resident #12 had Impaired physical mobility. Intervention: Assist resident in performing movements and tasks. Educate Resident and Representative on safety precautions. Educate resident and representative on safe transfer techniques. Resident #12 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to some cognitive deficits (related to mental process involved in knowing, learning, and understanding things) and safety concerns. Resident #12 required assistance with most aspects of ADL s. Intervention: Transfers: Resident #12 required one person assist with difficult transfers related to weakness. Resident #12 was at risk for falls. Resident #12 had a fall incident with transportation van on 11/15/2024 and was evaluated at emergency room with laceration and hematoma to back of head. Interventions: anti-roll back to wheelchair. Staff education on safe operation of van with loading and unloading residents. Van maintenance for proper function of the transportation van. Record review of Resident #12's nurses note dated 11/15/2024 at 3:30 PM reflected called by transportation driver to the front awning. Seen resident laying on her left side. Resident was assisted into a sitting position. Resident stated she hit her head and it was hurting her. Small laceration and formation of hematoma was noted to the back of her head. Resident complained of pain to her bottom but denied pain anywhere else. Upon further assessment, no other injuries noted. Focused neuro assessment was completed, resident was alert and oriented , Vitals BP- 140/90, P-92, Respiration- 24, Temperature- 98.6, O2- 100 % RA. Assessed residents ROM, WNL of resident's baseline. EMS was called, R/P, MD, DON , and Administrator notified. Resident consented to transport. Signed by RN A. Record review of the facility investigation report, dated 11/18/2024, reflected Transportation Aide T failed to raise the lift prior to rolling Resident #12 out of the van resulting in resident falling out of the rear exit of the van. The investigation was confirmed, and Transportation Aide T was terminated. Record review of Resident #12's incident report, dated 11/15/2024, reflected called by transportation driver to the front awning. Seen resident laying on her left side. Resident stated she hit her head and it was hurting. Small laceration and formation of hematoma to the back of her head. Resident complained of pain to her bottom but denied pain elsewhere. No other injuries noted. Resident stated I fell out the back of the van. Resident noted to be anxious. Resident knew where she was and able to inform the nursing staff her name and date of birth. The following was documented on the incident report: 1. Immediate action taken: Resident sent to local hospital by EMS. 2. Injuries observed at the time of incident: laceration to the back of head. 3. Level of Pain: Resident #12's pain level was a 10 (on scale of 1 to 10 and 10 being the maximal level of pain). Resident #12 was alert. 4. Mental Status: Resident #12 was oriented to the following: person, situation, place and, time. 5. Injuries report post incident: Resident #12 did not have any observed post incident. 6. Witnessed fall: Resident #12 fell outside. 7. Predisposing situation and physiological factors: none. 8. Other information: Lift was not in raised position. Lift was lowered to the ground from previous resident that was unloaded from the van. 9. Statements: TA T statement was not printed in its entirety. ( The sentences were not complete due to printing error on the incident report) Requested on 12/10/2024 at 2:30 PM from the DON for a new incident report. It was not provided prior to exit. Resident #12 incident report was provided in the facility investigation, however, it did not have the statement by transportation aide T. Agencies/People notified: Physician, DON, and Family member. Record review of Resident #12's first hospital visit on 11/15/2024 reflected findings of a fracture of the surgical neck of the right humerus, mild angulation, and impaction. Suspect second part fracture extending into the greater tubercle. No other evidence of injury. First hospital recommended Resident #12 sent to another hospital for further testing and assessment. Record review of Resident #12's second hospital visit on,11/15/2024, reflected history of present illness. Resident #12 was presented to the ED as a transfer status post fall from wheelchair. Outside hospital imaging was concerning for subdural and right humerus fracture. However repeat trauma imaging did not show any signs of subdural hematoma or new humerus fracture aside from an old fracture. Trauma CT scan revealed an incidental finding of right lower lobe segmental Pulmonary Embolism ( a blood clot that blocks an artery in the lungs, preventing blood flow to part of the lung). Resident #12 had new O2 requirement and required 2 L on nasal cannula. Resident #12 at baseline and did not require any oxygen at facility. The hospital completed CT scans and x-rays of all areas of Resident #12. Resident #12 had an old fracture and did not have any new injuries. Record review of Transportation Aide T personnel record reflected Transportation Aide T was hired on 04/15/2024 as a transportation aide. She received training by the former Transportation Coordinator U on 04/15/2024. Transportation Aide T and Transportation Coordinator U signed the facility form Steps for Operating the lift in the van. The facility followed protocol for any incident occurring in the facility van. Transportation Aide T results of the drug test was in the personnel file, and it was negative. Transportation Aide T was terminated on 11/15/2024. Record review of Transportation Aide R's personnel record reflected her training and orientation to be a transportation aide was completed on 11/18/2024 and 11/21/2024. Record review of Transportation Aides S personnel record reflected her training and orientation to be a transportation aide was begun on 12/2/2024 and was continued for 2 weeks. Record review of demonstration in-services completed by Transportation Coordinator on 11/18/2024 after the incident on 11/15/2024 with Resident #1 in the white ford van reflected all staff on the facility van insurance was required to demonstrate how to load residents on the van and how to unload the residents off the van. The following was demonstrated : Steps for operating the Lift in the [NAME] Ford Van 1. Ensure the van's engine is running. 2. Engage the emergency brake. 3. When a resident is positioned on the lift, lock the brakes on their chair. 4. Secure the strap behind the chair. 5. Gradually lower the resident and the ramp to the ground. If there is a second resident awaiting unloading inside the van, ensure their chair remains secure with a harness until the staff is ready to assist. 1. Secure the yellow strap belt. 2. Return the lift to its raised position. Please note: If the lift is left in the lowered position, an alarm will activate when the weight contacts the yellow-marked barrier on the lift mechanism. Steps for Operating a [NAME] Dodge Caravan or the Green/ Gray [NAME]: 1. The ramp is operated manually 2. Ensure the vehicle is parked at least four feet from the curb and facing away from the traffic to prioritize safety. 3. Lower the ramp while employing proper body mechanics. 4. Secure all residents using a four-point harness system. 5. Fasten each resident with a seatbelt for additional safety. 6. When loading a resident , they should face inward towards the van. 7. During unloading, ensure the resident descends the ramp while facing the interior of the van. Record review of Abuse and Neglect in-service dated 11/15/2024 reflected abuse and neglect was discussed during the in-service. Neglect- is the failure to care for properly. Cases of suspected abuse, neglect, or exploitation shall be reported immediately to the abuse coordinator, The Administrator or to The Director of Nurses. Record review on 12/11/2024 of the signs steps for operating a white dodge caravan or the green/gray [NAME] placed in the facility vans after the incident on 11/15/2024. The signs reflected the following: 1. The ramp is operated manually. 2. Ensure the vehicle is parked at least four feet from the curb and facing away from traffic to prioritize safety. 3. Lower the ramp while employing proper body mechanics. 4. Secure all residents using a four-point harness system. 5. Fasten each resident with a seatbelt for additional safety. 6. When loading a resident, they should face inward towards the van. 7. During unloading, ensure the resident descends the ramp while facing the interior of the van. Record review of QAPI for the upcoming meeting in January 2025 reflected the incident with the facility van would be addressed during the QAPI meeting and review the steps taken to prevent another incident on the van. Record review, on 12/10/2024 of additional steps to be taken to ensure the staff was operating the van per protocol the Transportation Coordinator will complete monthly random checks with the transportation aides and the other staff on the insurance card to ensure they are operating the van per protocol. These random checks will be unannounced. Record review, on 12/10/2024, of additional protocol was to perform drug testing on any new hires to drive the van and will do drug testing if suspect anyone is using illicit drugs. Record review on 12/10/2024, of a statement from Transportation Aide T given to Transportation Coordinator, dated 11/15/2024, reflected, Transportation Aide T had both Resident #12 and Resident #48 in the transit van out from of the facility. Transportation Aide T Unstrapped Resident #48, pushed her on the ramp, lowered the ramp, and proceeded to wheel Resident #48 into the nursing home. Transportation Aide T then went through the right side of the transit van to unstrap Resident #12. Transportation Aide T stated they were talking and making jokes while Transportation Aide. Unable to conduct observation of the facility van used to unload Resident #12 when she fell from the van onto the ground as it was not at the facility. The white dodge caravan was in the shop. Record review of the invoice faxed from the mechanic shop where the facility white caravan was being repaired reflected the mechanics were working on the transmission torque converter and not the wheelchair lift. In an interview on 12/10/2024 at 9:05 AM the Director of Nurses stated Resident #12 was returning from a doctor's appointment in the facility van. She stated Transportation Aide T had assisted Resident #48 off the facility van and into the facility. She stated when Transportation Aide T returned to the van she did not step onto the lift and maneuver the lift to the door instead she entered the van from the side door. She stated Transportation Aide T unhooked the belts and all the safety gear from Resident #12's wheelchair and began to assist her to the back of the van. The Director of Nurses stated Resident #12's back was toward the open door and Transportation Aide T was face to face to Resident #12. She stated Transportation Aide T pushed her off the van without the lift being at the door of the van. Resident #12 fell from the van onto the lift located on the ground. The Director of Nurses stated Resident #12 did not sustain any injuries. She was immediately transported to the emergency room by EMS and later transferred to another emergency room for further x-rays and CT scans. She stated the hospital report indicated no injury from the fall. The Director of Nurses stated Transportation Aide T was given a drug test per protocol of the facility's insurance and she was negative for any illicit drugs. She stated Transportation Aide T was terminated immediately for not following proper policies and procedures when transferring Resident #12 off the van. The DON stated during the investigation it was confirmed neglect. She stated the facility immediately began abuse and neglect in-services. The Transportation Coordinator on 11/18/2024 in-service everyone on the insurance card to demonstrate how to operate the vans. She stated this incident was on the next QAPI agenda. The Director of Nurses stated the facility will be doing random observation of staff operating the van and this would be unannounced. She also stated the facility has put in place to do drug screens on any staff will be operating the facility van and will do random drug screens if any suspicion of drug use when on duty. In an interview on 12/10/2024 at 9:45 AM Transportation Coordinator stated Transportation Aide T came into the facility and asked for a nurse immediately. Transportation Coordinator stated few nurses went outside and she heard people talking and she immediately went outside. She stated when she arrived outside under the awning near the front door was the Van ( white dodge van). Transportation Coordinator stated she saw Resident #12 on the ground and there were two or three nurses assessing Resident #12. She stated she spoke with Transportation Aide T, and she was very upset. She stated Transportation Aide T explained what happened with Resident #12. Transportation Coordinator stated she wrote a statement of what Transportation Aide T stated what occurred and she did not think to get Transportation Aide T to sign the statement. ( The statement is listed above this interview). Transportation Coordinator stated she could understand how the statement could be confusing. She stated Transportation Aide T left the lift ( ramp) on the ground after unloading Resident #48. She stated after Transportation Aide T Escorted Resident #48 into the facility she returned to the van and entered from the side door. Transportation Coordinator stated Transportation Aide T unhooked all the belts and safety devices from Resident #12 wheelchair. She stated Transportation Aide T was facing Resident #12 and was pushing her backwards to the open door in the back of the van. Transportation Coordinator stated Transportation Aide T did not have the lift to the van door. She stated Resident #12 back was facing the open door and Transportation Aide To push resident off the van and Resident #12 fell from the van onto the lift located on the ground. She stated she was informed by the Administrator to escort Transportation Aide T to get a drug test. Transportation Coordinator stated after the drug test she escorted her into the Administrator's office and Transportation Aide T was terminated immediately. Transportation Coordinator stated she had been in this position after Transportation Aide T was hired. She stated the former Transportation Coordinator U Trained Transportation Aide T. She stated all staff hired as transportation aides are trained 2 weeks or more before they can drive the vans. She stated there were two facility vans one is a [NAME] Dodge Caravan and this was the one Resident #12 was in when she fell . She stated there was another van a Green/Gray [NAME]. Transportation Coordinator stated all staff on the insurance card had been re-trained on how to operate the vans uploading and unloading on 11/18/2024. She stated there was a new hire on 12/02/2024 as a full-time van driver. Transportation Coordinator stated the new van driver received training on how to operate the van on 12/02/2024 and for 2 weeks prior to Transportation Aide S drove the van. She stated Transportation Aide S and any new hires received training and would observe the current Transportation Aide R before she drove the van. Transportation Coordinator showed her list of staff on the insurance card, and it matched the administrations list. Transportation Coordinator stated everyone on that list had been in serviced verbally and given form of steps for operating the lift on the vans and the staff had to demonstrate how to operate the van on an individual basis. She stated this was the first time Transportation Aide T had an accident/ incident with unloading a resident off the van. Transportation Coordinator stated she was not aware of any transportation aides or anyone driving the vans having an incident. Interview on 12/10/2024 at 1:00 PM Transportation Aide S stated she was hired on 12/02/2024 as a full-time transportation aide. She stated she did not work at this facility prior to being hired on 12/02/2024. Transportation Aide S stated she was given in-service and training over a week before she began driving the van. She stated she observed Transportation Aide R drive the van and observed residents being unloaded and uploaded on to the vans. She repeated how to upload a resident onto the van and unload a resident off the van. She stated she was in-serviced on resident neglect. In an attempt to interview via phone Transportation Aide T on 12/10/2024 at 2:23 PM, 12/11/2024 at 10:20 AM and 12/12/2024 at 12:22 PM unable to leave voice message and sent 3 texts on the same dates and time to return phone call. Transportation Aide T did not return phone call or respond to three text messages. Interview on 12/11/2024 at 10:30 AM RN A stated she heard staff calling for a nurse to go to the parking lot. She stated she was sitting in her office and immediately exit office and went to the parking lot. She stated she was first nurse to observe Resident #12. She stated Resident #12 was at an odd position on the lift and part of her side was on the ground. RN A stated Resident #12 was lying on the lift where a staff would push a resident onto the lift. RN A stated Resident #12 was lying on the arm of the wheelchair and Resident #12 was lying on the left side of wheelchair. RN A stated it was an unusual position and was difficult to describe. She stated Resident #12 buttocks was partially in the wheelchair. She stated Resident #12 was complaining of pain back of her head. RN A stated it appeared a small hematoma was forming, and she had a small laceration to back of the head. RN A stated there were two other nurses assisting with Resident #12. RN A stated the physician, EMR, Family, DON and the Administrator was contacted. She stated she wrote a nurses note, and another nurse completed incident report. RN A stated she did not speak with Transportation Aide A and was focusing on assessing Resident #12. She stated she knew Resident #12 fell from the bus on to the lift and ground and the lift was not at the door when she fell . She stated she knew this due to needing to know how she fell on to the ground. RN A stated there was a lot going on and she did not recall who gave this information. She stated she had been in serviced on Abuse and neglect. RN A stated she did not drive the vans. In an interview on 12/12/2024 at 8:15 AM former Transportation Aide/ Receptionist stated she did work with Transportation Aide T when she was full time transportation aide. She stated she had ridden with Transportation Aide T when she drove the van and observed her unloading and loading residents. Former Transportation Aide/ Receptionist stated she never saw Transportation Aide To do anything wrong with the operation of any part of both vans. She stated training on how to operate every part of the van including the lifts was very important to the facility and the staff received hands on training. She stated she had was in-service on abuse and neglect. She stated she is currently receptionist and does not drive the van any longer, however she did go through the training on 12/18/2024 as a precaution if there was an emergency, she would be willing to drive the van. She stated she was in-service on abuse and neglect. In an interview on 12/12/2024 at 10:55 AM Transportation Aide R stated she had been working at this facility as a MA and CNA since 11/7/2023. She stated she did drive the van as needed when Transportation Coordinator U was working at the facility, and he trained me how to use the vans. She stated Transportation Coordinator U would have me to demonstrate using a fake person in a wheelchair and observed me unloading, uploading , placing the straps secure and things like that in the van. She stated she was retrained on 11/18/2024 by the present Transportation Coordinator. She stated she is a full time Transportation Aide as of 12/02/2024 and was part time transportation aide prior to 12/02/2024. Transportation Aide R stated she did go through re orientation and in-service on abuse and neglect. In an interview on 12/12/2024 at 1:35 PM the Administrator stated Transportation Aide T, had returned to the facility in the facility white van with 2 residents from doctor appointments. Transportation Aide T Unloaded Resident # 48 off the facility van with the lift. She stated when Transportation Aide T returned to the facility van, she did not enter the van per facility protocol. The Administrator stated Transportation Aide T did not stand on the lift and move the lift from the ground to the back open door. She stated Transportation Aide T was required per policy to stand on the lift and maneuver the lift from the ground to the back door to use to transfer Resident #12 from the facility van onto the ground. Transportation Aide T entered the facility van from the side door and proceeded to unhook the straps and belts from Resident #12's wheelchair. Transportation Aide T pushed Resident #12 wheelchair to the open door where the lift was not at the back door. Transportation Aide T was facing Resident #12 and Resident #12's back was to the open door. She stated Transportation Aide T did not notice she had not moved the lift from the ground to the open door. The Administrator stated Transportation Aide T pushed Resident #12 backwards where Resident #12's back was facing the door and pushed her off the van. The Administrator stated it was approximately 3 or 4 feet. She stated Resident #12 fell from the facility van onto the lift located on the ground. She stated the lift was not used to assist Resident #12 off the facility van. The Administrator stated the facility protocol for unloading residents onto the lift of the van was not followed. She stated the white van was used during the incident with Resident #12 was in the shop at a dealership for repair. She stated the repair was not the lift. The Administrator facility staff checked the lift after the incident, and it did not have any mechanical issues. The lift was in good condition. The Administrator did not specify what staff checked the lift. In an interview on 12/12/2024 at 3:30 PM Resident #12 stated she did fall out of a van, and it was a long fall. She stated she was not hurt and was happy she did not break any bones. Resident #12 stated she was not afraid to ride on the van again. She stated accidents happens and she was lucky. Resident #12 stated she would ride the van anytime she was not afraid and was not nervous over the fall from the van. In an interview on 12/12/2024 at 3:45 PM Transportation Coordinator stated the protocol listed below was the facility protocol for unloading a resident off the van. Record review of the facility's protocol for Unloading Transportation Vans, not dated, reflected the following: 1. When unloading a resident, the resident is to be pushed onto the ramp, brakes engaged, and the driver is to ride down the ramp in front of the resident until the ramp is fully down and immobile on the ground. 2. Ensure that wheelchairs are always locked when not actively moving a resident . 3. Residents are required to have their wheelchairs secured in the van and the resident is to be wearing a seat belt. 4. Before unloading a resident, make sure the ramp is up all the way and ready for the resident to be pulled onto the ramp. 5. While unloading the van when transferring two residents, be sure to leave the resident not being unloaded at the same time secure in the van and have their wheelchair locked until ready to unload them.

Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 of 5 residents (Resident #38) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #38's Hydrocodone-Acetaminophen, a medication to help with pain. This failure could place residents at risk for not receiving prescribed medications. Findings included: Record review of Resident #38's admission record dated 12/12/24, reflected the resident was admitted [DATE]. Her diagnoses included dysphagia (difficulty swallowing), cerebral infarction (stroke), Rheumatoid arthritis (the immune system attacks the body's tissues, leading to swelling and joint deformity and pain), and pain. Record review of Resident #38's quarterly MDS dated [DATE] reflected a BIMs score of 0 indicating severe cognitive impairment. Record review of Resident #38's physician orders dated 11/3/24 reflected an active order for Hydrocodone-Acetaminophen 5-325mg 1 tablet oral every 24 hours as needed for pain. Record review of Resident #38's Medication Administration Record (MAR) dated 11/1/23 through 11/30/24 reflected the Hydrocodone-acetaminophen had not been administered at all. Record review of the facility's investigation of the missing hydrocodone-acetaminophen medication reflected on 11/03/24 during the shift change around 6AM the oncoming nurse noted a difference in color for 5 of the 60 tablets in the bottle. The charge nurse was notified. The charge nurse was not able to address the situation for some time but once she assessed the situation the on-call nurse and ADM were notified. The off going nurse that worked night shift had already left the facility and refused to return to perform a urine drug screen. The medications were found to be Imdur 60mg tab. No other resident in the facility had an order for Imdur. Record review of the Pharmacy consultant's notes dated 11/11/24 revealed, DON reported a discrepancy in bottle of Norco 5/325 generic. Bottle contained 60 tablets, but 55 were identified by ID on bottle and Ephorates app as Hydrocodone/Appa 5/325 as dispensed and 5 of the 60 were noted to be Isosorbide Mononitrate 60mg tablets-per ID on the tablets, and per Drugs.com. During an interview on 12/12/24 at 9:28 AM with LVN E, she stated she had worked at the facility for about a year. She stated that all controlled medications are to be counted when possession of responsibility for the cart changes. LVN E stated the first page in the count binder is a record of how many medications there are to be counted. Once the correct number of medications is verified then the quantity of each medication must match up to its paired sheet. LVN E stated if anything is off with the count or suspicion of anything not matching up correctly then it is to be reported to the DON immediately. She stated missing medications could mean that a resident does not get the medication when they are supposed to. During an interview on 12/12/24 at 9:53 AM with LVN F, she stated she had worked at the facility for about 4 years. She stated that all medication carts are to be counted before changing shifts. She stated that if anything is off with the count, then the DON is to be notified immediately. She stated if there are medications missing then it could affect the resident by causing a missed dose. A telephone message was left on 12/12/24 at 1:00 PM for Family member of Resident #38 requesting a return call. A return call was not received before close of business 12/13/24. During an interview on 12/12/24 at 2:39 PM with the DON, she stated she was notified a few hours after shift change about the medication being a different color and possible different pill. She stated that her investigation revealed that during the shift change it was discovered that 5 pills in a bottle of 60 pills were with a different color and imprint than the other 55 pills. The DON stated that the off-going nurse (LVN W) on that day when this discrepancy was revealed refused to do a urine drug screen and has been terminated from employment with this facility. She stated that she contacted the physician, the consultant pharmacist, the resident's responsible party, the dispensing pharmacy and the sheriff's office to make a report. The DON stated the 5 other pills were identified as isosorbide mononitrate 60mg using drugs.com as a reference. She said that she looked and no one in the building at that time was prescribed that medication and dosage. She stated that she has since in serviced staff that she is to be notified immediately and no one is to leave the building until further instructed. The DON stated that her investigation into the missing medication was considered confirmed. She stated that this could have impacted the resident if she had received the wrong medication, it could have caused harm. During an interview on 12/12/24 at 3:04 PM with the ADM, she stated Resident #38's family took her to the doctor in another city and returned with a bag from an outside pharmacy with a bottle of medication in the bag in October. The medication was counted and verified by staff. She stated, they asked their pharmacy to repackage it into a blister pack, but they would not do it because it was filled at a different pharmacy. After the incident, Resident #38's chart was reviewed, and it reflected no medication had been administered since the order was written. She stated the incident was reported to the police and the nurse that worked that night (LVN W) refused to do a urine drug screen and that nurse was terminated. The ADM stated it could have affected the resident if she had taken the medicine, but she looked back over Resident #38's medication administration record and the resident never received any medication from that bottle. Record Review of Policy titled Storage of Medications dated 2001 and revised in November 2020 states, Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 8. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 medication storage rooms reviewed for medications. The facility failed to remove 2 expired suppositories and 1 bag of expired medication from the medication storage room when it was observed on 12/11/24 at 12:50 PM. This failure could place residents at an increased risk of receiving expired and/or contaminated medications which could result in adverse health consequences. Findings included: Observation on 12/11/24 at 12:50 PM in the medication storage room revealed 2 suppositories of bisacodyl 10 mg with expiration date 09/24 and one bag of Gentamicin 60 mg in 100 ml 0.9% sodium chloride for intravenous use with expiration date 12/6/24, belonging to Resident #36. Review of Resident #36's admission record dated 12/12/24 revealed an [AGE] year-old female, admitted on [DATE] with diagnoses that include urinary tract infection, traumatic brain injury, sick sinus syndrome (irregular heart rhythm), hyperlipidemia (high cholesterol), and Hypertension (high blood pressure). Review or Resident #36's readmission MDS assessment dated [DATE] revealed a BIMS score of 15 indicating no cognitive impairment. Review of Resident #36's physicians order summary dated 12/12/24 revealed an order for Gentamicin Sulfate Injection Solution 40 mg/ml. Use 60mg intravenously at bedtime related to bacteremia (an infection in the blood) for 5 days. Status on hold. Start date 12/2/24. End date 12/7/24. Review of Resident #36's care plan dated 12/2/24 revealed Urinary tract infection; at risk for repeat urinary tract infections. Goal: Resident will show no signs/symptoms of infection. Interventions/Tasks: Administer antibiotic therapy as prescribed. In an interview on 12/11/24 at 12:50 PM LVN F stated she had been working in the facility since January 2021. She stated nurses and medication aides are responsible for checking for expiration dates. LVN F stated that medications could lose effectiveness over time and may not work as well if administered to a resident. In an interview on 12/12/24 at 9:27 AM LVN E stated she had been working in the facility since [DATE]. She stated that nurses, medication aides, and administration should check for expired medications at least once a month. LVN E stated the expired medications would not be as effective if given to a resident. In an interview on 12/12/24 at 1:20 PM LVN G stated she had been working in the facility since August 2022. She stated that nurses should check for expired medications. LVN G stated the expired medications would not be as effective if given to a resident. She stated that the medication that was expired for Resident #36 was because the resident had a lab level drawn to check for the antibiotic in the resident's blood. She stated that the level was too high and so the medication was held and not used. In an interview on 12/12/24 at 02:39 PM the DON stated she had been working at the facility since March 2021. She stated she expected the pharmacy consultant to check the medication room and carts monthly, and the nurses and medication aides to check at least weekly. The DON stated that using medications after they have expired could lead to decreased effectiveness or a possible adverse reaction. In an interview on 12/12/24 at 3:04 PM the ADM stated her expectation was for the nurses and medication aides to check the medication carts and room weekly on Sunday nights and for administration to check the carts/room monthly for expired medication. The ADM stated using the medication after the expiration date could lead to decreased effectiveness. Review of an undated facility policy and procedure titled Storage of Medications reflected The facility will store all drugs and biologicals in a safe, secure, and orderly manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 12 residents (Resident #9, Resident #25 , Resident #102, ) observed for infection control. 1. The facility failed to ensure all staff donned PPE when entering rooms of residents' rooms who were on droplet precautions. 2. The facility failed to ensure PPE was adequately stocked for residents on droplet precautions. These failures could place residents at risk of cross-contamination and development of infection. Findings included: Review of Resident #9 face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of Dementia (a decline in mental ability that affects memory, thinking, and behavior), heart failure, and chronic fatigue (a long-term illness that causes severe fatigue and makes it difficult to perform daily activities). Review of Resident #9 care plan revealed Resident #9 had increased potential to contract COVID 19 in facility. Interventions included to follow CDC and health department guidelines regarding COVID recommendations and precautions. Further review revealed of care plan with revision date of 12/11/2024 that resident had recent diagnoses of COVID 19 with position test. Interventions included to enforce strict isolation with proper donning and doffing of isolation equipment. Observation on 12/12/24 at 10:03 AM revealed CNA Y walked into Resident #9's room without face shield or goggles on. Review of Resident #25 face sheet revealed an [AGE] year-old male admitted on [DATE] with diagnoses of COVID-19 (an infectious disease caused by the SARS-CoV-2 virus), metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the blood that affects brain function) and anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress). Review of Resident #25 care plan dated 04/09/2024 revealed resident with increased potential to contract COVID due to communal living, interventions included to follow CDC and health department guidelines regarding COVID recommendations and precautions. Further review revealed care plan dated 12/07/2024 Resident #25 had recent diagnoses of COVID 19 with interventions to enforce strict isolation with proper donning and doffing of isolation equipment. Observation on 12/10/2024 at 2:19 PM revealed PPE observed outside of Resident #25's room. Resident had droplet precaution sign posted on door to room. Observation on 12/11/24 at 11:47 AM revealed no face shields available for staff outside of Resident #25's room. Review of Resident #102's face sheet revealed an [AGE] year-old female admitted on [DATE] with diagnoses of COVID-19 (respiratory virus), anxiety disorder (a mental health condition that causes excessive and uncontrollable feelings of fear or worry that can interfere with daily life), depression (a mental health condition that can affect how a person feels, thinks, and behaves), and essential hypertension (a condition where blood pressure is chronically elevated but there is no known cause). Review of nursing progress notes for Resident #102 dated 12/09/2024 revealed Resident to begin strict covid isolation - contact & droplet precautions. Review of Resident #102's care plan dated 12/09/2024 revealed resident with recent diagnoses of COVID 19 virus with interventions that included enforce strict isolation with proper donning and doffing of isolation equipment along with strict hand washing. Observation on 12/10/2024 at 12:00 PM revealed CNA O entered Resident #102's room with gown, gloves, N-95 mask and a surgical mask under the N-95 mask. CNA O was not wearing a face shield or goggles. Observation on 12/10/2024 at 2:13 PM revealed MA Q entered Resident #102's room with gown, gloves and surgical mask. MA Q was not wearing a face shield or goggles. Observation on 12/10/2024 at 2:14 PM revealed a plastic bin with PPE in front of Resident #102's room and it included gowns, gloves, N-95 masks and surgical masks. There were no goggles or face shields in the cart. Observation on 12/10/2024 at 2:19 PM revealed a sign on Resident #102's door that revealed droplet precautions were in place. Further observation revealed a sign titled sequence for putting on personal protective equipment (PPE) Instructions included to don gown, mask or respirator, goggles or face shield and gloves. Observation revealed an additional sign posted that everyone must make sure their eyes, nose and mouth are fully covered before room entry. During an interview on 12/10/2024 at 2:17 PM MA Q stated that Resident #102 had COVID. MA Q did state why she did not have a face shield or goggles on entering Resident #102's room. Observation on 12/11/2024 at 9:55 AM revealed a plastic bin with PPE in front of Resident #102's room and it included gowns, gloves, N-95 masks and surgical masks. There were no goggles or face shields in the cart. Observation on 12/11/24 at 11:47 AM revealed no face shields available for staff outside of Resident #25's room. Observation on 12/12/24 at 10:03 AM revealed CNA walked into Resident number #9's room without face shield or goggles on. Observation on 12/12/2024 at 10:35 am revealed a large box in the housekeeping manager's office with face shields in it. During an interview on 12/10/20245 at 2:17 PM MA Q stated that Resident #102 had COVID. Interview with LVN Z on 12/11/24 at 10:35 am, she stated that if a resident had droplet precaution it should have been posted on the door. They were supposed to follow the sign on the door for putting on and taking off the PPE. They were supposed to wear a face mask, dispose of all the gear inside, and wash their hands. If there was not PPE available, she would have requested it from housekeeping. Interview with CNA Y on 12/11/2024 at 10:03 am 12/11/2024, she stated that when she went into a room she put on gown, gloves and masks. When she exited a room, she took off gloves first, then gown, then mask, and then washed hands inside. She sanitized her hands outside the room. She stated that she did not like the face shield because it made her hot. She was not sure if she was supposed to wear the face shield. She stated if she did not have PPE, she would go to the nurse and ask her. She stated that housekeeping came to check and stock PPE. She thought she had an in-service from one of the nurses in November. She stated that if she does not have PPE, she could get other residents sick. Interview with LVN AA on 12/12/2024 at 10:13 am, she stated that housekeeping came to check and stock up on PPE. She thought they needed face shields, and she stated she had an in-service in November for infection control. If they did not have PPE housekeeping or nurses would get PPE it out of the linen closet. She stated that she could get other residents sick if they do not wear PPE properly. Interview with LA BB A on 12/12/2024 at 10:14 am she stated that another housekeeping staff was responsible for ensuring PPE was available. She stated that she did not check for PPE while she was cleaning the halls. She would occasionally check if the box were was obviously low from the outside. They had someone come this morning to fill up the PPE. If there was no PPE she would not go in the room. She thought her last in-service was 3 months ago. Interview with LA CC B on 1112/12/2024 at 10:35 am, she stated it was her responsibility to stock PPE. PPE included gowns, gloves, blue bags, face shields, and masks. She was responsible for placing signs on the doors and checking PPE every morning. If there was not enough PPE available when she was in the facility she expected a verbal request, a text or a phone call from any staff that needed more PPE. She stated there were plenty of face shields available for staff. She stated the residents could be in danger if she did not stock the PPE for the direct care staff. Attempted telephone interview with CNA O on 12/12/2024 at 12:19 PM. Attempted telephone interview with MA Q on 12/12/2024 at 12:20 PM. Interview with RN A, the infection preventionist, on 12/12/24 at 01:49 PM, she stated that employees were supposed to wear goggles or face shields when going in the rooms. Interview with the DON on 12/12/2024 at 1:45 PM she said the facility did yearly PPE in-services or anytime there was a new COVID case. She stated that staffed needed to wear face shields or goggles. There was no reason staff should not have face shields on. The housekeeping was responsible for stocking the PPE. They had designated one person to stock it each morning. She stated that it would spread disease to other residents if staff did not wear proper PPE. DON stated staff were supposed to wear N95 masks and staff should not just wear surgical masks. DON stated staff should not wear an N95 mask over a surgical mask. She stated staff knew the order of PPE because they should look at the signs on the door. DON stated staff should just throw the face shield away and get a new one after they exited a room. Review of facility in-services revealed an in-service was completed on 09/10/2024 with the topic of COVID-19. Informed review included how COVID-19 spreads, sequence for putting on PPE, and that staff must ensure their eyes, nose and mouth were fully covered. Review of facility policy dated September 2022 titled Coronavirus Disease (COVID-19) - Using Personal Protective Equipment revealed Personnel who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection adhere to standard precautions and use NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves and eye protection. Further review revealed an N95 respirator and eye protection (goggles or a face shield that covers the front and sides of the face) is applied upon entry to the resident room or care area.

Based on interviews and record reviews, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable state laws for 8 (Residents #1, #2, #3, #4, #5, #6, #7, and #8) of 9 residents reviewed for assessments. The facility failed to ensure the ADON had a current and active license. The ADON provided assessments to Residents #1, #2, #3, #4, #5, #6, #7, and #8 while her RN license was expired from [DATE] through [DATE]. This could place residents at risk for inadequate care and/or services. Findings included: Review of Resident #1's admission record, dated [DATE], reflected an [AGE] year old female who was admitted to the facility on [DATE], discharged on [DATE], and had diagnoses including malignant neoplasm of bilateral ovaries (a cancerous tumor in both ovaries), unspecified anxiety disorder, restlessness and agitation, age-related osteoporosis without current pathological fracture (a condition that occurs when bones become less dense and more likely to break due to aging), cognitive communication deficit, other irritable bowel syndrome, overactive bladder, generalized muscle weakness, other abnormalities of gait and mobility, and need for assistance with personal care. Review of Resident #1's assessments log, dated [DATE], reflected the ADON provided the following assessments to Resident #1: -Quarterly ADL Only Evaluation on [DATE] -Quarterly Elopement Evaluation on [DATE] -Braden Scale for Predicting Pressure Ulcer on [DATE] -Quarterly Fall Risk Evaluation on [DATE] -Quarterly Lift/Transfer Evaluation [DATE] -Dehydration Risk Evaluation on [DATE] -Bowel and Bladder Program Screener on [DATE] -Quarterly BIMS evaluation on [DATE] -Quarterly PHQ9 on [DATE] -Quarterly Mini nutritional assessment screening on [DATE] -Quarterly social services quarterly note on [DATE] Review of Resident #1's comprehensive care plan, closed [DATE], reflected charge nurses, which were RNs, were required to assess Resident #1's skin weekly for breaks in skin integrity and changes in usual appearance and follow up with physician with concerns. RNs were also required to monitor/document/report PRN any signs/symptoms of dehydration, UTI, any changes in cognitive function, changes in ADLs, and any possible causes of incontinence and malnutrition and perform risk evaluations and scheduled clinical evaluations per facility's protocol. Review of Resident #2's admission record, dated [DATE], reflected an [AGE] year old female who was readmitted to the facility on [DATE] and had diagnoses including myopathy (diseases that affect skeletal muscles), major depressive disorder, primary osteoarthritis in the left shoulder (a type of arthritis that occurs in joints over time without a known cause), unspecified dementia, unspecified depression, unspecified anxiety disorder, memory deficit following cerebral infarction (a medical condition that occurs when blood flow to the brain is disrupted, leading to brain cell death), other speech and language deficits following unspecified cerebrovascular disease, generalized muscle weakness, overactive bladder, other abnormalities of gait and mobility, cognitive communication deficit, need for assistance with personal care, history of falling and other fatigue. Review of Resident #2's assessments log, dated [DATE], reflected the ADON provided the following assessments to Resident #2: -Quarterly social service quarterly note on [DATE] -Quarterly bowel and bladder program screener on [DATE] -Elopement evaluation on [DATE] -Quarterly BIMS evaluation on [DATE] -Quarterly social service quarterly note on [DATE] -Quarterly PHQ9 on [DATE] -ADL only evaluation on [DATE] Review of Resident #2's comprehensive care plan, dated [DATE], reflected RNs were required to monitor/document for signs/symptoms of UTI, any possible causes of incontinence, changes in ADL status and abilities, change in mental status, changes in cognitive function, immobility, depression, and immobility, and perform scheduled clinical evaluations per facility's protocol. Review of Resident #3's admission record, dated [DATE], reflected a [AGE] year old female who was readmitted to the facility on [DATE] and had diagnoses including urinary tract infection, unspecified protein-calorie malnutrition, dehydration, unspecified altered mental status, cognitive communication deficit, other lack of coordination, other abnormalities of gait and mobility, and generalized muscle weakness. Review of Resident #3's assessments log, dated [DATE], reflected the ADON provided the following assessments to Resident #3: -Quarterly social services note on [DATE] -Quarterly PHQ9 on [DATE] -Quarterly BIMS evaluation on [DATE] Review of Resident #3's comprehensive care plan, dated [DATE], reflected RNs were required to perform clinical evaluations per facility's protocol and monitor/document/report PRN any changes in status, any potential for improvement, reasons for self-care deficit, expected course, and declines in function, confounding communication problems, and UTI. Review of Resident #4's admission record, dated [DATE], reflected an [AGE] year old female who was readmitted to the facility on [DATE] and had diagnoses including metabolic encephalopathy (a brain disorder that occurs when an underlying condition causes a chemical imbalance in the blood that affects the brain), unspecified anxiety disorder, dehydration, unspecified depression, unspecified altered mental status, restlessness and agitation, unspecified dementia, other recurrent depressive disorders, unspecified Alzheimer's disease, other chronic pain, unspecified low back pain, repeated falls, need for assistance with personal care, and history of falling. Review of Resident #4's assessments, dated [DATE], reflected the ADON provided the following assessments to Resident #4: -Quarterly social services note on [DATE] -Quarterly BIMS evaluation on [DATE] -Quarterly PHQ9 on [DATE] -Bowel and bladder program screener on [DATE] -ADL only evaluation on [DATE] Review of Resident #4's comprehensive care plan, dated [DATE], reflected RNs were required to monitor/document/report to MD PRN signs and symptoms of UTI, any changes, any potential for improvement, reasons for self-care deficit, expected course and declines in ADL function, any possible causes of incontinence, change in mental status, agitation, complications related to constipation, changes in cognitive function, abnormalities for urinary output, dehydration, and perform scheduled clinical evaluations per facility's protocol. Review of Resident #5's admission record, dated [DATE], reflected an [AGE] year old female who was readmitted to the facility on [DATE] and had diagnoses including unspecified ataxia (a neurological sign that indicates a loss of muscle coordination and control), cognitive communication deficit, need for assistance with personal care, unspecified depression, generalized muscle weakness, other specified disorders of muscle, other abnormalities of gait and mobility, and other lack of coordination. Review of Resident #5's assessments, dated [DATE], reflected the ADON provided the following assessments to Resident #5: -Admission social services history and initial assessment on [DATE] Review of Resident #5's comprehensive care plan, dated [DATE], reflected RNs were required to evaluate Resident #5's desire to return to the community and perform clinical admission evaluation. Review of Resident #6's admission record, dated [DATE], reflected a [AGE] year old female who was admitted to the facility on [DATE] and had diagnoses including unspecified candidiasis (a fungal infection caused by an overgrowth of the Candida yeast), other abnormalities of gait and mobility, history of falling, unspecified chronic fatigue, cognitive communication deficit, generalized muscle weakness, and need for assistance with personal care. Review of Resident #6's assessments, dated [DATE], reflected the ADON provided the following assessments to Resident #6: -Quarterly social services note on [DATE] Review of Resident #6's comprehensive care plan, dated [DATE], reflected RNs were required to perform scheduled clinical evaluations per facility's protocol and monitor/document/report PRN any changes in ability to communicate, potential contributing factors for communication problems and potential for improvement, physical/ nonverbal indicators of discomfort or distress and confounding communication problems such as decline in cognitive status and mood. Review of Resident #7's admission record, dated [DATE], reflected an [AGE] year old male who was readmitted to the facility on [DATE] and had diagnoses including unspecified anxiety disorder, major depressive disorder that was recurrently severe without psychotic features, cognitive communication deficit, vascular dementia (a condition that occurs when blood flow to the brain is disrupted, causing changes in memory, thinking, and behavior), generalized muscle weakness, unspecified abnormalities of gait and mobility, and unspecified lack of coordination. Review of Resident #7's assessments, dated [DATE], reflected the ADON provided the following assessments to Resident #7: -Quarterly social services note on [DATE] and [DATE] Review of Resident #7's comprehensive care plan, dated [DATE], reflected RNs were required to perform clinical evaluations per facility's protocol and monitor/document/report PRN any changes any potential for improvement, reasons for self-care deficit, expected course and declines in function, changes in cognitive function, confounding communication problems such as decline in cognitive status and mood, ability to communicate, potential contributing factors for communication problems, potential for improvement, ability to express and comprehend language, memory, reasoning ability, and problem solving ability and ability to attend. Review of Resident #8's admission record, dated [DATE], reflected an [AGE] year old female who was readmitted to the facility on [DATE], admitted on [DATE], and had diagnoses including unspecified fracture of shaft of right arm, insomnia, need for assistance with personal care, unspecified altered mental status, history of falling, restlessness and agitation, age-related cognitive decline, generalized muscle weakness, other abnormalities of gait and mobility, cognitive communication deficit, unspecified depression, unspecified anxiety disorder, and unspecified Alzheimer's disease. Review of Resident #8's assessments, dated [DATE], reflected the ADON provided the following assessments to Resident #8: -Quarterly social services note on [DATE] and [DATE] -Preadmission memory screening form on [DATE] Review of Resident #8's comprehensive care plan, dated [DATE], reflected RNs were required to monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course and declines in function, any changes in cognitive function, signs/symptoms of non-verbal pain, confounding problems such as decline in cognitive status, mood and decline in ADL, physical/ nonverbal indicators of discomfort or distress, ability to express and comprehend language, memory, reasoning ability and problem solving ability and ability to attend, changes in ability to communicate, potential contributing factors for communication problems and potential for improvement, change in mental status, and signs/symptoms of UTI. Review of the Texas Board of Nursing Primary Source License Verification Database, dated [DATE], reflected the ADON's license was originally issued on [DATE] and currently issued on [DATE]. Review of the ADON's personnel file, dated [DATE], reflected the ADON was hired as the ADON position on [DATE]. Review of the ADON's personnel change form information change, undated, reflected the ADON changed from the ADON to the DON effective [DATE]. During an interview on [DATE] at 10:35 AM, CNA A stated she worked at the facility from February 2024 through [DATE]. CNA A stated she observed the ADON provide direct care to residents. CNA A stated she recalled the ADON performing perineal care on a resident two months ago . CNA A couldn't recall who the resident was that the ADON performed perineal care on. During an interview on [DATE] at 12:02 PM, the WCN stated the current DON used to be the ADON. During an interview on [DATE] at 12:07 PM, the Wound Care MD stated the DON used to be the ADON and rounded with him. The Wound Care MD stated he couldn't recall when the ADON last rounded with him. During a confidential interview on [DATE] at 12:15 PM, the CE stated they were working at the facility when the DON used to be the ADON. The CE stated the ADON worked the floor and provided direct care to residents, performed resident COVID-19 tests and signed off and charted resident assessments and medication administrations during the day shift and night shift . The CE stated the ADON also signed the staff schedules stored at the nursing station as RN daily and presented herself as an RN during the time her license was delinquent from [DATE] through [DATE] . The CE stated the ADON promoted to DON on [DATE] according to a social media post in which the facility presented the ADON as having a BSN RN on [DATE]. The CE stated there were nursing staff who observed the ADON working the floor and providing direct care to residents . During an interview on [DATE] at 12:52 PM, the MD stated he visited the facility once a week. The MD stated the ADON rounded with him. The MD stated he observed the ADON reposition residents and unwrap residents' bandages with him in the past . The MD stated he couldn't recall the last time that the ADON repositioned residents and unwrapped residents' bandages with him. During an interview on [DATE] at 3:41 PM, the ADM stated she was the DON for 4 years until [DATE] when she got her administrator license. The ADM stated LVNs and RNs were responsible for completing residents' assessments, such as elopement and fall risk evaluations. The ADM stated LVNs and RNs must have a current license in order to do those residents' assessments. The ADM stated the current DON used to be the ADON and had a delinquent license for several months . The ADM stated on [DATE], it was discovered that the ADON's license was delinquent . The ADM stated the Texas Board of Nursing reinstated the ADON's license on [DATE]. The ADM stated the ADON didn't perform any nursing duties during the delinquent period. The ADM stated the ADON didn't know her license was delinquent. The ADM stated she knew RNs' licenses renew during RNs' birthday months. The ADM stated the former ADON didn't get the notification when her license was required to renew. The ADM stated in 2024, the Texas Board of Nursing stopped mail notification. The ADM stated she knew that the ADON didn't have a nursing license on [DATE] during the facility's state readiness process. The ADM stated the HR must check annually at minimum to ensure nursing licenses were current. The ADM stated the facility had a payroll system transition period that started in 2023 and messed up the HR's automatic notifications. The ADM stated the HR's backup process during the payroll system transition period was that the HR checked nursing licenses manually. The ADM stated the HR was unaware that the ADON didn't have an active RN license. During an interview on [DATE] at 3:54 PM, the HR stated she couldn't recall when the ADON was hired as the DON, but she believed it was [DATE] or [DATE]. The HR stated she was required to check LVNs and RNs licenses upon hire. The HR stated that six months ago, she was told to start reviewing LVNs and RNs licenses every quarter. The HR stated she couldn't recall when she was told to start reviewing licenses quarterly. The HR stated she forgot to check the LVNs and RNs licenses last quarter. The HR stated she started reviewing licenses again a month ago ([DATE]). The HR stated she was trained to print out all LVNs and RNs licenses and place them in a binder. The HR stated she was under the impression that she was to check only new hire LVNs and RNs licenses. The HR stated the BOM previously worked as the HR until she was hired in [DATE]. The HR stated the BOM trained her to check new hire LVNs and RNs licenses using the EMR/CNA/CMA/Nursing license sites. The HR stated the BOM trained her to input information to ensure LVNs and RNs had their license and to ensure licenses were not expired. The HR stated she misunderstood the BOM's training and thought she was to check LVNs and RNs licenses who were in the process of being hired and when first hired. The HR stated she misunderstood the training that the BOM gave her two months ago. The HR stated she believed she misunderstood the training on [DATE] or [DATE]. During an interview on [DATE] at 4:04 PM, the BOM stated she was trained to check LVNs and RNs licenses to ensure they were current at the time of hire. The BOM stated she would print the LVNs and RNs license status results and place them in the LVNs and RNs files. The BOM stated she didn't know how often she was required to check LVNs and RNs licenses at the time of interview because she wasn't familiar with the facility's current process. The BOM stated she trained the HR how to check LVNs and RNs licenses and to check licenses at time of hire. The BOM stated the nursing administration taught the HR more on that process than she did. The BOM stated she didn't know who from the nursing administration taught the HR more on the process. During an interview on [DATE] at 5:35 PM, LVN B stated LVNs and RNs perform assessments on residents. LVN B stated LVNs and RNs must have current licenses to perform assessments on residents. LVN B stated he was not sure if residents were at risk if LVNs and RNs performed assessments on them without current licenses. LVN B stated he was not sure if he was notified of his license requiring renewal or expiring soon. During an interview on [DATE] at 5:42 PM, RN C stated she was notified by mail and email from the Texas Board of Nursing as to when her license was due for renewal. RN C stated LVNs and RNs complete assessments on residents. RN C stated LVNs and RNs licenses must be current to perform evaluations on residents. RN C stated LVNs and RNs were not supposed to perform assessments on residents without a current license. RN C stated LVNs and RNs shouldn't even be in the building if they didn't have a current license. During an interview on [DATE] at 6:02 PM, LVN D stated a staff member had to be an LVN or RN to perform assessments on residents. LVN D stated LVNs and RNs must have a current license to perform assessments on residents. LVN D stated she was notified by mail when her license was due for renewal. During an interview on [DATE] at 6:13 PM, the ADON stated she started her DON position on [DATE]. The ADON stated she was previously the ADON and Infection Control Preventionist. The ADON stated her license lapsed. The ADON stated she couldn't recall when her license lapsed . The ADON stated no one would knowingly let their license lapse because it's more expensive to reapply for a license than to renew. The ADON stated she didn't check the status of her RN license. The ADON stated she wasn't monitoring her own license status. The ADON stated she relied on the notification by mail as to when she needed to renew her license. The ADON stated when her RN license lapsed, she found out she no longer received a mail notification. The ADON stated her RN license expired on her birthday month . The ADON stated she knew her license expired on her birthday month because this was the second time she was renewing her license. The ADON stated she didn't think to check her license status and didn't get a notification. The ADON stated her license expired in February 2024 . The ADON stated she used to be notified by mail when her license was due for a renewal. The ADON stated the HR didn't realize she was supposed to be running LVNs and RNs nursing licenses quarterly. The ADON stated she wasn't sure that licenses were supposed to be checked quarterly to verify status. The ADON stated the HR didn't have any oversight to ensure the process of checking license statuses was completed prior to her license incident. The ADON stated the HR notified her that her license was expired. The ADON stated she couldn't recall when the HR notified her that her license was expired. The ADON stated the facility wasn't responsible for notifying her to keep up to date with her license. The ADON stated she expected RNs and LVNs to keep their licenses up to date. The ADON stated the importance of staying up to date with an LVN or RN license was to ensure that education and certification was current. The ADON stated she didn't give direct care a lot to residents. The ADON stated she also couldn't recall if she performed any evaluations or nurse duties during her delinquency license period. The ADON stated she didn't know she performed assessments on residents during her license delinquency period. The ADON stated she didn't know if LVNs and RNs needed a current license to perform evaluations on residents, such as fall risk evaluation. The ADON stated anyone who was more than capable of asking a question and answering questions in a residents' electronic health record evaluation, especially for evaluations related to social service didn't need a current license to do so. The ADON stated if a staff member could be trained, they could evaluate residents without a LVN and RN license. The ADON stated having anyone complete the evaluation without a current license also depended on questions in the evaluation unless the questions were nursing related. The ADON stated a person just needed to know how to answer yes or no questions in residents' evaluations that ask for a yes or no answer. Review of the facility's job description for charge nurse, undated, reflected, Qualifications: Must have successfully completed state board of registration or licensure and carry a current state license as a registered or licensed vocational nurse. Responsibilities: 6. Make meaningful rounds of all patients utilizing Resident Assessment and Comprehensive Care Plan 7. Insures that the individual Resident Assessment and Comprehensive Care Plan is followed to meet the resident's needs according to generally accepted nursing practices in the State of Texas 8. Assist in writing and updating the Resident Assessment and Comprehensive Care Plan as resident's condition changes, with the help of the Director of Nursing, Activities Director, Dietary Manager, and designated nurse 19. Directs charting on his/her shift and makes regular detailed evaluation of all resident charting at least monthly so chart reflects progress and condition of resident at all times. Is responsible for approving and signing each chart when observations are made 20. Be aware of legal implication if physician's orders are not carried out correctly 22. Know when situation cannot be handled and be willing to ask for help and to know who to ask 23. Abide by policies of facility and ascertain that employees under his/her supervision do the same 25. Insure that all medications and treatments are charted after the fact: by the person administering the medication or completing the treatment on his/her assigned shift. 29. Detect and correct situations that have a high probability of causing accidents or injuries to residents 30. Ensures continuing promotion of the resident's physical and emotional health by assisting him regarding their medical care. Review of the facility's job description for assistant director of nursing, undated, reflected, Qualifications Needed: Must be a graduate of an accredited school of vocational or professional nursing and have a current nursing licensure in the state of Texas. Responsibilities and Duties: Provide nursing care on shift when needed Review of the facility's resident assessments policy and procedure, revised [DATE], reflected, 7. All members of the care team, including licensed and unlicensed staff members, are asked to participate in the resident assessment process. 9. The results of the assessments are used to develop, review, and revise the resident's comprehensive care plan.

Based on interview and record review, the facility failed to follow guidelines for mandatory electronic submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 3 quarters reviewed for payroll data information (Quarter 3 2023). The facility failed to submit PBJ staffing information to CMS for the 3rd quarter (April 1 - June 30) of fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Review of the facility's undated Civil Rights Survey Report (Form 3761) indicated the following: 7 RNs 24 LVNs 42 Direct Care Staff 14 Dietary 22 Housekeeping & Laundry 12 All Others Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report) 1705 D FY Quarter 3 2023 (April 1 - June 30), dated 10/18/2023, indicated the following entry: Metric Failed to Submit Data for the Quarter, Result Triggered Definition Triggered = No Data Submitted for Quarter. In an interview on 10/26/2023 at 9:54 AM, the DON was asked who in the facility was responsible for quarterly PBJ reporting. The DON stated that the BOM was responsible for reporting to CMS. The DON stated that she knew they also had a payroll consultant that assisted with preparation. The DON stated that she knew that the PBJ information is provided to CMS to ensure adequate staffing and is very specific to RN coverage requirements. In an interview on 10/26/2023 at 10:00 AM, the BOM stated that PBJ reporting was the responsibility of her office during the 3rd quarter of fiscal year 2023. The BOM stated that she had an ABOM that was responsible for the quarterly submission of the report but stated that assurance of submission was her responsibility. The BOM stated that the PBJ report was to be submitted to CMS quarterly and was due within 45 days of the final day in the quarter. The BOM stated that the PBJ report contains staffing hours for nurses, agency, dietary consult, and pharmacy. The BOM stated that the PBJ reporting was important because it goes towards their star rating and CMS uses the report to ensure staffing ratios. The BOM was questioned about how failure to submit the PBJ report could affect residents and she stated she could only think of the star rating. The BOM stated that they utilized a consultant who puts together the information and provides it back to the facility, which then is provided electronically to CMS. The BOM was notified that they failed to electronically file their 3rd quarter PBJ. The BOM stated that she knew the ABOM had been working on it. The BOM was asked if the ABOM still worked for the facility, and she stated she did not. The BOM stated that the ABOM was a part time employee who they terminated for not coming into work and mistakes with payroll. The BOM was requested to provide employment dates for the ABOM, which were later provided as December 6, 2022, through July 11, 2023. The BOM was asked if she would be able to provide email correspondence from the consultant for the 3rd quarter or the PBJ report that may have been prepared by the ABOM but not submitted. The BOM stated that she did not have an email from the consultant and that it likely would have been sent to the ABOM. The BOM stated that she would check to see if she could locate information the ABOM completed but stated that she would likely be unable to do so. In an interview on 10/26/2023 at 10:44 AM, the Administrator stated the PBJ reporting was important because it helps to determine and ensure that necessary staffing ratios were met by the facility. The Administrator stated that he knew it was a requirement of CMS to report their PBJ information quarterly and knew that their failure to do so lowered their star rating. The Administrator stated that while it was not his direct responsibility, he failed to ensure that the PBJ was reported for the 3rd quarter. In an interview on 10/26/2023 at 12:20 AM, the BOM stated that she was not able to retrieve any email information from the ABOM's account due to it being inaccessible. The BOM further stated that she was not able to recover or locate a prepared 3rd quarter PBJ report. Review of facility Reporting Direct Care Staffing Information (Payroll-Based Journal) policy with a revised date of August 2022 indicated: Policy Statement: Direct care staffing information is reported electronically to CMS through the Payroll-Based Journal system. Policy Interpretation and Implementation: 1. Complete and accurate direct care staffing information is reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS. 8. Technical specifications for uploading data directly from a payroll or time and attendance system will be accessed through: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html. 9. Direct care staffing information is submitted on the schedule specified by CMS, but no less frequently than quarterly. 10. Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows: Fiscal Quarter Date Range Submission Deadline 1 October 1 - December 31 February 14 2 January 1 - March 31 May 15 3 April 1 - June 30 August 14 4 July 1 - September 30 November 14 References: OBRA Regulatory Reference Numbers - 483.70(q) Mandatory submission of staffing information based on payroll data in a uniform format. Survey Tag Number - F851

Based on observation, interview, 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 for two of four residents reviewed for catheter care (Resident #6 and Resident #30). A) The facility failed to ensure Resident #6's catheter was secured to her body with a catheter secure device per the care plan and physician's orders. B) The facility failed to ensure Resident 30's catheter was secured to his body with a catheter secure device per the care plan and physician's orders. This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections. Findings included: Review of Resident #6's Face Sheet dated 10/26/2023 reflected a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses Extended Spectrum Beta Lactamase (ESBL) (A type of enzyme or chemical produced by some bacteria that can break down the active ingredients in many common antibiotics), Personal History of Urinary Tract Infections, Retention of urine and Down Syndrome (A genetic disorder associated with physical growth delays, characteristic facial features and mild to moderate developmental and intellectual disability. It is caused by the presence of full or partial extra copy of chromosome 21.) Review of Resident #6's Quarterly MDS dated [DATE] reflected Resident #6 was assessed to have a BIMS score of 6 indicating moderate cognitive impairment. Resident #6 was assessed to require dependent assist for ADLs. Resident #6 was further assessed to have an indwelling urinary catheter. Review of Resident #6's Comprehensive Care Plan reflected a problem area dated 03/07/2023 and revised on 04/10/2023 The Resident has a indwelling Foley Catheter related to neuromuscular dysfunction of bladder with potential for complications related to long term use of Foley catheter . Interventions included Catheter: Change Foley catheter as indicated for infection, obstruction or when closed system is compromised .check tubing for kinks every shift and ensure that catheter is draining properly to bedside privacy bag and leg strap in place Review of Resident #6's Consolidated Physician's Orders reflected an order dated 03/07/2023 Catheter: ensure catheter is draining properly to bedside, privacy bag in place and leg strap in place. Review of Resident #6's Nurse Medication Administration Record dated October 2023 reflected an entry Catheter: ensure catheter is draining properly to bedside, privacy bag in place and leg strap in place. Entry was signed every shift as Yes. Observation on 10/26/23 at 9:54 AM revealed Resident #6 lying in bed while CNA B, CNA C, and CNA D performed catheter care. Resident #6 was observed with an indwelling urinary catheter draining to a bag on the side of the bed. There was no leg strap or other stabilizing device in place. When CNA C and CNA D turned Resident #6 to her left side, it caused tension on the catheter tubing. They stopped turning the resident and adjusted the position of the drain bag then continued with the procedure. Review of Resident #30's Face Sheet dated 10/26/203 reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Cystitis (Infection or inflammation of the urinary bladder or any part of the urinary system caused by a type of bacteria called Escherichia coli (E. coli). This results in urge to urinate, blood in urine and burning while urinating.), Obstructive and reflux uropathy (Is a term that refers to conditions that affects the urinary tract due to blockage or backward flow of urine) and Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.). Review of Resident #30's Annual MDS dated [DATE] reflected Resident #30 was assessed to have a BIMS assessment not conducted indicating Resident #30 had severe cognitive impairment. Resident #30 was assessed to require extensive to dependent assist for ADLs. Resident #30 was further assessed to have an indwelling catheter. Review of Resident #30's Comprehensive Care Plan reflected a problem with the start date of 08/30/2022 and revised on 09/13/2023 The resident has indwelling catheter related to diagnoses of neuromuscular dysfunction of bladder with increased risk of urinary tract infections . Interventions included .ensure catheter is draining properly to bedside with privacy bag and leg strap in place. Review of Resident #30's Consolidated Physician's Orders reflected an order dated 09/12/2022 CATHETER: Ensure Catheter is draining property to Prescriber bedside privacy bag and leg strap is in place. Review of Resident #30's TAR and MARs dated October 2023 reflected no entry for checking Resident #30's leg strap for his catheter. Observation on 10/25/23 at 2:49 PM revealed Resident #30 lying in bed while CNA A and CNA B performed catheter care and incontinent care. Resident #30 was observed with an indwelling urinary catheter but no leg strap or other stabilizing device in place. During an interview on 10/26/23 at 9:56 AM with CNA B, she stated they used catheter stabilization devices on some people adding, It all depends. She stated sometimes the devices got wet so she would let the nurse know. During an interview on 10/26/23 at 10:41 with LVN E, she stated they had two types of stabilization devices; one has adhesive on the back and the other was a leg strap. LVN E reached into the nurses' cart and retrieved a stabilization device with the adhesive on the back and stated she preferred that type as is stayed in place better. She stated the CNAs let her know if a device needs to be replaced. She stated if a resident with a catheter did not have a stabilization device in place, the catheter could get pulled out which could be painful. In an interview on 10/26/23 at 10:49 AM with RN F, she stated they do use stabilizing devices for residents with indwelling catheters. She stated there was a device that sticks on the leg, kind of like a bandage that has a clamp where you would put the tubing. RN F stated, Lots of times we just use the clamp that comes on the catheter bag. She described the clamp on the drain bag tubing that is usually attached to the sheet or bed. She stated without a stabilization device, residents were at risk of having the catheter pulled on, pulled out, and pain. In an interview on 10/26/23 with the DON, she stated they used a couple different stabilizing devices including the ones that stick to the leg. She stated it is her expectation that all resident with a catheter will have a stabilizing device. She stated without the device, the catheter could get caught on something or pulled out. She stated it did not meet her expectations that two residents with catheters had been observed without a stabilization device. A policy for indwelling catheters was requested. Review of the facility's policy Catheter care, Urinary dated August 2022 reflected The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Steps in the Procedure . 16. Secure catheter with catheter securement device

Based on observation, interview, and record review, the facility failed to assess the resident for risk of entrapment from bed rails prior to installation for one (Resident #1) of three residents reviewed for use of side or bed rails, in that: The facility failed to ensure full length bed rails were securely fastened to Resident #1's bed. She became entrapped between the rail and her mattress on 01/06/23, sustaining a femur fracture. This deficient practice could affect residents who use bed or side rails as enablers, resulting in entrapment or injury. An Immediate Jeopardy (IJ) existed from 01/06/23 - 01/07/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. The findings included: Review of Resident #1's undated face sheet reflected a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses including osteoarthritis (inflammation of joints), spinal stenosis (a condition where spinal column narrows and compresses the spinal cord), and muscle weakness. Review of Resident #1's quarterly MDS assessment, dated 10/15/22, reflected a BIMS of 11, indicating a moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected she required extensive assistance with repositioning. Section P (Restraints and Alarms) reflected she did not require bed rails. Review of Resident #1's quarterly care plan, dated 10/23/22, reflected she was at risk for future falls with serious injuries related to past history of falls with fractures with an intervention of using full side rails on both sides of bed to aide in bed mobility and to provide sense of security when in bed (per MD and family request). It further reflected she needed bilateral full siderails related to recent fall with fracture with potential for serious adverse effects with an intervention of ensuring the resident was positioned correctly with proper body alignment while restrained. Review of Resident #1's hospital discharge orders, dated 07/08/21, reflected an order for bed rails on both sides of bed. Review of Resident #1's Bed Side Rail Permission form, dated 07/08/21, reflected her RP was aware of the risks of using a bed rail and consented to full side rails x2 per resident, family, and physician to aide her with bed mobility and repositioning and to provide sense of security in bed. Review of Resident #1's Side Rail Evaluations, dated 07/08/21, 10/22/22, and 01/18/23, reflected she was able to express her desire for use of side rails and that the side rails did not put her at risk. Review of Resident #1's quarterly MDS assessment, dated 10/15/22, reflected a BIMS of 11, indicating a moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected she required extensive assistance with repositioning. Section P (Restraints and Alarms) reflected she did not require bed rails. Review of Resident #1's quarterly care plan, dated 10/23/22, reflected she was at risk for future falls with serious injuries related to past history of falls with fractures with an intervention of using full side rails on both sides of bed to aide in bed mobility and to provide sense of security when in bed (per MD and family request). It further reflected she needed bilateral full siderails related to recent fall with fracture with potential for serious adverse effects with an intervention of ensuring the resident is positioned correctly with proper body alignment while restrained. Review of Resident #1's progress notes in her EMR, dated 01/07/23 at 2:12 AM, documented by RN B, reflected the following: [CNA A] alerted need for reposition [Resident #1] in bed. Upon entering the room, [Resident #1] was laying on her left side against the side rail. [Resident #1] did not voice any pain. With assistance from [CNA A], [Resident #1] was repositioned comfortably in bed in a supine position, with assistance of the draw sheet . Review of Resident #1's progress notes in her EMR, dated 01/07/23 at 7:00 AM, documented by RN C, reflected the following: .[Resident #1] stated that her left hip hurts too bad and doesn't want to get up . Noted swelling to left hip area and leg slightly deformed . will be sending [Resident #1] to ER for eval. Review of Resident #1's progress notes in her EMR, dated 01/07/23 at 12:05 PM, documented by RN C, reflected the following: Received a call and [Resident #1] was being admitted to (hospital) for Dx: left femur fracture. Review of a witness statement for Resident #1, dated 01/07/23, documented by RN B, reflected the following: On 01/06/23, [CNA A] requested my presence . [Resident #1] was lying in bed but was up against the railing to her left side . When we proceeded to adjust her, the bottom railing to her left side fell to the floor . Review of a witness statement for Resident #1, dated 01/07/23, documented by CNA A, reflected the following: On 1/6/2023 I entered [Resident #1]'s room and found her on her side crunched up by the bed rails. I called [RN B] to [Resident #1]'s room to help adjust her in bed. When [RN B] and [CNA A] first entered the room to adjust [Resident #1], the rail at the foot of the bed was loose and slipped out of position . During an interview on 01/24/23 at 9:59 AM with CNA A, she stated when she checked on Resident #1 on 01/06/23, the bed rail was loose, and she was lodged between it and the bed. She stated the resident complained of hip and head pain. She stated the bed rail was often loose, but it had never caused an issue, so she had not notified anyone. Observation on 01/24/23 at 11:22 AM revealed Resident #1 asleep in her room. Her bed was in a low position and her call light was by her left hand. The side rails were sturdy and did not budge when pushed on. During an interview on 01/24/23 at 11:30 AM with the ADM and DON, the DON stated when Resident #1 returned from the hospital after sustaining a femur fracture as a result of a fall from her bed on 07/14/21, there were orders for bed rails on both sides of her bed. The DON stated she was against bed rails, but Resident #1's RP was insistent. She stated they spoke about the risks involved and suggested other alternatives such as a low bed or scoop mattress. The DON stated the RP would not budge on the topic. She stated they had an old hospital bed with rails from a resident who had passed away years before, so they put the hospital bed in Resident #1's room. She stated there was no medical necessity for the hospital bed, but it had bed rails that were easy to lock in place. The DON stated the hospital bed apparently broke and MAINTW D moved in a new bed and attached old school railing that should not have been in the facility at all. The DON stated she was never made aware that Resident #1's bed had broken until after the incident on 01/06/23. She stated she nor the ADM were also not notified that the rails on the new bed were loose. The ADM and DON both stated it was their expectation to be notified upon any kind of equipment malfunction, as it could place residents at risk of being injured. The ADM stated he also expected for anything that needed repair to be written in the maintenance request log binder, but the staff had a bad habit of just verbally telling the maintenance team. The DON stated she did not allow Resident #1 to be readmitted from the hospital until they had purchased the correct mattress that was manufactured to fit with the appropriate rails, and she was currently utilizing the purchased bed. The DON stated the staff had not been educated on ensuring bed rails were attached properly or what to look for until after the incident with Resident #1. She stated there were no other residents in the facility with full length bed rails. During an interview on 01/24/23 at 11:44 AM with MAINTW E, she stated Resident #1's hospital bed broke about three weeks before the incident on 01/06/23. She stated she did not specifically remember notifying the ADM or DON, but it was probably talked about in morning meeting. She stated MAINTW D moved in a new bed with an air mattress and attached some old rails they had outside in their storage. She stated neither she nor MAINTW D measured the distance from Resident #1's head to the bed rail, as they must have forgotten to do so. She stated the rails that were put on the bed were easy to make loose just by pulling on them. She stated she had not realized it could cause Resident #1 to be at risk of getting hurt. During an interview on 01/24/23 at 12:14 PM with MAINTW D, he stated when he attached the rails to Resident #1's bed, he tightened the screws real tight. He stated did not check on bed rails to ensure they were in need of maintenance on a regular basis. He stated if an aide told him something was wrong with a bed rail, he would then go look at it. He stated he was not notified by any staff members that the rails were loose on Resident #1's bed, and no maintenance requests were made in the maintenance request log binder. On 01/24/23 from 12:10 PM 1:04 PM, three aides, 1 nurse, and one housekeeper were interviewed and were able to identify when/who to notify when any resident equipment needed repair. Review of the Maintenance Request Log from 12/01/22 01/24/23, reflected no requests maintenance of bed rails. Review of QAPI minutes, dated 01/13/23, reflected bed rails safety/installation was discussed. Review of an in service, dated 01/07/23, reflected the MAINTW's were educated on not using the old bed rails in the facility. Review of an in service , dated 01/07/23, reflected the following education was provided: Nursing Administration and/or Facility Administrator should be notified of all safety concerns including, but not limited to: malfunctions of beds, side rails, bed canes, loose boards, wheelchairs, hoyer lifts, and furniture and other miscellaneous devices that could pose risks to resident safety. After notifying nursing administration, ALL concerns should be written in the maintenance log. Review of signatures reflected all staff were in serviced. On 01/24/23 from 12:10 PM 1:04 PM, three aides, 1 nurse, and one housekeeper were interviewed. Thy acknowledged being in serviced and were able to identify when/who (DON immediately then document the request in the maintenance request log book) to notify when any resident equipment needed repair. Review of the facility's Bed Safety policy, revised December of 2007, reflected the following: Policy Statement: Our facility shall strive to provide a safe sleeping environment for the resident.2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattresses, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; .d. Ensure that bed side rails are properly installed and other pertinent safety guidance to ensure proper fit (e.g. ensure proper distance from the headboard and footboard, etc.) Review of the facility's Maintenance Service policy, revised December of 2009, reflected the following: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Review of the facility's Identifying Neglect policy, date April of 2021, reflected the following: .3. 'Neglect' is defined as the failure of the facility to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish, or emotional distress. An Immediate Jeopardy (IJ) existed from 01/06/23 - 01/07/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation.

44174 Based on observation, interviews and record review the facility failed to develop and implement comprehensive care plan to meet the medical and nursing needs for 2 of 10 residents reviewed for care plans (Resident # 66 and Resident #75). - The facility failed to ensure Resident #75's Comprehensive Care Plan was developed in a personalized manner to address refusal of diet recommendation. - The facility failed to ensure Resident # 66's Comprehensive Care Plan was developed to address physical needs for devices to prevent wounds or other skin concerns. -The facility failed to ensure Resident #66 was provided bunny boot to left foot at all times as tolerated as ordered by his physician. This failure could place residents at risk for not having their individualized needs met in a timely manner and communicated with providers and could result in an injury, pressure ulcer and a decline in physical well-being and in quality of life. Findings included: Review of Resident #75's face sheet dated 08/24/2022 revealed Resident #75 was an [AGE] year-old female admitted to the facility 08/17/2017 with a diagnoses of pneumonia, dysphagia (trouble swallowing), urinary tract infection and vascular dementia (loss of cognitive functioning that interferes with a person's daily life and activities). Review of Resident #75's MDS Significant Change assessment dated [DATE] revealed Resident #75 was admitted to hospice care which resulted in the significant change assessment . Resident #75 had a BIMS score of zero to indicate severely impaired cognition. Resident #75 received a mechanically altered diet and did not receive a therapeutic diet. Review of Resident #75's Care Plan dated 08/01/2022 revealed Resident #75's care plan was not updated to include an Informed Refusal of Diet Recommendation for Resident #75 to have a mechanical soft diet order instead of the recommended pureed diet order. Review of Resident #75's Physician orders dated 08/09/2022 revealed Resident #75 was ordered a regular diet, pureed texture with nectar thick liquids. Review of Resident #75's Nursing Progress Note dated 08/03/2022 revealed Change of condition care plan meeting held with social services, activities, dietary manager, MDS nurse, DON and administrator in attendance; resident and Family Member A on conference phone call; no participation by resident or hospice this date; resident w/ recent admission to hospice; requires extensive to total assistance with all aspects of ADL's; resident admitted hospice related to diagnosis of cerebrovascular disease, vascular dementia, dysphagia, aspiration pneumonia; comfort medications in place; resident with recent diet change as per family wishes as resident disliked pureed diet; FamilyMember A signed waiver understanding potential risks to change of diet to mechanical soft; Family member A and Family member B both stated they hoped resident would eat better but understand possible risk of aspiration w/diet change; resident current weight is 133.4 pounds and stable at present. In an interview on 08/23/2022 at 2:00 PM, the DON stated Resident #75 had aspiration pneumonia at the end of June 2022 and was hospitalized . She said when Resident #75 returned to the facility the physician ordered a pureed diet to decrease the risk of further aspiration pneumonia or other complications from dysphagia. She said Resident #75 did not like the pureed foods and Resident #75's RP brought it to their attention. She said Resident #75's RP said that for Resident #75's quality of life they wanted Resident #75 to have a regular diet or mechanical soft diet. She said she spoke with them regarding a waiver to allow the upgraded diet and that they were aware of the risks for Resident #75. She said Resident #75's RP agreed to signing the Informed Refusal of Diet Recommendation and they held a care plan meeting to discuss the diet changes and Resident #75 going on hospice care. She said after the waiver was signed on 08/09/2022 and the diet order was changed, Resident #75's care plan was not updated. She said Resident #75's care plan was updated with the hospice care information, but not the diet order information. In an interview on 08/23/2022 at 11:20 AM, MDS LVN G stated Resident #75's care plan should have been updated with the new diet order of mechanical soft and that the Informed Refusal of Diet Recommendations Waiver was in place with the risks noted on her care plan. She said it could result in Resident #75 not receiving appropriate and safe care if her care plan was inaccurate. Review of Resident # 66's face sheet dated 08/24/2022 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] and 07/19/2022 with a diagnoses type 2 diabetes mellitus with diabetic neuropathy, unspecified (high blood sugar can injure nerves throughout the body. Most often damages nerves in the legs and feet), type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene (a blood vessel disease caused by high blood sugar levels), cutaneous abscess of left lower limb ( a localized collection of pus in the skin and may occur on any skin surface), cellulitis of right and left lower limb ( potentially serious bacterial skin infection. The affected skin is swollen and inflamed and is typically painful and warm to the touch), local infection of the skin and subcutaneous tissue , unspecified ( bacterial or fungal that enters any break in the skin and can invade the subcutaneous tissue) and localized edema ( your small blood vessels leak fluid into nearby tissues). Review of Resident #66's MDS Admission assessment dated [DATE] reflected resident had a BIMS score of 11 which indicated resident cognition was mildly impaired. Resident #66 was assessed to require extensive assistance with one-person physical assist with bed mobility, transfers, dressing and personal hygiene. He required extensive assistance with two persons assist with toileting. Resident #66 was also assessed to have limited range of motion in lower extremity on both sides. Resident was at risk for developing pressure ulcers/injuries. Resident required a pressure reducing device for chair. Review of Resident #66's MDS Significant Change assessment dated [DATE] reflected resident had a BIMS score of 13 indicated his cognition was intact. Resident #66 required assistance with ADL's. Resident was also assessed at risk of developing ulcers/injuries and had an unhealed pressure ulcer/injury which was unstageable. He was assessed to require a pressure ulcer reducing device for bed. Review of Resident #66's Comprehensive Care Plan dated 8/11/2022 reflected Resident #66's bunny boot to left foot at all times as tolerated every day and night shift and offloading cushion to float bilateral heels while in bed every day and night shift related to pressure-induced deep tissue damage of left heel was not care planned. Review of Resident #66's Physician Orders dated 07/19/2022 reflected bunny boot to left foot at all times as tolerated every day and night shift related to pressure-induced deep tissue damage to left heel. Offloading cushion to float bilateral heels while in bed every day and night shift related to pressure induced deep tissue damage to left heel. Review of Resident #66's Wound- Weekly Observation Tool dated 07/08/2022, 7/15/2022 and 7/22/2022 reflected special equipment offloading cushion and bunny boot to left heel at all times as tolerated. The physician was notified of skin status by Treatment Nurse-LVN on each wound-weekly observation tool. The wound to resident's left heel was acquired on 07/05/2022 and resolved on 07/22/2022. Review of Resident #66's Nurses Notes from 07/23/2022 thru 08/24/2022 reflected a fluid filled blister to his left heel. Resident #66 frequently had edema to his left lower leg. Nurse's notes did not reflect documentation about an offloading cushion or a bunny boot to left heel. Observation and interview on 08/22/2022 at 3:46 PM revealed Resident #66 was in his room sitting in his recliner with his feet propped on the footrest of the recliner. Resident #66 stated he had pain in his knees and legs. He stated he was wearing house socks due to his feet were swollen and he was unable to wear his shoes. He stated he did have a sore on his left heel, but it was no longer there. He stated he currently had a blister on his left heel and pulled his sock down to show surveyor the fluid filled blister . He stated he was supposed to be wearing some type of boot, but he didn't know if the doctor had taken it away from him. He also stated the boot helped when he was sitting in his recliner. Observation on 08/22/2022 at 4:15 PM, Resident #66 was sitting in his recliner asleep. He was not wearing his bunny boot to his left foot and his left foot had edema. Observation on 08/23/2022 at 8:17 AM, Resident #66 was sitting in his room eating breakfast. His left foot had edema. He was not wearing bunny boot to his left foot. Observation and Interview on 08/23/2022 at 12:33 PM revealed Resident #66 was sitting in his room in the recliner. He did not have his shoes on or his bunny boot to left foot. He had nonskid house socks. Resident stated his legs and feet was hurting and he needed to prop his feet up to help with the swelling. He stated his shoes fit perfect except when his feet swell. He stated he must be careful about his heel because he had a blister. (he pointed to the left heel and showed the blister). Resident stated he didn't want to get any wounds to his legs, feet or anywhere if he could prevent it. Observation and Interview on 08/24/2022 at 11:45 AM revealed Resident #66 was sitting in wheelchair in his room. Resident had his shoes on, and he stated he had been to therapy. He also stated his legs and feet was hurting him and he was waiting on staff to assist him to his recliner. He stated he was going to take his shoes off and put on some socks. He stated no one had placed a bunny boot on his left foot in a very long time. He stated he wore it a few times when he had a wound on his left heel but did not wear it all the time. He also stated he was taking medication for his swollen feet. He stated he did not know the exact days staff looked at his heel. In an interview on 08/25/2022 at 9:30 AM, LVN A stated the offloading cushion and the bunny boot to Resident #66's left foot was required to be care planned. She stated the staff would not know if a resident needed a device if it wasn't on the care plan. She stated the interventions on the care plan was transferred to electronic medical records for the staff to know what type of personalized care each resident needed. She stated any type of device most definitely needed to be care planned. She stated the cushion and the bunny boot was to prevent skin breakdown or any other skin issues. She also stated it was the Treatment Nurse, DON and MDS nurses' responsibility to monitor the care plans. In an interview on 08/25/2022 at 10:00 AM, MDS LVN B stated if there was a physician order for a bunny boot to left heel and an offloading cushion for a resident to use daily, these devices were required to be care planned. She stated any type of interventions related to skin concerns/ wounds were the Treatment Nurses responsibility to document those concerns on the care plan. She also stated care plans were developed for the staff to know what type of care and interventions each resident needed. She stated the CNA's had access to electronic medical record and these devices would be in the ADL section for the CNA's to know what type of intervention each resident would need to help with their physical condition. She also stated it was the Treatment Nurse responsibility to monitor any care plans related to skin concerns. She also stated the nurses was documenting in the nurses notes of new fluid filled blister on his left heel. In an interview on 08/25/2022 at 11:45 AM, CNA C stated Resident # 66 had not been wearing a heel boot to his left heel. She stated she didn't know he needed to be wearing a heel boot. She stated she was not aware of a cushion he needed in bed. She stated Resident #66 wasn't in bed during the day. She also stated if a resident needed any type of devices such as: alarms for bed/wheelchair, cushions, or heel boots, it would be in the electronic medical record under ADL. She stated no staff informed her verbally or in writing that Resident #66 required a heel boot. She stated the charge nurse would inform the staff if there were any changes with residents' care. She stated if any resident refused a device, she would report it to the nurse working on that hall. She stated she did not see any type of devices located under the ADL tab for Resident #66. She also stated if Resident #66's feet became swollen, he preferred to sit in his recliner with his feet propped up. She stated he preferred to wear non-skid socks when his feet were swollen. In an interview on 08/24/2022 at 12:00 PM, CNA D stated she was assigned to care for Resident #66 sometimes. She stated if anyone had heel protectors, alarms, cushions, or any type of device it would be located under the ADL tab in the electronic medical record. She stated she had not noticed Resident #66 wearing a heel boot. She also stated Resident #66 feet did swell sometimes. She stated she didn't give care to Resident #66 very often and didn't know his routine. She further stated if a resident refused to wear a device staff would inform the nurse on the 400 hall. She stated any devices or any type of care a Resident needed would be under the ADL tab in the electronic medical record. She stated she didn't know he was to have a bunny boot. In an interview on 08/24/2022 at 12:45 PM, LVN E stated if any resident required any type of special device it would be in the electronic medical record for the CNA's to know what type of device / care to give each Resident. She stated she would need to review the electronic medical record to determine if Resident #66 needed bunny boot or cushion. She also stated Resident #66 did have a wound on his left heel approximately 3 weeks, but it was healed. She stated a bunny heel protector could possibly prevent further skin breakdown. She stated Resident #66 did have a blister on his left heel at this time and the bunny heel protector could benefit him from having another wound. She also stated he was high risk for skin breakdown on his legs and feet. She stated the CNA's never reported to her of Resident #66 refusing to wear the bunny heel protector. She also stated the Treatment Nurse F did not verbally inform her or give her any information in writing concerning Resident #66 needing a heel protector or offloading cushion In an interview and record review on 08/24/2022 at 1:05 PM, the DON stated the bunny boot and uploading cushion for Resident #66 was a preventive measure to prevent any wounds or skin breakdowns. She reviewed the physician order and care plan during the interview and stated the cushion and heel protector was expected to be care planned. She also stated the care plan was implemented for the staff to know what type of care to give each resident. She stated if it wasn't on the care plan the information would not be on the electronic medical record for the staff to know what type of devices,/ care Resident #66 needed. She also stated if Resident #66 was not wearing left heel bunny boot or using the cushion there was a potential the wound could reopen or develop other skin concerns. She stated it was Treatment Nurse F's responsibility to care plan interventions for wounds, skin concerns or any devices needed to prevent skin breakdown She also stated it was the Tx Nurse F responsibility to monitor these type of care plans. In an interview on 08/25/2022 at 1:15 PM, Treatment Nurse F stated Resident #66's offloading cushion and bunny boot documented on the physician order most definitely needed to be care planned. She stated the care plan was where the staff received information of what type of care/ interventions the residents needed to prevent skin breakdown or to help hear any type of skin concerns. She also stated Resident #66 needed to be wearing the bunny boot as tolerated. She stated his feet had edema sometimes and this was when resident preferred to sit in his recliner with his feet elevated. She stated Resident #66 did have a blister to his left heel. She also stated a bunny boot would be more beneficial to Resident #66 than him wearing his shoes especially when his feet had edema. She stated if Resident #66 did refuse the bunny boot the staff would report it to her, or the nurse would document it in the nurse's notes. She also stated any type of interventions on the care plan would be transferred over to the ADL in the electronic medical record for the staff to know what type of devices Resident #66 required. She stated if these were not on the care plan it wouldn't be in the ADL electronic medical record for the staff to know to use these devices. She stated she would print a copy of the ADL's in the electronic medical record and bring it to the conference room to review with surveyor. Records of CNA's ADL and the MARS was requested from the treatment nurse on 08/24/2022 and these records were not provided at time of the exit. Review of Facility's Policy on Care Plans, Comprehensive Person -Centered revised March 2022 reflected A. The interdisciplinary team in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 1. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes. b. Describes the services that are to be furnished attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c. Reflects currently recognized standards of practice for problem areas and conditions. 2. Care plan interventions are chosen only after data gathering, proper sequencing of events, Careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on interview and record review, the facility failed to develop and implement written policies and procedure that prohibit and prevent abuse, neglect, and exploitation of resident and misappropriation of resident property for one (OT) of five employees reviewed for file. The facility failed to complete criminal history checks prior to or upon hire for the occupational therapist. This failure could place residents at risk for abuse, neglect, and exploitation. Findings included: Record review of OT employee file revealed hire date of 09/07/2004. The personnel records did not include criminal history check. During an interview on 08/24/22 at 11:44 AM with the DOR, he stated OT was still employed with the company and has valid license. The DOR stated for OT to renew the license the background check has to be completed. OT has active license. The DOR stated he was not employed with the company at the time OT was hired. The DOR stated job description was conducted for OT on 12/20/2004 by the current DOR. The DOR stated he cannot speak for what had happened prior to his employment. During an interview on 08/24/22 at 1:10 PM with the Admin, he stated he has been with the company for a month and cannot speak for what happened prior to his start date. The Admin stated HR/pay roll personnel was responsible to ensure all new hire employee screening were done and ultimately, he himself was responsible. Admin stated employee background check should be conducted prior to hire and they were not allowed to work inside the facility until it has been completed. The Admin stated his expectation was to make sure everything was completed as it should be if it was required. During a phone interview on 08/24/22 at 1:23 PM with the CEO, he stated the therapy employees were contracted to the nursing facility. The CEO stated he thought OT's background check and all other documents were in the personal file and to give time to check the office. During an interview on 08/24/22 1:42 PM with the CEO, he stated he could not find any documents and stated, We will fix it moving forward and we will correct it. Review of facility's background screening investigation policy dated March 2019 states: Our facility conducts employment background screening checks; reference checks and criminal conviction investigation checks on all applicants for positions with direct access to resident.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in response to six (6) of 12 Residents with unknown COVID 19 status. (Resident #1, #2, #3, #4, #5 and #6) 1. The facility failed to appropriately screen employees for signs, symptoms and exposure of COVID -19. 2. The facility failed to ensure residents with unknown status of COVID-19 were separated from COVID-19 negative residents and develop a system where PPE supplies and signage were in place for residents with unknown COVID 19 status. An IJ was identified on 11/21/2020 at 3:09 PM. While the IJ was lowered on 11/28/2020 at 5:30 PM, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not IJ identified as pattern due to the facility's need to evaluate the effectiveness of their plan of removal. These failures placed residents at risk of exposure to COVID-19, which could result in illness, hospitalization , or death. Findings included: 1. In an observation on 11/20/20 at 9:45 AM, Screener A conducted the screening process by taking the temperature of the surveyor. Screener A instructed the surveyor to document their temperature and to answer the signs/symptoms questions. Screener A did not sign the form of the person taking the temperature or review the screening form upon completion per facility's policy. In an interview on 11/20/20 at 9:50 AM, Screener A stated I didn't look at the log after you and staff answered questions on the screening form. I didn't know I needed to sign the section of the form to have signature of person taking temp. I have not been in serviced on screening anyone. I know I am to take temperature as indicated on the screening form and ask staff to answer questions if they have had any signs or symptoms of COVID-19. I have not been trained on the screening process. In an interview on 11/20/20 at 10:20 AM the Director of Nurses stated, The staff is expected to answer all questions. The staff is signing they are taking their own temperatures according to the screening log. All staff are to answer information on the screening log. The Director of Nurses stated the person taking temperatures should be signing under the section on the form that states signature of person taking temp. The screener is expected to review the screening log after each person answers the questions. If questions are not answered, the log isn't being monitored consistently. I have in-services on screening staff and visitors. I will need to review the in-services of Screener A. Record review of the Screening Log dated 11/20/20 at 9:48 AM, revealed Surveyor answered signs/ symptom questions, Screener A did not sign the log. A copy of the record was requested on 11/20/20 at 9:50 and received on 11/20/2020 at 9:54 of request. Further review of the screening log revealed Screener A had not signed taking the temperatures of 20 staff. There were two staff that did not answer screening questions related to COVID-19 and three staff that did not have a date by their name. In an observation on 11/21/20 at 1:30 PM Screener A conducted screening process by taking temperature of surveyor. Screener A instructed the surveyor to document her temperature and to answer the COVID -19 questions. Screener A did not review the screening form after the surveyor completed the questions and documented temperature. Screener A did not sign the form as the person taking the temperature. In an interview on 11/21/20 at 1:34 PM Screener A stated I have not been informed about the screening process. I didn't know to sign my name under the section that says signature of person taking the temperature. I sometimes sign my first name under comments. It doesn't show that I was the one taking staffs temperatures or your temperature when signing under comments. In an interview on 11/21/20 at 2:40 PM the Director of Nurses stated Yes I have in-serviced the screeners in the past on the process of screening everyone enters the facility. The process of documenting on the screening record and check the entries after each staff or visitor. Screener A has been trained I will provide her training records. Record Review on 11/21/2020 at 3:45 PM revealed Screening Records from 11/01/20 thru 11/21/20 had inconsistencies of documenting lunch temperature, end of day temperature, answering COVID-19 signs and symptoms questions and signature of the person taking temperatures. The screening records further reflect staff was frequently taking their own temperature. Staff signed their name under the section of the form for the signature of person taking temperature. In-services on the screening to 11/20/20 was not provided at the time of exit on 11/28/20. 2. Resident #1 Record Review of Resident #1's Face Sheet reflected a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Record Review of Resident # 1's Quarterly MDS dated [DATE] reflected a BIMS score of 10 indicating she was moderately impaired. Record Review of Regular Floor Isolation/ Surveillance log on 11/20/20 at 11:58 PM reflected Resident #1 re-admitted [DATE], Resident #2 re-admitted [DATE], Resident #3 re-admitted [DATE], Resident #4 re-admitted [DATE] and Resident #5 is a new admit. These resident's cohort with other residents on cold zone (first section) 200 hall, the front, middle and end of 400 hall and the middle to end of 500 hall. (residents without signs/ symptoms of COVID-19). Records of resident testing negative or positive after return from hospital wasn't provided. Observation on 11/20/20 from 10:40 AM - 2:00 PM revealed a PPE container in front of Resident #1's room with signs on the door indicating the resident was on isolation. CNA A , CNA B and Med-Aide C entered and exited Resident #1's room throughout the day and entered other Residents' room without washing their hands. In an interview on 11/20/20 at 10:44 AM CNA B stated Resident #1 returned from hospital on isolation this week and admitted to her original room. CNA B stated Resident #1 stayed in her room almost all day prior to being moved to a private room on the same day. In an interview on 11/20/2020 at 10:50 AM Med- Aide C stated Resident #1 was placed to her original room with roommate prior to being admitted to hospital. Resident #1 was later moved during the day to a private room [ROOM NUMBER]. In an interview and observation on 11/20/20 at 11:10 AM The Director of Nurses stated, Resident #1 was on isolation. (At this time the DON showed the surveyor the isolation signs and PPE for Resident #6.) The DON stated Resident # 1 was on isolation and they would not have placed PPE outside of her door, or put up isolation signs, if she was not on isolation. The DON said, The resident on isolation is Resident #1 and she must be in the bathroom; the reason she isn't in her room. This is Resident #6 roommate of Resident #1. I don't know where Resident #1 is currently. The Director of Nurses stated I found out from Med Aide C Resident #1 was moved to a private room on 400 hall (Cold Zone). I am the acting Infection Control Nurse and I am responsible for removing isolation signs and PPE and responsible for setting PPE containers and placing isolation signs on the doors of residents return from hospital or a new admit. I didn't realize Resident #1 had been moved. I don't know if the results of resident testing positive or negative when in hospital is in the charts. Observation on 11/20/20 at 12:12 PM revealed CNA D did donn PPE and entered Resident #1 and Resident #4's room to deliver food to Resident #1 and Resident #4 on isolation. CNA D doffed prior to exiting room and sanitized her hands. In an interview on 11/20/20 at 2:50 PM Resident #1 stated she was in hospital and returned to her original room and then she was moved to her current room. Resident #1 stated a nurse told her if she had [MEDICAL CONDITION] she was not supposed to share a room because her friend ( roommate) had not been in the hospital and that was why they moved her to another room. Observation on 11/21/20 at 8:35 AM CNA D donned and doffed PPE correctly room # 414. (Resident #1 and Resident #4's room) Observation on 11/21/20 at 8:30 AM revealed Resident #1, #2, #3, #5, #6, #7 and #8 still resided on the cold zone hall 400 and hall 500 (residents without sign/ symptoms of COVID -19). Resident #2 Record Review of Resident #2's Face Sheet reflected a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record Review of Resident #2's Admission MDS dated [DATE] reflected a BIMS score of 8 indicating he was moderately impaired. Record Review of Regular Floor Isolation/ Surveillance log on 11/20/20 at 11:58 PM reflected Resident #1 re-admitted [DATE], Resident #2 re-admitted [DATE], Resident #3 re-admitted [DATE], Resident #4 re-admitted [DATE] and Resident #5 is a new admit. These resident's cohort with other residents on cold zone (first section) 200 hall, the front, middle and end of 400 hall and the middle to end of 500 hall. (residents without signs/ symptoms of COVID-19). Records of resident testing negative or positive after return from hospital wasn't provided. Observation on 11/20/2020 at 12:10 PM reflected Resident #2 and Resident #3 were on the 400 hall (residents without signs/ symptoms of COVID-19). Resident #2 and Resident #3 did not have PPE beside their doors or isolation signs on their doors. Attempted to interview Resident #2 resident didn't respond to questions. Observation on 11/20/20 from 12:15 PM to 12:45 PM revealed CNA D, CNA B and Med-Aide C entered Resident #2 and Resident #3's rooms without donning appropriate PPE. CNA D, CNA B and Med-Aide C were passing meals to all residents on the 400 hall. Staff did not sanitize hands while passing meals. In an interview on 11/20/20 at 12:49 PM Med-Aide C stated, staff on 400 hall had not been informed of Resident #2 and Resident #3 requiring staff to wear any type of PPE. Med-Aide C stated she had questioned the isolation of Resident #2 and Resident #3 after they returned from hospital and no one would respond to her questions. Med Aide C stated she did not want to reveal who she questions about PPE and isolation for Resident #2 and Resident #3. Med -Aide C stated she did question why residents return from hospital was not on isolation. Management didn't respond to her question. Observation on 11/21/20 at 8:30 AM revealed Resident #1, #2, #3, #5, #6, #7 and #8 still resided on the cold zone hall 400 and hall 500 (residents without sign/ symptoms of COVID -19). Resident #3 Record Review of Resident # 3's Face Sheet reflected a [AGE] year-old -female admitted on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Record Review of Resident #3's Quarterly MDS dated [DATE] reflected BIMS score of 3. Record Review of Regular Floor Isolation/ Surveillance log on 11/20/20 at 11:58 PM reflected Resident #1 re-admitted [DATE], Resident #2 readmitted ,[DATE],20, Resident #3 re-admitted [DATE], Resident #4 re-admitted [DATE] and Resident #5 is a new admit. These resident's cohort with other residents on cold zone (first section) 200 hall, the front, middle and end of 400 hall and the middle to end of 500 hall. (residents without signs/ symptoms of COVID-19). Records of resident testing negative or positive after return from hospital wasn't provided. Observation on 11/20/2020 at 12:10 PM reflected Resident #2 and Resident #3 were on the 400 hall (residents without signs/ symptoms of COVID-19). Resident #2 and Resident #3 did not have PPE beside their doors or isolation signs on their doors. Attempted to interview Resident #2 resident didn't respond to questions. Observation on 11/20/20 from 12:15 PM to 12:45 PM revealed CNA D, CNA B and Med-Aide C entered Resident #2 and Resident #3's rooms without donning appropriate PPE. CNA D, CNA B and Med-Aide C were passing meals to all residents on the 400 hall. Staff did not sanitize hands while passing meals. In an interview on 11/20/20 at 12:49 PM Med-Aide C stated, staff on 400 hall had not been informed of Resident #2 and Resident #3 requiring staff to wear any type of PPE. Med-Aide C stated she had questioned the isolation of Resident #2 and Resident #3 after they returned from hospital and no one would respond to her questions. Med Aide C stated she did not want to reveal who she questions about PPE and isolation for Resident #2 and Resident #3. Med -Aide C stated she did question why residents return from hospital was not on isolation. Management didn't respond to her question. Observation on 11/21/20 at 8:00 AM revealed Resident #3 resided in a cold zone, 400 hall (residents without signs/ symptoms of COVID 19). Resident #3 did not have PPE outside of the room and isolation signs were not posted. Further observation revealed Resident #3 had a roommate. In an interview on 11/21/20 at 8:30 AM Resident #8 stated she was happy Resident #3 was back with her. She stated she saw staff wear a mask but had not seen staff wear a gown. Observation on 11/21/20 at 8:30 AM revealed Resident #1, #2, #3, #5, #6, #7 and #8 still resided on the cold zone hall 400 and hall 500 (residents without sign/ symptoms of COVID -19). Resident #4 Review of Resident #4's medical chart reflected he returned from hospital on [DATE] with positive antibodies. Record Review of Regular Floor Isolation/ Surveillance log on 11/20/20 at 11:58 PM reflected Resident #1 re-admitted [DATE], Resident #2 readmitted ,[DATE],20, Resident #3 re-admitted [DATE], Resident #4 re-admitted [DATE] and Resident #5 is a new admit. These resident's were cohorted with other residents on cold zone (first section) 200 hall, the front, middle and end of 400 hall and the middle to end of 500 hall. (residents without signs/ symptoms of COVID-19). Records of resident testing negative or positive after return from hospital was requested but not provided prior to exit. Observation on 11/20/20 at 10:25 AM revealed CNA A, CNA B and Med -Aide C entered other residents' rooms on the 400 hall after exiting Resident #4's room. All three staff did not sanitize hands after entering and exiting Resident #4's room. Observation on 11/20/20 from 10:40 AM - 2:00 PM revealed a PPE container in front of Resident #4's room with signs on the door indicating the resident was on isolation. CNA A , CNA B and Med-Aide C entered and exited Resident #4's room throughout the day and entered other Residents' room without washing their hands. Observation on 11/21/20 at 8:35 AM CNA D donned and doffed PPE correctly room # 414. (Resident #1 and Resident #4's room) Observation on 11/21/20 at 8:30 AM revealed Resident #1, #2, #3, #5, #6, #7 and #8 still resided on the cold zone hall 400 and hall 500 (residents without sign/ symptoms of COVID -19). Resident #5 Record Review of Regular Floor Isolation/ Surveillance log on 11/20/20 at 11:58 PM reflected Resident #1 re-admitted [DATE], Resident #2 readmitted ,[DATE],20, Resident #3 re-admitted [DATE], Resident #4 re-admitted [DATE] and Resident #5 is a new admit. These resident's cohort with other residents on cold zone (first section) 200 hall, the front, middle and end of 400 hall and the middle to end of 500 hall. (residents without signs/ symptoms of COVID-19). Records of resident testing negative or positive after return from hospital wasn't provided. Observation on 11/20/20 at 3:15 PM revealed Resident #5 resided on hall 200 and was the only room prior to entering the hot zone ( hall 200). Resident #5's room had PPE and isolation signs on her private room door. Observation on 11/21/20 at 8:30 AM revealed Resident #1, #2, #3, #5, #6, #7 and #8 still resided on the cold zone hall 400 and hall 500 (residents without sign/ symptoms of COVID -19). Resident #6 An observation on 11/20/20 at 10:20 AM revealed PPE in a three-drawer container was outside Resident #6 's room. There were droplet precautions on Resident #6's door and instructions on how to doff and donn PPE. CNA A, CNA B and Med-Aide C was entering the room without donning PPE. In an interview on 11/20/20 at 10:44 AM CNA B stated Resident #6 was not on isolation. CNA B stated Resident #6 had not been in hospital or had any reason to be on isolation as stated by Med-Aide C. CNA B stated no one knew if any of the Residents had tested positive for COVID-19. In an interview on 11/20/20 at 10:50 AM Med Aide C stated, The lady in Resident # 6 isn't on isolation. In an interview on 11/20/20 at 3:05 PM Resident #6 sated her roommate returned from the hospital and was in the same room with her for half a day or more before she was moved to another room due to Resident #1 coming back from the hospital and needing to be in the same room with her until she was better and checked for [MEDICAL CONDITION]. Resident #6 stated the staff wore a face mask and she had one as well and wore it. She stated she had not seen staff wear a gown and that they wore a face mask. Observation on 11/21/20 at 8:30 AM revealed Resident #1, #2, #3, #5, #6, #7 and #8 still resided on the cold zone hall 400 and hall 500 (residents without sign/ symptoms of COVID -19). Resident #7 Observation on 11/20/20 at 11:40 AM revealed Resident # 7 returned from hospital and placed on isolation precautions. Resident #7 was on the cold zone middle to end of 500 hall (residents without signs/ symptoms of COVID-19). Observation on 11/21/20 at 8:30 AM revealed Resident #1, #2, #3, #5, #6, #7 and #8 still resided on the cold zone hall 400 and hall 500 (residents without sign/ symptoms of COVID -19). In an interview on 11/20/20 at 1:15 PM CNA B and CNA C stated they wanted to speak with the surveyor in private. CNA B stated she had questioned residents returning to the facility from the hospital and not being placed on the isolation unit. CNA B stated she was told to mind her own business and they were too busy to talk with her. CNA B and CNA C stated we have been concerned about residents returning from the hospital and being admitted to 400 hall over a month CNA B stated she had concerns with residents returning to the facility from the hospital had COVID-19. She stated she did not know, or if other staff knew, if the residents returning from hospital needed to be on isolation. She stated management had not told the staff anything and had not placed PPE or isolation signs on those residents doors. CNA B stated she did not feel comfortable revealing the staff she had spoken to. In an interview on 11/20/20 at 1:27 PM CNA C stated she agreed with everything CNA B had said. She stated she had also asked management about residents returning to the facility from the hospital and being placed in the same room they are in prior to transfer to the hospital. She stated she was told they could not talk with her and they were too busy. CNA B stated it was not explained if residents needed to be on isolation when they return from the hospital or if they were a new admit. CNA B stated no one had said anything to her about wearing PPE in resident rooms but they did wear PPE in residents' rooms with isolation signs on the door and PPE outside of the room. CNA B stated she did not want to reveal the people she had spoken to about her concerns. In an interview on 11/20/2020 at 1:45 PM the Housekeeper F stated she did not work on the isolation halls ( halls 200 and 300). She stated she did not know there were residents that needed to be on isolation and no one had told her. Housekeeper F stated she had not been wearing gowns or anything but her mask except in rooms with isolation signs on the door reflected the resident on isolation. In an interview on 11/20/20 at 2:35 PM the Director of Nurses stated there was no issue with readmitting residents from hospital to their original room. She stated the facility was unable to place these residents on the warm unit (hall 300 ). The Director of Nurses stated all of the residents on the hot zone ( hall 200) would be moving to their heir original rooms on the warm zone ( hall 300). The Director of Nurses stated there were enough rooms on the warm zone ( hall 300) for all current residents on isolation on (hall 400 and hall 500 cold zones) to be moved but they did not see that as a necessity. The Director of Nurses stated she was responsible for all the duties and one of those duties was being infection control nurse. She stated it was her responsibility to educate staff on wearing PPE when residents returned from the hospital or if the had a new admission. The Director of Nurses stated she was doing all that she could to keep the facility following guidelines. She stated she did not inform staff on recent readmits wearing PPE. She stated she failed to place PPE outside of some of the residents' doors and to place isolation signs on the door. Director of Nurses stated she had no excuse except having a lot of duties. The Director of Nurses stated if the staff was not informed of residents needing to be on isolation and if there were not isolation signs on the residents' door then the staff did not know to wear PPE and that was her fault. In an interview on 11/21/20 at 8:55 AM RN G stated they were not always informed when a resident readmitted to the facility. RN G stated there was not a lot of communication between management and staff who worked with the residents. RN G stated she had asked the Director of Nurses questions about residents being readmitted from the hospital to the same room and was told by the Director of Nurses she was too busy to talk. RN G stated there were residents returning from the hospital and not being placed on the warm zone. She stated the staff did not know the guidelines they needed to follow in order to care for readmitted residents who were placed on halls with residents not on isolation. RN G stated she was informed the Director of Nurses was the infection control nurse and she was responsible for placing PPE outside of the residents' rooms and posting isolation signs on their door. RN G stated it was confusing staff. Residents on isolation doesn't have any PPE or Signage and residents not on isolation has PPE and isolation signs. She stated Management would send out a group text message but not everyone received the text messages and most of the time she did not receive the text messages. In an interview on 11/21/2020 at 10:00 AM RN I stated she had not been informed of any protocol to use when residents return from the hospital. She stated her understanding was that it was the infection control nurse's duty to place PPE containers and isolation signs on the door to alert staff a resident was on isolation. RN N stated it was her understanding if a resident returned from the hospital they were to be admitted to the warm zone and not placed with residents who were not on isolation such as halls 400, 500 and 600. She stated the Director of Nurses was the infection control nurse. The Director of Nurses was notified an IJ was identified on 11/21/20 at 3:09 PM. IJ template was provided by Surveyor. The POR was submitted 11/25/2020 at 12:41 PM and accepted. The POR was as follows: Plan of Removal I. 1) 11/21/2020: DON immediately updated Screening Policy: Only an in-serviced, screening staff takes temperatures and document temperatures; screening staff ask log questions to all staff and complete each questionnaire; screeners only sign off on temperatures and answered questions; all staff is screened by screening staff upon arrival and at mid-day. No staff member takes their own temperatures. 2) On 11/21/2020, DON in-serviced and trained screening staff on Updated Screening Policy that included that every blank on the screening questionnaire must be filled in and no blank sections are allowed. 3) On 11/21/2020, DON In-serviced screening staff on limiting movement on employees/visitors while in the screening area and [MEDICATION NAME] social distancing. DON explained that X were placed on the floors for visual identification of areas 6 feet apart. 4) On 11/21/2020, DON provided documentation of education to screening staff to ensure all screening staff was aware and understood the Updated screening policy as well as current visitation policy and procedures. 5) On 11/21/2020, DON reviewed and in-serviced screeners on screening recommendations from the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2020 (COVID-19) Pandemic page 2 of 12 ensuring that each screener was trained to date each entry, sign off on each temperature taken, and notify nursing department if an employee has a headache, sore throat, cough, nausea, vomiting, diarrhea, shortness of breath, lack of taste or smell before employee is allowed in the building. *Proficiency checks will be logged daily for three months by ICN or designee and reported to the DON and QAPI Committee. *Administrator will make random checks to ensure proper screening continues and will report concerns noted to the DON, ICN and QAPI Committee. II. 1) On 11/21/2020, DON, ADON, and Assigned Staff, first tested all residents currently on Hall 400. 2) On 11/21/2020, DON, ADON and Assigned Staff, next tested all employees on Hall 400. 3) On 11/21/2020, DON, ADON and Assigned Staff, tested all residents in the building. 4) On 11/21/2020, DON, ADON and Assigned Staff, tested the remaining staff in the building. 5) On 11/21/2020, DON ADON and Assigned Staff established a Warm Unit within the facility with signage that identified an additional area as Warm Zone, with proper Isolation Precautions signage on individual rooms of residents on isolation. 6) On 11/21/2020, DON assigned and moved residents to the Warm Zone designated staff to receive continued care once moved. 7) On 11/21/2020, DON, ADON, ICN, and Admissions nurses in-serviced Warm Zone designated staff and all on duty staff on infection control policies and procedures for establishing hot, warm and cold zones within the facility per Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease-19. 8) On 11/21/2020, ADON removed temporary signage, name plate, and sanitation cart from room no longer used as a temporary Warm Room. 9) On 11/21/2020, ICN and Admissions Coordinator in-serviced staff on proper use of PPE, including KN95 and N95 or higher level of respirator, eye protection (goggle or face shield), gloves, gown. 10) On 11/21/2020, ICN and Admissions Coordinator in-serviced staff on proper procedure to don and doff PPE. 11) On 11/21/2020, ICN and Admissions Coordinator in-serviced staff on proper procedure for identifying signs and symptoms of COVID, proper hand washing procedure to prevent COVID or further spread. 12) On 11/21/2020, DON trained Admissions, Social Worker, and staff on proper admission practices for residents coming from hospital, coming from home, coming from hospital as re-admits into properly designated units per Responding to Coronavirus (COVID-19) in nursing homes Resident Cohorting and Considerations for new admissions or readmission to the facility. 13) On 11/21/2020, ICN and Admissions Coordinator in-serviced s Admissions Coordinator, Social Worker, and staff regarding admitting residents to ensure they are quarantined for 14 days in a Warm Zone, per Responding to Coronavirus (COVID-19) in nursing homes Resident Cohorting and Considerations for new admissions or readmission to the facility. *Look back checks to ensure proper signage, name plates, and isolation carts are properly placed will be logged daily for three months by ICN or designee and reported to the QAPI Committee. *Administrator will make random checks to ensure proper signage, name plates, and isolation carts are properly placed, and will report concerns noted to the DON, ICN and QAPI Committee as needed. III. 1. On 11/21/2020, DON and ADON, established a Warm Zone and assigned staff moved all residents with unknown COVID status or who was identified as a new admit or re-admit to the Warm Zone ensuring cohorting was only with residents who needed quarantine/isolation. 2. On 11/21/2020, DON and assigned staff tested all residents on the hall where the potential for exposure of COVID 19 occurred. 3. On 11/21/2020, DON, ADON, and ICN in-serviced staff in the building on the proper procedure for cohorting residents. Proper admission practices for residents coming from hospital, coming from home, coming from hospital as a re-admit to properly designated units per Responding to Coronavirus (COVID-19) in nursing homes Resident Cohorting and Considerations for new admissions or readmission to the facility into their properly designated Zones per Responding to Coronavirus (COVID-19) in nursing homes Resident Cohorting and Considerations for new admissions or readmission to the facility. *Look back checks to ensure proper cohorting of residents into the Warm and Cold Zones will be logged daily for three months by ICN or designee and reported to the QAPI Committee. *Administrator will make random checks to ensure that any cohorting of residents will be into the appropriate zone, and will report concerns noted to the DON, ICN and QAPI Committee as needed. IV. 1. On 11/21/2020, DON, ADON, and ICN in-serviced all clinical staff, all clinical designated staff, and all staff on duty on the Policy and Procedure for properly utilizing dedicated staff in the Warm Zone and Hot Zones. 2. In-services and corrections required for the Plan of Removal were completed on 11/24/2020. Staff members, who have not finished required in-services, will not be allowed to work until he or she has completed all in-services required for Plan of Removal. *DON or designee will make daily Look back checks to ensure Warm and Hot Zones have designated staff as staffing permits and will report the findings to the QAPI Committee for 3 months. *Administrator will make random checks to ensure that any designated staff are in the Warm and Hot Zones, and will report concerns noted to the DON, ICN and QAPI Committee as needed. Administrator Monitoring of the POR: Observations on 11/28/20 at 2:40 PM revealed Resident #'s 1,2,3,5,6,7 and 8 had been moved to warm zone and Resident #4 had been moved to the hot zone per nurse practitioner orders. Resident #4 had positive antibodies and was COVID-19 positive 08/23/2020. Resident #4 was moved to the hot zone. Observations on 11/28/20 at 2:45 PM revealed signage for Hot, Warm and Cold zones had been set up for appropriate halls. Observations on 11/28/20 at 2:40 until 4:30 PM revealed staff donn and doff PPE appropriately and performed hand hygiene as required. Interviews on 11/28/20 at 3:05 PM with 1 Med-Aide, 3 CNA's and 1 LVN revealed they had received in service on Hot, Warm, Cold zones, instructions on properly wearing PPE and the new COVID -19 screening process. They stated they also in-serviced the appropriate residents lives on each zone. Infection Control and update on COVID-19 protocols. Record Review of in-services dated 11/21/20 and 11/23/2020 reflected Staff had been in serviced on new screening process, Policy on (TRUNCATED)