Every finding on record at Stonebridge Health Rehab

Based on observation, interview, and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 8 residents (Resident #16 reviewed for pain.The facility failed to ensure Resident #16 received pain management to the fullest extent possible, resulting in her experiencing pain on 04/22/2026. This failure placed residents at risk of uncontrolled pain. Findings included:Record review of the undated face sheet for Resident #16 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cancer of both lungs, brain cancer secondary to lung cancer, chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), generalized anxiety disorder, and pain.Record review of the quarterly MDS assessment for Resident #16 dated 03/04/2026 reflected a BIMS score of 07, indicating severe cognitive impairment. It reflected that she had experienced pain frequently and pain had made it difficult for her to sleep over the previous five days. It reflected pain had occasionally interfered with her activities during the day. It reflected that she received both scheduled and PRN pain medications over the previous five days.Record review of the care plan for Resident #16 dated 02/06/2026 reflected the following: FOCUSThe resident has PRN pain medication therapy r/t cancer of lung and brain.GOALThe resident will be free of any discomfort or adverse side effects from pain medication through the review date.INTERVENTIONS:Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT.Review per facility protocol for pain medication efficacy. assess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required; Controlled adequately by therapeutic regimen no treatment regimen or change in regimen required but continue to monitor closely; Controlled when therapeutic regimen followed, but not always followed as ordered; Therapeutic regimen followed, but pain control not adequate, changes required.Record review of physician orders for Resident #16 reflected the following orders:-FentaNYL Patch 72 Hour 100 MCG/HR Apply 2 patch transdermally every 72 hours for pain apply 2 patchesof 100 mcg to = 200 mcg; total dose 200 mcg; remove old patch first and remove per schedule dated 01/25/2026-oxyCODONE HCl Oral Tablet 20 MG (Oxycodone HCl) Give 1 tablet by mouth every 2 hours as needed for pain dated 08/25/2025-MONITOR FOR PAIN EVERY SHIFT USE 0-10 SCALE (A) FOR ALERT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUMENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING. every shift dated 08/05/2025.Record review of the pain assessment tool on Resident #16's April 2026 treatment administration record reflected a pain level of 0 (indicating no pain) on all three shifts (day, evening, night) for 04/21/2026 and a 9 (indicating severe pain) on the day and evening shifts for 04/22/2026. Record review of the April 2026 medication administration record for Resident #16 reflected that she received a Fentanyl patch on 04/19/2026 at 1:51 PM and again on 04/22/2026 at 11:59 AM. It reflected that she received PRN administrations of oxycodone with a pain scale of 4 reported (indicating mild pain) on 04/21/2026 at 8:17 PM and another with a pain scale of 9 reported (indicating severe pain) at 9:51 AM the following morning.Observation on 04/21/2026 at 9:04 AM, 11:08 AM, and 2:53 PM revealed Resident #16 sat in the doorway of her room and told any staff who walked by that she was in pain and needed medication. She touched her chest and said that was where she hurt and that she also had a very bad headache. At 9:04 and 11:08 AM, LVN D responded to her immediately. At 02:53 PM, RN A was already standing near to her and responded to her. (These observations correlate with PRN administrations of oxycodone listed above.) Observation at 3:00 PM revealed CNA J pulled back Resident #16's shirt to reveal a fentanyl patch on her back dated 04/19/2026. Observation on 04/22/2026 at 7:12 AM revealed Resident #16 was in her wheelchair at her door saying she needed help and was in pain. She was not wincing, grimacing, red-faced, or sweating, but she did appear anxious. She called out to anyone she saw on the hall, and CNA J responded to her and took her into the bathroom and then back out again after a few minutes. There was no nurse observed on the hall at this time. Resident #16 sat in her wheelchair in her doorway for the next hour and a half, occasionally asking for help. CNA J responded to her requests each time and assisted her to the bathroom once. The ADON was observed entering the hall at 08:15 AM with a medication cart and began working her way up the hall passing medications to residents in each room. During an interview on 04/22/2026 at 7:18 AM, Resident #16 stated she was in a lot of pain in her chest. She stated she had cancer in her lungs which had spread to her brain, and she hurt mostly in her chest but also had a headache. She stated she did not know when the last time she had a pain pill was, but she wanted one. During an interview on 04/22/2026 at 10:00 AM on the hall just outside Resident #16's room, the ADON stated she was working the floor that day, because the nurse who had been scheduled did not show up for the shift. She stated Resident #16 was on Hospice, and the IDT was responsible for reviewing pain assessments and PRN administration so that the Hospice physician could determine if a change in orders was warranted. She stated she knew Resident #16 to frequently complain of pain and that Resident #16 had a diagnosis of lung and brain cancer that was likely to cause pain. She looked at the pain assessment tool on the medication cart computer and stated she could see that the zeros on the pain assessment may not have properly reflected the pain that resident was experiencing. She stated she also noticed that she had documented Resident #16's pain at a 9 that morning, and there had been no administration of PRN pain medication all night. The ADON stated she had just administered a PRN oxycodone to Resident #16 and was waiting to complete the follow up evaluation to ensure it was effective. She stated it made sense that Resident #16's pain level might not have gotten all the way to a 9 if she had received earlier PRN administrations of oxycodone. She stated she could see that Resident #16 was not receiving pain medication as often as she might need it to stay on top of her pain.During an interview on 04/23/2026 at 2:20 PM, CNA J stated she worked both the daytime and evening shifts on the hall where Resident #16 lived. She stated part of providing care was asking if residents were in any kind of pain. She stated Resident #16 had frequent pain, and she always reported the pain to the nurse. She stated she had no idea when pain medications were administered and could not access that information on the EMR. She stated there were many things that helped distract Resident #16 from her pain such as snacks and visitors, but she said she was in pain nearly every time she was asked. During an interview on 04/23/2026 at 3:27 PM, the MD stated she talked with Resident #16 every time she visited the facility, which was once per month. She stated that when considering whether Resident #16 needed more pain medication available in her orders, she looked at how frequently the medication was administered PRN. She stated she did not usually look at the pain assessment tool, because the pain assessment also had to be conducted when a PRN oxycodone was administered. She stated if pain was being underreported on the pain assessment tool, it might not give an accurate reflection of Resident #16's need for pain control. During an interview on 04/23/2026 at 3:48 PM, the DON stated they had asked Hospice to review Resident #16's chart in January and had increased the dosage of her Fentanyl patch and felt it might have been time to ask them to come back and review the pain control. She stated Resident #16 would come and ask for pain medication, so they had felt sure she would be getting as much pain medication as she needed. She stated she did not consider that the nursing staff might be too busy to assess Resident #16 as often as she needed it assessed to prevent pain from breaking through. The DON stated she ensured that resident pain was controlled by interviewing residents, reviewing medications, and reviewing the frequency residents requested PRN pain medication so she could notify the doctor if it became especially frequent. She stated the potential negative outcome of underutilizing a PRN pain medication was the resident would not feel well and would not have good quality of life. During an interview on 04/23/2026 at 4:22 PM, the ADM stated the floor nurses were responsible for assessing and treating pain in residents who experienced pain. She stated oversight of the pain management system in the facility was the responsibility of nursing administration (ADON, DON). She stated she monitored for compliance through morning meetings and talking with the nurse administration. She stated a potential negative outcome of a failure to control a resident's pain would be increased pain. Record review of facility policy dated October 2022 titled Pain- Clinical Protocol reflected the following: Assessment and recognition1. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity.a. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level.2. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example, wound care, ambulation, or repositioning.3. The staff and physician will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls.4. The nursing staff will identify and document residents with a history of opiate use disorder and those who are currently receiving medication assisted treatment for opiate dependence (e.g., methadone, buprenorphine, buprenorphine/naloxone, naltrexone).MonitoringThe staff will assess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain.5. The staff will evaluate and report the resident/patient's use of standing and PRN analgesics.a. Depending on the characteristics of pain, the physician may start with PRN doses or supplement standing doses with PRN doses for breakthrough pain.b. If there are more than occasional analgesic requests, the physician will consider changing to regular administration of at least one analgesic with another medication for PRN use, increasing the standing dose of an existing analgesic, switching to another analgesic, and/or adding nonpharmacological measures.

Based on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 3 residents (Resident #36) reviewed for medication errors. 1. The facility failed to administer the correct dosage of medication to Resident #36 on 04/22/26. 2. The facility failed to administer the medication to Resident #36 at the time ordered by Physician 04/22/26. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization. Findings included: Record review of Resident #36's undated face sheet reflected a [AGE] year-old female with an initial admission date 12/07/2018. Resident #36 had diagnoses that included Alzheimer's disease unspecified (a progressive neurodegenerative disorder causing dementia, with symptoms including memory loss, cognitive decline, and behavioral changes), anxiety disorder (serious mental health conditions characterized by persistent, excessive fear or worry that interferes with daily life, going beyond temporary stress), unspecified bipolar disorder, current episode mixed, moderate (manic and depressive symptoms occur simultaneously or in rapid succession), dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance ( cognitive impairment caused by underlying conditions cognitive impairment caused by underlying conditions), history of fallings, and psychophysiologic insomnia (chronic sleep disorder characterized by learned sleeplessness, where anxiety about falling asleep, often tied to the bedroom environment, causes heightened arousal). Record review of Resident #36's annual comprehensive MDS, dated [DATE] reflected a BIMS score of 00 which indicated severe cognitive impairment. Record review of Resident #36's undated care plan reflected an ADL self-care performance deficit r/t generalized deconditioning, weakness, cognitive impairment, has impaired cognitive function/impaired thought processes r/t changes occurring with progression of Alzheimer's disease. Resident #36 uses antidepressant medication r/t depression and insomnia. Resident #36 has potential to be physically/verbally aggressive is resistive to care at times r/t Dementia r/t bipolar disorder. Resident #36 is at risk for falls r/t unsteady gait. She uses mood stabilizer/anticonvulsants medications r/t bipolar. She uses antipsychotic medications r/t bipolar disorder. Record review of Resident #36's physician orders reflected the following: Zyprexa oral tablet 2.5 MG (Olanzapine) Give 1 tablet by mouth two times a day related to bipolar disorder, current episode mixed, moderate dated 09/11/2025. Zyprexa oral tablet 2.5 MG (Olanzapine) Give 2 tablets by mouth at bedtime related to bipolar disorder, current episode mixed, moderate dated 09/11/2025. Record review of Resident 36's medication administration record scheduled for April 2026 reflected Zyprexa oral tablet 2.5 MG (Olanzapine) Give 1 tablet by mouth two times a day related to bipolar disorder, current episode mixed, moderate. Start date- 09/11/2025. Hours: 07:00 a.m., 4:00 p.m. Record review of Resident 36's medication administration record scheduled for April 2026 reflected Zyprexa oral tablet 2.5 MG (Olanzapine) Give 2 tablet by mouth at bedtime related to bipolar disorder, current episode mixed, moderate. Start date-09/11/2025. Hours: 9:00 p.m.During an observation of administration of medication on 04/22/2026 at 08:34 a.m., revealed MA G administered Resident #36's scheduled medication Zyprexa oral tablet 5 MG instead of Zyprexa oral tablet 2.5 MG. During an observation of administration of medication on 04/22/2026 revealed MA G administered Resident #36's scheduled medication Zyprexa oral tablet 5 MG at 08:34 a.m. instead of at 07:00 a.m. During an interview on 04/23/2026 at 08:38 a.m. with MA G he stated he has been working in the facility as a CNA since 2018 and he was working as a MA for about 5-6 months. He stated this job is new to him. He had his medication administration training during onboarding to this job. He stated that medication administration training covered the most important thing is that medications must be given in the residents' rooms, to document if a resident refused medications and the reason for refusal. He stated that MAs must check the orders for medications and for the time medications to be given. He stated he has never given a wrong dose of medication because he checks that medication is right. He stated if he notes that a wrong dose of medication is given, he will notify his nurse. He stated he did not notice any changes in any residents yesterday. During an interview on 04/23/2026 at 09:53 a.m. with LVN B she stated she had been working here for 2.5 years. She stated she had medication administration in-service about a month ago. This training covered 8 medication administration rights such as right resident, right medication, right time, right dose, right strength, right route. She stated she has never given a wrong dose of medication to residents, but she had late administration of medications after calling the doctor and getting an order for it. She stated if the wrong dose of medication was administered, she would notify the doctor and get orders to monitor the resident. To avoid administering the wrong dose of a medication the nurse must check the order in the resident's chart and check the right medication to match it on the medication blister's pack. She stated that administering the wrong dose of medication can make residents sick, they can get adverse reaction , it is a medication error . During an interview on 04/23/2026 at 12:05 p.m. MA F he stated he has been working here for almost 2 years. He stated his last medication administration in-service was about 2 weeks ago. The training covered 6-7 rights of medication administration rights: right dose, route, strength, right time, right patient, right medication. There are a lot of things that can happen if a wrong dose of medication was given to a resident; it depends on the medication, but it would affect resident in a negative way. Any medication error must be reported to a charge nurse, and the charge nurse will take over. During an interview on 04/23/2026 at 3:59 p.m. with DON she stated she has been working here since August of 2025. She stated she recently had medication administration training but could not recall the exact date. She stated the training covered 6 medication administration rights: right patient, right medication, right dose, right time, right strength. She stated DON and ADON are responsible for providing training to the medication aids and nurses, responsible for checking med pass progress, calling in from pharmacy and hospice refills. She stated that if the wrong dose of medication was administered to a resident it can negatively affect the resident, depending on medication and if it was too much or too little of dose. The MAs were expected to notify nurses about any med errors and the residents affected and they will be closely monitored . During an interview on 04/23/2026 at 4:28 p.m. with ADM she stated she has been working in the facility since August of 2025. She stated she was not trained in administration of medications. ADM stated that administering a wrong dose of medication to a resident may cause side effects from the medication and negatively impact resident. The record review of the undated facility's Delivery, Receipt and Storage of Medication Policy reflected: 1. A triple check of these Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. a. Check#1: Select the Medication- label, container and contents are checked for integrity and compared against the medication administration record (MAR) by reviewing the 5 Rights. b. Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights. c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights. The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged, indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. When a medication order is changed and the current supply can continue to be used, the container should be flagged right away, and the order change communicated to the provider pharmacy so that the next supply of the medication is labeled with the current directions. 2. Medications are administered within 60 minutes before or after scheduled time, except for orders to administer with meals which must be administered based on mealtimes.

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 1 of 1 resident (Resident #22) observed for infection prevention. 1. The facility failed to ensure CNA H was following the infection control procedures during peri-care when CNA H cleaned Resident #22's anal area first before cleaning his scrotum. 2. The facility failed to ensure CNA H and CNA I were following the infection control procedures when the same wipe was folded multiple times and used for multiple strokes while providing peri-care to Resident #22. 3. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and PPE was used when CNA H and CNA I provided care for Resident #22. Thes failures could place incontinent residents at risk for infection, hospitalization, and decreased quality of life. The findings included: Record review of Resident #22's face sheet, dated 04/22/26, reflected an [AGE] year-old male admitted to the facility 03/25/26. His diagnoses included chronic atrial fibrillation unspecified (persistent irregular heart rhythm), heart failure, unspecified (chronic, progressive condition where the heart cannot pump blood efficiently, causing fluid buildup in the lungs and body), and pulmonary fibrosis, unspecified (chronic, progressive scarring of lung tissue). Record review of Resident #22's comprehensive MDS assessment, dated 03/28/26, reflected a BIMS score of 12 which indicated moderately impaired cognition. The MDS reflected Resident #22 was dependent on helper for toileting hygiene. The MDS reflected he was always incontinent of both bladder and bowel. Record review of Resident #22's undated acute care plan reflected he had an ADL self-care performance deficit r/t weakness. Resident #22 has bowel and bladder incontinence r/t Activity Intolerance. Interventions - Clean peri-area with each incontinent episode. Monitor/document for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Enhanced Barrier Precautions r/t Wounds. Goal- Enhanced barrier precautions will be maintained, and resident will not develop an opportunistic infection through the review date. Target Date: 07/02/2026. Interventions - Follow enhanced barrier precaution guidelines when providing close contact resident care. Post EBP signs on or beside the door to make precautions clear to those who are entering the room. Record review of Resident #22's order summary report reflected: Bilateral buttocks wound: cleanse with normal saline, pat dry, apply collagen to wound bed, then cover with dry dressing, change daily, one time a day for wound care, start date: 04/22/2026 Enhanced barrier precaution for wounds every shift, start date: 04/21/2026 Wound consult with skilled wound care surgical group until wounds resolved, ordered 04/21/2026 Micatin Cream 2 % (Miconazole Nitrate) Apply to groins topically one time a day for rash, start date: 04/22/2026 Santyl Ointment 250 UNIT/GM (Collagenase) Apply to left heel topically every day every shift for wound care, start date: 04/22/2026 Record review of Resident #22's completed orders reflected: Ceftriaxone sodium 1 GM solution reconstituted. Directions: Inject 1 GM intramuscularly one time only for dysuria and increased confusion for one day. Please give injection after labs have been collected. Completed on: 03/30/2026 Ceftriaxone sodium 1 GM solution reconstituted. Directions: Inject 1 GM intramuscularly one time a day for S/S of UTI for 3 days- Completed on: 04/03/2026 Ceftriaxone sodium 1 GM solution reconstituted. Directions: Inject 1 GM intramuscularly one time only for leukocytosis for 1 day- Completed on: 04/14/2026 During an observation of incontinent care on 04/22/2026 at 08:43 a.m., revealed CNA H and CNA I as they were preparing to perform incontinent care for Resident #22. They both put on Personal Protective Equipment before entering the high-risk Resident #22's room. Resident #22 was lying supine (on his back) in bed. CNA H explained his intention to perform incontinent care; resident verbalized a response. CNA H and CNA I went into the bathroom, washed their hands, then came out and put on clean gloves. CNA H performed incontinent care of Resident #22's genital area cleaning the resident's penis in circular motions first. CNA H used one cleaning wipe for one stroke, moving from clean area to dirty and from front to bottom. CNA H and CNA I assisted Resident #22 to turn to his left side, where the resident's buttocks were now exposed. CNA I was assisting Resident #22 to stay on his left side. CNA H removed his soiled gloves, performed hand hygiene, and put on clean gloves. Further observation at 08:51 a.m., revealed Resident #22 had a small bowel movement; CNA H cleaned Resident 22's anal area going from clean to dirty area and from front to back. CNA H removed his soiled gloves, performed hand hygiene, and put on clean gloves. CNA H started wiping Resident 22's scrotum which was covered with a white substance. CNA H used one wipe for two strokes on Resident #22's scrotum area. He then repeated the same steps with the second wipe before tossing wipe. Further observation revealed CNA I pulled out a new wipe and wiped the scrotum in a circular motion; she then folded the wipe and used it for one more swipe before tossing it. CNA I pulled out another fresh wipe, she made a swipe in a circular motion around the Resident #22's scrotum area, she then folded the wipe and made another two swipes folding the same wipe between swipes. CNA H and CNA I changed the gloves, performed hand hygiene, and applied a clean brief to Resident #22. CNA H and CNA I removed their gloves and gowns at Resident #22's bedside, performed hand hygiene, put on new gloves and assisted resident to reposition in bed by moving Resident #22 to the middle of his bed, fixing his pillow at the head and placing a pillow under his feet while both CNAs' scrubs were touching Resident 22's bedding. CNA H and CNA I gathered trash, removed gloves and washed hands in the resident's bathroom before leaving Resident #22's room. The CNAs changed gloves and cleansed their hands at appropriate intervals. The CNAs failed to wear gowns while providing high contact care to Resident #22 when the Signage noted outside of his door reflected that resident was on EBP. PPE was stored at Resident #22's door. During an interview on 04/23/2026 at 09:53 a.m. with LVN B she stated that she had infection control in-service training a couple of weeks ago. The training covered different isolation precautions and use of proper PPE. The training also covered hand hygiene topics. She stated she does not provide peri care to residents, but she knows the wipe needs to be disposed of after every stroke while providing peri care to residents. She stated that a charge nurse is looking over to provide proper peri care to residents. She stated that not following infection control procedure is an infection control issue, residents can get UTIs. During an interview on 04/23/2026 at 10:14 a.m. CNA H said he has been working here for about 19 years. He has been trained in infection control; his last infection control in-service training was 2 weeks ago. That training covered putting PPE on, washing hands, covering the linens when they are taken out of the residents' rooms that are on EBP, sanitizing hands every time you put gloves on, sanitizing hands before staff goes to residents' rooms and putting PPE on when providing care to residents on EBP. He stated he had a check-off training on providing Peri care about 3 weeks ago. He stated that the check-off training covered the following steps: letting a resident know about the care to be provided, gathering all the supplies, providing privacy, washing hands, wiping resident's front private area first by using one wipe for one stroke and throwing the wipe away. CNA H stated after finishing providing peri care on resident's front area, turning resident on one side of the resident's body and continue providing peri care around resident's buttocks using one wipe for one stroke. CNA H stated using one wipe for multiple strokes is an infection control issue; residents can get UTIs due to cross contamination. He stated that Resident #22 had UTIs in the past. During an interview on 04/23/2026 at 11:34 a.m. with CNA I revealed she has been working in the facility for about 22 years. She stated she had an infection control in-service training a few weeks ago. The training covered the proper use of PPE and changing gloves. PPE must be used when providing care to the residents who have colostomy bags, wounds, foley bags, and to those residents that are in EBP rooms. When providing peri-care to residents the CNAs must make sure residents are not in pain and they are comfortable and explain to the residents the care will be provided. Start providing peri care on the resident's front genital area, going from clean to dirty area from top to bottom and after finishing with the front area the resident to be placed on his side. She stated when providing peri care to the resident's buttocks area by wiping the area from dirty to clean; side to side first and then the buttocks' middle area, using a wipe with every stroke and throwing the wipe away. CNA I was able to recall that she was using the same wipe to clean the Resident # 22's scrotum area by folding a wipe after each stroke. She stated she thought it was okay to do so since she watched the Peri care training video where she saw the wipes were folded after each stroke. She stated that not following the infection control procedures while providing Peri care might cause residents to get sick. During an interview on 04/23/2026 at 3:59 p.m. with DON she stated that she recently had her annual infection control check offs and the ADON and she were providing the infection control check offs to the facility's staff annually where they are going step by step over the infection control policy and procedures and staff also demonstrates peri care skills. She stated that she does not remember providing peri care in-service training to the staff. She stated that staff were expected to use one wipe for one stroke while providing peri care to residents; not following this is an infection control concern; the residents can get UTIs. During an interview on 04/23/2026 at 4:28 p.m. with ADM she stated she has been trained in infection control. She stated she recently took infection prevention control course required by the CDC and the HHS infection control modules required by State. She stated that she is familiar with providing peri care to residents in general. It is recommended to start providing peri care from resident's front and then proceed to back, doing strokes from front to back, and it must be done from the clean area of the body to dirty using clean supplies. During an interview on 04/23/2026 at 4:43 p.m. with ADON she stated that she is trained in providing peri care to residents; she had training early this year. She stated it is expected that during providing peri care to residents staff must go from clean to dirty areas using a single wipe for each stroke. Not following this expectation is an infection control issue and potentially may cause UTIs. She stated that any staff that is providing direct care to the residents in EBP rooms must put the PPE on at the entrance to the room and the PPE must be removed at the door before exiting the room. The facility's infection control policy was requested on 04/21/2026. The policy was not provided during the survey.

Based on interview and record review, the facility failed to assist a resident in making transportation arrangements to an outside provider for one (Resident #1) of seven residents interviewed for transportation services. The facility failed to ensure Resident #1 received transportation to his scheduled medical appointment after being provided with adequate notice. This failure could lead to the worsening of acute or chronic health conditions and a decreased quality of life. Findings included: Resident #1 was a [AGE] year-old male admitted to the facility on [DATE], for rehabilitation services. Pertinent diagnoses include infection of internal joint prosthesis (infection of a joint replacement), chronic obstructive pulmonary disease (a condition in which the lungs are unable to exchange gases efficiently), and the presence of cardiac implants and grafts (including a pacemaker). Review of the MDS admission assessment dated [DATE], reflected a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Record Review of Resident #1's care plan dated May 1, 2025, reflected that he had skin integrity issues due to infections and surgical wounds. Interventions included, Administer treatment as ordered per physician. A record titled [company] Dr. Instructions, uploaded on May 21, 2025, contained a typed note stating, Ok to use his hand, wrist, elbow for all activities of daily living (ADLs), including eating and drinking. Handwritten on the same document was the note, next appointment 05/21 at 10:45. Received 05/15/25 at 3:00 PM. This note was signed by [name], Advanced Practice Registered Nurse (APRN), and dated May 16, 2025. Interview with Responsible Party (RP) for Resident #1 on June 17, 2025, at 9:45 AM revealed she had submitted a note and verbally reminded facility staff multiple times about the appointment. She was unable to recall which staff member received the note. She stated she reminded staff on May 20, 2025, that the appointment was the following day. The RP arrived at the facility at 9:30 AM on May 21, 2025, and found that transportation had not been arranged. The ADM informed her at that time that the SW was responsible for scheduling all transportation appointments. The RP stated she was not aware of this responsibility prior to that discussion. She expressed frustration regarding poor communication among facility staff. Although the appointment was rescheduled for the following day and Resident #1 was not harmed, she was concerned. Interview with the MDS Nurse on June 17, 2025, at 11:51 AM revealed all documents placed into a resident's file had already been processed by nursing. The MDS Nurse stated the transportation information should have been relayed to the SW by the staff member who received the appointment document from the family. Interview with the ADON on June 17, 2025, at 1:05 PM revealed she had never seen the document listing the follow-up appointment. She stated she had attempted to contact the doctor's office for clarification on Resident #1's weight-bearing status. She stated that, had she seen the document containing transportation information, she would have forwarded it to the SW. She stated there was no reason the resident should have missed his appointment if the document was indeed in the file and emphasized that it was a resident's right to have transportation to outside appointments. Interview with the MR staff on June 17, 2025, at 1:40 PM revealed the document was uploaded on its effective date. MR stated she was the last person to act on and file paper documents in the facility. She explained nurses are expected to submit documents for physician review and signature before placing them in her box for scanning and upload. MR stated any necessary actions such as transportation arrangements should be handled by floor or charge nurses and communicated appropriately. She noted that to her knowledge, no other appointments had been missed and confirmed that Resident #1 typically had many outside appointments. Interview with the SW on June 17, 2025, at 1:55 PM stated an outside transportation company was used and one to two days' notice was required for scheduling. The SW stated she had never seen the appointment document in the file and a nurse or certified nursing assistant (CNA) should have informed her earlier. She stated there was a breakdown in communication and explained the proper process to the RP on the day of the missed appointment. The SW was able to secure a new appointment and transportation for the next day. She stated the family was very upset initially but were satisfied once everything was rescheduled. Interview with the DON on June 17, 2025, at 2:45 PM revealed awareness of the missed appointment and stated that the SW resolved the issue. The DON stated there was difficulty securing last-minute transportation and stated the facility had multiple backup companies available. The DON explained families are informed during initial care plan meetings that the facility does not provide onsite transportation, and that timely communication of appointments was critical. The DON stated the document should have triggered a physician order and processing through the system. She also confirmed that no in-services had been conducted on transportation procedures, as there had been no prior issues reported. Interview with the ADM on June 17, 2025, at 2:05 PM reflected the SW was proficient in managing transportation and that the facility had no ongoing issues in this area. The ADM stated outside appointments and associated transportation are routine for residents receiving skilled nursing care. She stated appointment-related communication responsibilities are explained to families during care plan meetings and stated that physician receipt of the document demonstrated that the facility had received notification. ADM stated the situation as a miscommunication was resolved. Record review of in-service records from January 2025- June 2025 on June 17, 2025, revealed no staff education had been provided regarding transportation to outside appointments. Requested transportation policy from administrator before exit on 06/17/25 and none was provided. Record review of the admission agreement on June 17, 2025, reflected the following: For non-Medicaid residents: The resident or resident's representative is generally responsible for transporting residents to and from medical appointments. In the case of Medicaid residents, Medicaid will be billed for emergency ambulance services. The community will transport Medicaid patients.

Based on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 (Resident #195) residents reviewed for pain. The facility failed to provide scheduled Morphine and Tramadol for Resident #195 from 02/07/2025-02/09/2025 which resulted in mental anguish and untreated pain. An IJ was identified on 02/11/2025. The IJ template was provided to the facility on [DATE] at 04:56 PM. While the IJ was removed on 02/14/2025, the facility remained out of compliance at a scope of isolated and a severity level of 1 because all nursing staff had not been trained on pain assessments and the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life. Findings included: Record review of Resident #195's admission record, dated 02/14/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included pneumonia (an infection in lungs), dementia (a condition that affects thought processes), insomnia (difficulty sleeping), chronic pain syndrome, hypertension (high blood pressure), osteoarthritis (a condition that affects the cartilage that cushions the ends of the bones), scoliosis (a sideways curvature of the spine), and spinal stenosis (narrowing of the spinal canal in the low back). Record review of Resident #195's care plan, dated 02/12/2025, revealed Resident #195 had pain with relevant interventions that included administer analgesia and evaluate effectiveness of pain interventions. Record review of Resident #195's hospital discharge physician orders dated 02/07/2025 revealed the following order: Morphine SR 30mg oral three times a day last administered at 02/07/2025 at 08:19 AM. The physician progress note reflected, chronic backache continue home regime. Record review of Resident #195's physician's orders, dated 02/10/2024, revealed: Morphine Sulfate Oral Tablet 30mg Give 1 tablet three times a day for pain with a start date of 02/07/2025 07:00PM Tylenol Tablet 325mg Give 2 tablet by mouth every 4 hours as needed for mild pain with a start date of 02/08/2025 12:30AM Tramadol 100mg Give 1 tablet by mouth every 8 hours as needed for pain. Give medication until he gets Morphine Sulfate 30mg TID with a start date of 02/09/2025 02:00AM and an end date of 02/09/2025 02:10AM Tylenol Extra strength 500mg Give 2 tablet by mouth every 8 hours for pain with a start date 02/09/2025 07:00AM and an end date of 02/09/2025 03:42PM Tramadol 100mg Give 1 tablet by mouth every 8 hours for pain to be given until Morphine is available with a start date of 02/09/2025 07:00AM and end date of 02/09/2025 03:41PM. Record review of Resident #195's medication administration record for 02/07/2025-02/10/2025 revealed: Morphine Sulfate Oral Tablet 30mg Give 1 tablet by mouth three times a day for pain with start date of 02/07/2025. Missed doses with documented awaiting arrival from pharmacy noted were: 02/07/2025 07:00 PM 02/08/2025 07:00 AM 02/08/2025 01:00PM 02/08/2025 07:00PM 02/09/2025 07:00 AM 02/09/2025 01:00PM First dose of medication documented for 02/09/2025 at 08:54 PM. Tylenol 325mg Give 2 tablet by mouth every 4 hours as needed for mild pain. Medication documented as given: 02/08/2025 12:40 AM 02/08/2025 03:25 PM 02/10/2025 01:48 AM Tramadol oral tablet 100mg Give 1 tablet by mouth every 8 hours as needed for pain start date 02/09/2025 02:00 AM and end date 02/09/2025 02:10AM. No signature noted on medication administration record for this medication. Tramadol oral tablet 100mg Give 1 tablet by mouth every 8 hours for pain start date 02/09/2025 07:00 AM and stop date 02/09/2025 03:41 PM. Medication documented as not given 02/09/2025 07:00AM with notation waiting for the pharmacy to deliver, the nurse was notified. Medication documented as not given 02/09/2025 03:00 PM with notation Hold medication per nurse's request. Tylenol Extra strength 500 mg Give 2 tablet by mouth every 8 hours for pain start date 02/09/2025 07:00 AM and stop date 02/09/2025 03:42 PM. Medication documented as not given 02/09/2025 03:00 PM with notation Hold medication per nurse's request. Record review of Resident #195's progress note, dated 02/08/2025 at 10:09 PM and documented by LVN A, revealed the following: Resident has not received his Morphine 30 mg po tablet. He is really frustrated over this issue. Faxed another triplicate to [MD] and awaiting delivery. Tylenol 650mg and not enough. Record review of Resident #195's progress note, dated 02/09/2025 at 02:44 AM and documented by LVN A, revealed the following: Resident continue to call for his Morphine 30mg. Called on call NP for [MD] temporarily orders Tramadol 100mg q 8 hrs to be given together with Tylenol ES 1000 mg po q 8 until Morphine comes. First dose already given. Discussed about the Morphine with resident and stated that he has the medication at home. Encouraged resident to communicate with his [family member] to bring the medication today. Record review of Resident #195's progress note, dated 02/09/2025 at 02:58 AM and documented by LVN A, revealed the following: No pain noted or expressed. Pain level is currently at 10. Record review of Resident #195's progress note, dated 02/09/2025 at 08:54 PM and documented by LVN A, revealed the following: Received 10 tablets of Morphine 30mg and given to resident. Tramadol and Tylenol d/c as Morphine received. Record review of Resident #195's progress note, dated 02/09/2025 at 08:56 PM and documented by LVN A, revealed the following: Resident verbalizes or expresses presence of pain. Pain level is currently at 10. Resident demonstrates non-verbal signs of pain. Record review of Resident #195's progress note, dated 02/10/2025 at 01:44 AM and documented by LVN A, revealed the following: Resident awake and alert in bed. Called several times asking for his Morphine medication. Explained to him that the medication is to be given 3 x a day at 7am, 1pm, and 7pm .Tylenol 650 mg po given prn at 1:40am. During an interview and observation on 02/10/2025 at 10:06 AM, Resident #195 revealed he had concerns about his morphine not being administered since he was admitted . The resident stated he had been taking Morphine three times a day for a long time. He stated his primary care physician had him set up on the medication to control his pain and it had worked in the past. Resident #195 stated he hadn't been below a level 7 of 10 pain(Scale 0=no pain and 10=the worst possible pain), and he hurt in his lungs and lower back. When asked to describe the pain he rated at 10, the resident stated hell and sharp. The resident exhibited facial grimacing and appeared in pain during the interview. During an interview on 02/10/2025 at 03:01 PM, LVN D stated she was the nurse on duty when Resident #195 was admitted to the facility on [DATE] around 03:30 PM. She stated she faxed a request for a triplicate (specialized prescription for controlled medications) for the Morphine to the MD per protocol, but she wasn't sure what time. The Morphine didn't come in before she left her shift on 02/08/2025 at 06:00 AM. She stated she passed it on in report and documented it on the 24-hour report. She stated there had been some communication errors with the pharmacy getting prescriptions. She stated they needed to continue to attempt to obtain the medication needed. LVN D stated not getting pain medication that was ordered could cause discomfort for the resident. During a telephone interview on 02/10/2025 at 03:23 PM, LVN E stated he worked the next morning after Resident #195 was admitted . He stated he was not aware that Resident #195 was missing his Morphine on that day. LVN E stated if he had been aware of the need for pain medication, he would have contacted the on-call NP to get an order for something stronger than Tylenol until the Morphine arrived and the DON to expedite getting the medication. During a telephone interview on 02/10/2025 at 04:11 PM, NP L stated if a resident needed a triplicate, then the nurse needed to fax a completed request form to the MD. She stated the MD received the faxes on the weekend too and addressed the requests as they were received. She stated Tylenol 650mg is not a comparable pain medication to Morphine Sulfate 30mg. During a telephone interview on 02/10/2025 at 04:17 PM, the MD stated he received the request for a triplicate prescription for Resident #195 on 02/07/2025. He stated he sent the prescription to the wrong pharmacy. The MD stated he wasn't sure how the lack of pain medication could affect the resident since he had not assessed the resident yet. During an interview on 02/11/2025 at 10:42 AM, the DON stated the facility preferred to get the orders prior to the residents' admission to ensure a triplicate could be requested prior to the resident's arrival. She stated the policy was for the nurse to fax a request form to the MD. The MD then would send the prescription to the pharmacy, and the facility should have received the medication on the next delivery. The DON stated if there were issues with obtaining the medication then that medication needed to be put on hold and an order should have been obtained for a substitute that could have been pulled from the E-kit or the nurse should have administered Tylenol from the standing orders. She stated she did not consider Morphine and Tylenol to be equivalent. The DON stated Resident #195 arrived at the facility around 3:30PM on 02/07/2025. She stated the nurse requested a triplicate when the resident arrived. The DON stated Resident #195's Morphine wasn't received on 02/07/2025 or 02/08/2025. She stated Morphine should have been placed on hold after the first delivery without it. She stated the nurse and medication aide just documented the medication was unavailable. The DON stated the nurse that worked 02/09/2025 at 02:20AM pulled the Tramadol from the emergency kit and administered it. She stated Resident #195 received Tylenol an additional 3 times prior to his Morphine arriving on 02/09/2025 around 09:00 PM. She stated that uncontrolled pain might affect each resident differently. During a phone interview on 02/11/2025 at 11:54 AM, LVN A stated he worked with the resident the nights of 02/09/2025 and 02/10/2025. He stated he called the pharmacy on 02/09/2025 to locate the Morphine. They had not received a triplicate. He stated the only orders Resident #195 had for pain was Tylenol 650mg, so he contacted the NP and received an order for Tramadol and Tylenol together. He stated the NP was going to follow up with the MD for the triplicate for Morphine. LVN A stated he then pulled the Tramadol from the E-kit and gave the initial dose. He stated the resident was rating the pain a 10 before the Tramadol and between a 6 and 8 after the Tramadol. During a phone interview on 02/11/2025 at 01:16 PM, MA N stated she worked with Resident #195 on 02/08/2025 and 02/09/2025. She stated she notified the nurses that were working that the Morphine was unavailable. MA N stated, I was told to just document it as unavailable by them[the nurses]. She stated [Resident #195] was in a lot of pain and stuff. During an interview on 02/11/2025 at 01:26 PM, CNA I stated he worked with the Resident #195 on 02/08/2025 and 02/09/2025. He stated Resident #195 complained of pain on those days. CNA I stated he gave Resident #195 a bed bath on 02/09/2025 because Resident #195 was in too much pain to get up. He stated he notified LVN M about Resident #195's pain. During an interview on 02/11/2025 at 01:40 PM, the FM stated Resident #195 had been taking Morphine Sulfate 30mg three times a day for more than a decade. The FM stated during a visit on 02/08/2025, Resident #195 had facial grimacing worse than ever before. During an interview on 02/11/2025 at 02:36 PM, the DON stated she didn't have an answer for why the nurse didn't pull the second dose of Tramadol from the E-Kit. She stated there was Tramadol in the E-kit at that time and the nurse should have pulled the medication to administer it to the Resident #195. Record review of facility policy titled Pain-Clinical Protocol, dated 2001 and revised October 2022, revealed: Assessment and Recognition 1. The physician and staff will identify individuals who have pain or who are at risk for having pain . 2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. . Monitoring 1. The staff will assess the individual's pain and related consequences at regular interval, at least each shift for acute pain or significant changes in levels of chronic pain. Record review of facility policy titled Admission Assessment and Follow Up: Role of the Nurse, dated 2001 and revised in September 2012, revealed Purpose-The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan and completing required assessment instruments, including the MDS. . Steps in the Procedure . 7. Conduct an admission assessment (history and physical), including: . d. Current medications and treatments . 11. Reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution, according to established procedures. 12. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. Record review of undated facility policy titled Delivery, Receipt and storage of medication revealed: 6.1 Delivery schedules .Orders requiring more urgent delivery will be communicated by the facility to the pharmacy either by fax or verbally. The pharmacy will expedite delivery of those medications within a 4-hour window. The ADM and DON were notified on 02/11/2025 at 04:56 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 02/12/2025 at 03:29 PM and included: On 02/10/25 an abbreviated survey was initiated at [facility name]. On 02/11/2025 the surveyor provided an Immediate Threat (IT) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of the alleged immediate jeopardy states as follows: The facility failed to provide effective pain interventions for Resident #195 for 2 days. Action: Upon learning of the deficient practice, the Director of Nursing and Nursing Admin began a review of resident's charts for pain assessment orders, reviewed current PRN pain medication usage for all residents, and reviewed all residents who are flagging for increased pain to assure effective pain management regimens. A total of 12 residents were identified. The 12 identified residents have received an evaluation by the provider (NP or Hospice RN) to evaluate the effectiveness of the current pain regimens. All new orders have been transcribed and confirmed. Monitoring: This will be monitored for completion through the morning clinical meeting process. The DON or designee will oversee this until this is completed. This task has been completed and does not require further oversight due to completion. Responsible: Director of Nursing and Nursing Administration Start Date: 02/11/2025 Completion Date: 02/12/2025 Action: Regional Director of Clinical Services contacted Pharmacy to aid in a MAR to Cart Medication Audit to assure all ordered medications are available. The results from the MAR to Cart Medication Audit are available in a report sent by the consultant pharmacist. Monitoring: DON/Designee to complete MAR to Cart Audit on all narcotic pain medications once monthly for three months to ensure compliance. The Administrator will provide oversight of the monitoring. Responsible: Regional Director of Clinical Services Start Date: 02/11/2025 Completion Date: 02/11/2025 Action: Regional Director of Clinical Services provided in-service education to Director of Nursing and Nursing Administration regarding pain assessments for all resident each shift to include acute pain or significant changes in levels of chronic pain and when to notify the physician regarding pain not being managed by regimen in place, how to conduct a pain assessment properly and proper action when ordered pain medication is not available. ADON and Nursing Administration provided verbal summary of educational material to ensure comprehension. Responsible: Regional Director of Clinical Services Start Date: 02/11/2025 Completion Date: 02/11/2025 Action: DON began in-service education for all nurses currently on shift regarding pain assessments for all resident each shift to include acute pain or significant changes in levels of chronic pain and when to notify the physician regarding pain not being managed by regimen in place, how to conduct a pain assessment properly and proper action when ordered pain medication is not available. Nursing Administration will complete a second pain assessment on 5 residents twice weekly for 3 months to ensure proper assessment of resident pain and level of nurse proficiency. Comprehension was verified through return demonstration and verbal summary. Monitoring: Ongoing education will be provided to all new hires, PRN, leave of absence prior to first shift worked. Responsible: Director of Nursing or Designee Start Date: 02/11/2025 Completion Date: Ongoing Action: Regional Director of Clinical Services initiated and completed an audit of pain evaluation assessments on 100% of residents on 02/11/25. No residents were identified as having a pain rating score of greater than 5. The pain evaluation assessment is available for review in the resident's individual chart. Responsible Party: Regional Director of Clinical Services Start Date: 02/11/2025 Completion Date: 02/11/2025 Action: All CNAs and MAs will be educated on how to enter a pain alert in PCC (the electronic health record) and to verbally notify charge nurse of resident complaints of pain. All CNAs and MAs currently working have been educated on the process. Comprehension was verified through return demonstration and verbal summary. PRN and/or new staff will be educated prior the start of their next shift. Comprehension will be verified through return demonstration and verbal summary. Facility does not currently utilize agency staff. Monitoring: Alerts will be reviewed in morning and afternoon meeting process to ensure they have been addressed. Responsible Party: DON/ADON or Designee Start Date: 02/11/2025 Completion Date: Ongoing Action: All licensed nursing staff will be provided with in-service education regarding pain assessments for all resident each shift to include acute pain or significant changes in levels of chronic pain and when to notify the physician regarding pain not being managed by current regimen and proper action when medication is not available prior to next shift worked, including new hires, PRN, Vacation, and Leave of Absence staff. Validation of triplicate receipt will be completed by the assigned nurse upon admission. If a resident is admitted with a new controlled medication that a triplicate has not been received for, they will immediately contact the primary care physician. Comprehension was verified through return demonstration and verbal summary. Responsible Party: DON/ADON or Designee Start Date: 02/11/2025 Completion Date: Ongoing Action: Confirm that pain assessment order was placed on the resident chart for all new admissions, readmissions during clinical morning meeting process to ensure compliance with plan. Monitoring: The DON/ADON or designee will follow the morning meeting process to ensure compliance. This will be documented on the morning clinical follow-up sheet. During weekend hours, the on-call nurse will verify that a pain assessment order has been entered for all admissions and/or readmissions. Responsible Party: DON/ADON or Designee Start Date: 02/11/2025 Completion Date: Ongoing Action: Confirm Pain medications are available for all new Admissions, Readmissions, or newly received orders for pain medication during clinical morning and afternoon meeting process to ensure pain medication availability. If the medication is unavailable, the medication will be removed from the Med Bank. During weekend hours the on-call nurse system will be utilized if a medication is unavailable. Monitoring: Follow the morning meeting process to ensure compliance Responsible Party: DON/ADON or Designee Start Date: 02/11/2025 Completion Date: Ongoing Action: Review all residents currently identified for increased or change in pain weekly during WE CARE clinical meeting to confirm ongoing interventions and physician notification. Monitoring: Follow WE CARE meeting process to ensure compliance. This will be documented on the We Care form. The Administrator will provide oversight for the ongoing monitoring. Responsible Party: DON/ADON or Designee Start Date: 02/11/2025 Completion Date: Ongoing Action: AD HOC (as needed) QAPI meeting conducted to discuss plan of removal for compliance Monitoring: Review any compliance issues in QAPI meeting for 3 months. Responsible Party: Administrator Start Date: 02/11/2025 Completion Date: 02/11/2025 Action: Medical Director notified of alleged deficient practice. Monitoring: Will update Medical Director of any compliance issues during QAPI meeting for 3 months. Responsible Party: Administrator Start Date: 02/11/2025 Completion Date: 02/11/2025 The Surveyor monitored the POR on 02/13/2025 and 02/14/2025 as followed: During interviews and observations on 02/13/2024 from 11:40 AM - 12:04 PM and 02/14/2025 at 12:31 PM, CNA K, CNA Q, and MA R, from different shifts, stated they were in-serviced on pain management before working their shift. The CNA K and CNA Q stated any time a resident verbalized pain they were to notify the nurse immediately and put an alert in the EHR. CNA K, CNA Q and MA R stated if a resident could not verbalize pain, then they monitored for non-verbal signs of pain including facial grimacing or behaviors out of the ordinary. If they were to notice any of the non-verbal signs of pain, then they were to notify the nurse immediately and put it in the EHR. All staff then demonstrated how to enter the alert in the EHR. During an interview on 02/14/2025 at 10:44 AM with the RDCS, revealed that she did in-service the DON and the ADM regarding pain assessments, acute pain, change in level of pain and who to notify. During interviews on 02/14/2025 from 01:18 PM - 01:41 PM, LVN S, LVN T, and LVN U from different shifts stated they had been in-serviced on pain management before their shifts. All three LVNs verbalized how to assess for pain in residents, which included non-verbal pain indicators. All stated for new residents with orders for pain medication that required a triplicate, they needed to contact the pharmacy and physician to ensure a triplicate was received. All staff stated they would follow up to ensure the triplicate was received by the pharmacy. The nurses stated they would give the pain medication and follow up a short time later to ensure the medication was effective. If the medication was ineffective, then the provider would be contacted for something else. Observation of 4 medication carts 02/13/2025 at 11:23am revealed that pain medications were available for all residents on the list of residents that had orders for pain medication provided by the pharmacy. Record review of Pain Assessments for 16 of 16 residents reviewed revealed they all had a Pain Assessment done on 2/11/2025. Record Review revealed that the RDCS used a Census Sheet to verify all pain assessments were completed on 02/11/2025. She also wrote a statement of completion. Record review of 11 of 11 residents' charts revealed pain level was entered for every shift. Record review revealed the pharmacy conducted a medication/nursing cart audit on 02/11/2025. Record review revealed in-service training with the DON and Nursing Administration was completed on 2/11/2025 related to pain assessments, acute pain, change in level of pain and who to notify. Record Review revealed 37 of 45 nursing staff were in-serviced for pain management from 02/11/2025-02/14/2024. Record review of morning clinical follow-up sheets revealed they were filled out for follow up items on 2/12/2025, 2/13/2025 and 2/14/2025. Record review revealed that the facility had already scheduled a We Care Meeting for 2/17/2025 to 2/20/2025. Record Review of QAPI held on 2/11/2025 over Plan of Removal revealed that all required members attended the meeting and signed off, including the MD. The ADM and DON were notified on 02/14/225 at 03:08 PM that the IJ had been removed. While the IJ was removed on 02/14/2025, the facility remained out of compliance at a scope of isolated and a severity level of 1 because all nursing staff had not been trained on pain assessments and the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The cook was not wearing hair restraints while in the kitchen. The cook did not practice appropriate hand washing prior to preparing and cooking food. The cook did not wash hands or wear gloves when moving from one operation to another. The DA did not wash hands or wear gloves when moving from one operation to another. Non-dietary staff, CNA entered the kitchen without hair restraint. Non-dietary staff did not wash hands. The DM improperly cleaned the thermometer while checking holding temperatures of foods prior to meal service. The DM did not have knowledge of cleaning and sanitization of the thermometer. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Finding included: Observation on 02/11/2025 at 9:29 a.m. revealed the following: The DA in the kitchen was preparing liquids by covering with plastic wrap prior to meal service. The DA was not wearing gloves. At one point the DA left out the back door of the kitchen, returned a few minutes later, she put on gloves without washing her hands and returned to her task. Observation on 02/11/2025 at 11:43 a.m. revealed the DM was monitoring food temperatures with used thermometer sanitizer wipes. When he realized he was cleaning the thermometer with the used wipes he proceeded to dip the thermometer directly into the red sanitation bucket that was in use with murky gray water, sanitizing solution, and cleaning clothes located on shelf below hot food table and stated, I use this when I run out of wipes. He then inserted the thermometer with dripping liquid into the pan with tomato soup to check the temperature. He performed this same step a 2nd time and inserted the thermometer into the soft vegetables pan and checked the temperature. He stated the red sanitation bucket contained water and sanitizing solution for towels used to clean kitchen surfaces. He stated this was the process he used to sanitize and clean the thermometer when he ran out of wipes. Observation on 02/11/2025 at 11:50 a.m. revealed CNA O entered the kitchen to check meal tickets and he did not wash hands or wear hair restraints. Observation on 02/12/2025 at 2:50 p.m. revealed [NAME] rushed into the kitchen from the backdoor. He did not wash his hands; he did not put on a hair net or beard guard; and he did not put on gloves, and he went immediately to the stove and began mixing food that was cooking in a large pot. Observation on 02/12/2025 at 3:04 p.m. revealed [NAME] exited the kitchen to the dining room, handled his personal cell phone, returned a few minutes later and he did not wash his hands; he did not put on a hair net or beard guard; and he did not put on gloves, and returned to the oven and removed a pan of meat. During an interview on 02/12/2025 at 2:25 p.m., the DM stated the Licensed RD visited two times a month. He stated the RD spends one full day, 9 a.m. - 5 p.m. with kitchen staff and one full day for clinicals to go over resident needs and diets. He stated quality assurance of the kitchen is conducted monthly by the RD. When she visits with him, she provides a consult on puree consistency, reviews, and signs off on menu substitute logs, consults on food storage practices, hand hygiene and hygienic practices, emergency food supply, proper storage practices, rotation of produce, preparing regular, mechanical soft, and puree foods, preparing puree foods and maintaining nutritional value, and food holding times. He stated she, provides him with in-service topics monthly, the training materials, sign-in sheets, and training assessments to provide to the dietary staff to confirm their understanding of the different kitchen topics. He stated he will conduct the trainings in English and Spanish for the dietary staff and have them complete the assessment for understanding, which are reviewed by the RD. He also stated his Food Manager Certification program trained him to use the FDA Handbook as a guide. During an interview on 02/12/2025 at 2:56 p.m., the [NAME] stated he has been employed four years with the facility. He spoke primarily Spanish and used his phone to translate a few words. He stated he has received training in infections, wearing hairnets and contamination. He stated you should always wash hands and wear gloves when cooking to avoid contamination. He stated that he understood that he was not wearing a hairnet or beard guard and was not wearing gloves while he was cooking because he was rushing onto shift late and was moving too quickly. He stated he knows this was not an excuse, but it was what happened. During an interview on 02/12/2025 at 03:10 p.m., DA stated she has been employed five months with the facility. She was primarily a Spanish speaker and used her phone to translate using Google. She stated she has received training on preparing food, cleaning the kitchen, washing hands, wearing hair nets to avoid contamination. She stated she received training monthly. She stated it was important to wash hands and put on a hair net every time she leaves the kitchen and returns. She stated staff should not enter the kitchen without their hair net or washing their hands as they could contaminate food or equipment, and this can be harmful to the residents and make them sick. During an interview on 02/12/2025 at 03:21 p.m., the DM stated he had been employed at the facility since 2025. The DM stated the RD provides him and his staff training and monitoring of sanitation buckets cleaning schedule and routine cleaning of equipment, staff washing hands, using hair nets, and wearing gloves when handling food. The DM stated staff not practicing appropriate hand hygiene, glove use during food preparation, not employing hygienic practices, and not wearing hair restraints can lead to foodborne illnesses and cross contamination. He stated he would be conducting in-services with all dietary staff immediately and will get better. During an interview on 02/13/2025 at 01:25 p.m., the ADM stated she has been employed at the facility for about a year. The ADM stated on numerous occasions, I feel your questions are noting specific concerns in the kitchen and perhaps speaking to the RD would be helpful. She also stated, I don't feel comfortable answering your questions without reviewing the facility's policies on dietary expectations as I don't want to be giving the wrong answer. She stated the DM is on site and works closely with the RD that is consulting for the facility. She stated she is the direct report staff for the DM. She stated dietary staff are expected to practice appropriate hand hygiene, glove use when necessary, during food preparation activities, and wearing hair restraints to prevent cross-contamination. She stated all staff entering the kitchen area should be washing their hands with soap and water and using hair restraints to prevent cross contamination. She stated the facility practice for checking food temperatures and cleaning thermometers between checks is expected to happen before serving foods to residents. She stated the consultant RD visit summaries also note the training the dietary staff is receiving on these specific concerns. During an interview on 02/14/2025 at 01:03 p.m., the RD, Account Manager and Clinical Supervisor of Nutrition Lifestyle stated she is stepping in for the RD that consults and oversees the facility. She stated she just concluded an hour in-service with the DM and kitchen staff. She stated the in-service with kitchen staff addressed hand hygiene, hair nets, beard guards, following menus, proper puree, food holding, thermometer, and proper usage for temping foods. She stated several dietary staff were in attendance. She stated several dietary staff members are primary Spanish speakers, but the usual consultant finds ways to provide training that is understood. She stated she was contacted by the ADM to go over any potential concerns in the kitchen. All kitchen staff are expected to follow hand hygiene practices and hand washing, use gloves, and wear hairnets. She stated she was not aware that staff could not use a sanitization bucket with used cleaning towels to clean a thermometer during temperature checks. She stated that when kitchen staff do not follow kitchen practices, they have received training in can cause concerns for patients and cause illnesses that can be severe. Review of facility's document provided titled QA I Monitor Report dated 02/06/2025 reflected: Dietary staff underwent a monitoring and evaluation of kitchen practices conducted by the RD in general sanitation and cleanliness, dishwashing, tableware sanitation and storage, staff sanitation, food storage, meal service observation, and tray cards. Results of the monitoring were reviewed with the ADM, DM, and dietary staff. Dietary staff were redirected during the evaluation to improve quality and safety ensuring facility practices are achieved. Monitoring areas which staff met expectations: practices appropriate hand washing when cooking and serving food; washes hands or changes gloves when moving from one operation to another; Non-dietary staff are prohibited from entering the kitchen; all dietary staff have a current food handler's certificate; cook can demonstrate knowledge of final cooking temperature and use of a thermometer; foods cooked in a manner to conserve nutritive value, flavor, appearance, and texture; consistencies prepared correctly; portion sizes agree with menus; food service started within 30 minutes after food was placed on the steam table; Menu prepared as written; Recipes followed Monitoring areas that staff did not meet facility expectations and RD recommended for further training and follow-up: i. Hair nets and beard guards not in use, which was corrected during the monitoring. Review of facility's document provided titled QA I Monitor Report dated 01/10/2025 reflected: Dietary staff underwent a monitoring and evaluation conducted by the RD which addressed kitchen practices in general sanitation and cleanliness, dishwashing, tableware sanitation and storage, staff sanitation, food storage, meal service observation, and tray cards. Results of the monitoring were reviewed with the ADM, DM, and dietary staff. Dietary staff were redirected during the evaluation to improve quality and safety ensuring facility practices are achieved. Monitoring areas which staff met expectations: staff practices appropriate hand washing when cooking and serving food; staff washes hands or changes gloves when moving from one operation to another; hair nets and beard guards in use; non-dietary staff are prohibited from entering the kitchen; all dietary staff have a current food handler's certificate; cook can demonstrate knowledge of final cooking temperature and use of a thermometer. Monitoring areas that staff did not meet facility expectations and RD recommended for further training and follow-up: i. No sanitation buckets in use. ii. Dietary staff cooking with long acrylic nails - not using gloves when handling food per policy. iii. Recommend current DM educate kitchen staff on taking temperatures on the line (RD demonstrated but language barrier was difficult). Review of facility's document provided titled Quality Assurance Monitor II Tray Line and Test Tray Audit dated 01/10/2025 reflected: Dietary staff underwent an audit conducted by the RD which addressed kitchen practices in meal preparation, tray line preparation, tray line service, meal service, steam table temperatures, and test tray. Audit results were reviewed with the DM and dietary staff and presented to the ADM. Dietary staff were redirected during the audit to improve quality and safety ensuring facility practices are achieved. Audit areas which staff met expectations: thermometer sanitized between each food item: staff utilizes hygienic practices. No bare hand contact with food. Using tongs when needed: Audit areas that staff did not meet facility expectations and RD recommended for further training and follow-up: i. Staff struggled to take temps, RD educated staff on tray line temps and reheating. Review of facility's document provided titled Quality Assurance Monitor I Kitchen/Food Service Observation dated 12/10/2024 reflected: Dietary staff underwent a monitoring and evaluation conducted by the RD which addressed kitchen practices in general sanitation and cleanliness, dishwashing, tableware sanitation and storage, staff sanitation, food storage, meal service observation, and tray cards. Results of the monitoring were reviewed with the DM and dietary staff and presented to the ADM. Dietary staff were redirected during the evaluation to improve quality and safety ensuring facility practices are achieved. Monitoring areas which staff met expectations: staff practices appropriate hand washing when cooking and serving food: staff washes hands or changes gloves when moving from one operation to another: hair nets and beard guards in use: non-dietary staff are prohibited from entering the kitchen: all dietary staff have a current food handler's certificate: cook can demonstrate knowledge of final cooking temperature and use of a thermometer: i. Monitoring areas that staff did not meet facility expectations and RD recommended for further training and follow-up: None noted. Review of facility's document provided titled 2022 Food Code U.S. Food and Drug Administration, undated reflected: Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. Food-contact surfaces and equipment used for time/temperature control for safety foods should be cleaned as needed throughout the day but must be cleaned no less than every 4 hours to prevent the growth of microorganisms on those surfaces. Alcohol swabs or other suitable equipment for sanitizing probe thermometers.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 1 medication storage room and 2 of 3 medication carts. A) The facility failed to ensure expired supplies and medications were removed from the medication storage room. B) The facility failed to ensure expired supplies and medications were removed from the nurses' medication cart for 400 hall. C) The facility failed to ensure that the nurses medication cart for 100 hall was secured by a lock when it was left unattended by LVN A. These failures could place residents at risk of contamination causing illness, decreased effectiveness of medication, and risk of injury to other residents if medication left unsecured were consumed. Findings included: A. During an observation on 02/12/2025 at 02:24 PM of the medication storage room with the ADON revealed one bottle of Senna S that expired 01/2025, 16 alcohol wipes that expired 12/2024, 1 safety blood collection set that expired 11/2017, 57 hypodermic needles that expired 05/30/2023 and 34 blunt fill needles with filter that expired 2/27/2024. B. During an observation on 02/12/2025 at 02:48 PM of the 400 hall nurse's medication cart with LVN B revealed 2-10ml syringes of Ativan-Benadryl-Haldol compound syringes for Resident #36 that expired 02/08/2025, 2-10ml syringes of Ativan-Benadryl-Haldol syringes for Resident #39 that expired 02/08/2025, 1 tube of Dimethacone body shield 5% that expired 04/2023, 1 tube of Skintegrity Eco Hydrogel that expired 09/10/2024, 1 tube of Phytoplex Antifungal Ointment that expired 10/2024, 2 bottles of PVP Povidone Iodine 10% that expired 12/2024, and 1 honey coated absorbent dressing that expired 6/2023. C. During an observation on 02/12/2025 from 04:40 PM- 04:52 PM revealed the 100-hall nurse's medication cart was left unlocked and unattended against the wall near the nurse's station. During the observation the ADON walked past the cart 4 times; the Administrator walked past the cart 3 times; and LVN A walked past the cart 2 times. At 04:52 PM as the DON and ADON approached the nurses' station it was noted the nurses' medication cart was unlocked and the DON secured the cart by locking it. During an interview on 02/12/2025 at 02:33 PM, the ADON stated she checked the medication room on 02/11/2025 for expired medications but didn't know about the supplies in the cabinets. She stated there was not one specific person that was responsible for checking for expirations dates and that it was a group effort between the nurses, and she wasn't sure how often it was done. The ADON stated using the supplies past the expiration dates could lead to contamination or defective supplies. She stated taking the medication past the expirations date could lead to decreased effectiveness or ad verse effects including sickness. During an interview on 02/12/2025 at 02:51 PM, LVN B stated all of the nurses were responsible for checking for expiration dates on the medications and supplies in the medication carts. He stated using the expired medications and supplies could lead to the medications and topical treatments not being as effective. During an interview on 02/13/2025 at 05:00 PM with LVN A revealed he was responsible for the nurse's medication cart that was left unlocked. He stated he was expected to lock the nurse's medication cart when he walked away from it. He stated if it was left unlocked then a resident could open a drawer and take anything that was not for them. He stated he had left the cart unlocked because he was busy with assisting with dinner meal trays. During an interview on 02/14/2025 at 04:18 PM with the DON revealed numerous staff, including her and the ADON, were responsible for ensuring expired medications were pulled from the medication room and carts. She stated the contract pharmacist checked the medication room and carts once a month to ensure all expired and discontinued medications were removed. The DON stated her expectation of staff when they walk away from the medication cart was to lock it. She stated she had provided in-services to the staff, and she visually monitored daily. Record review of undated facility policy Delivery, Receipt and Storage of Medication revealed 6.3 Storage of Medication The facility should ensure that only authorized facility staff should have access to the medications storage areas. Authorized facility staff should include nursing staff and those authorized to administer medications. Scheduled medications should be stored in a separate locked area within the medication carts or medication room. Record review of in-service, dated 10/17/2024, titled Med cart compliance revealed Remove D/C meds, meds from res. who discharged or expired, expired meds timely *Includes ointments, nebs prn meds, narcs . must keep cart locked @ all times if away from cart.

Based on observation, interview, and record review the facility failed to prepare foods by methods that conserve nutritive value, flavor, and appearance in the facility's only kitchen. The DM prepared food 2 1/2 hours prior to meal service. The DM held food in a convection steamer and/or on a hot food table for more than 2 1/2 hours prior to meal service. Food service started 150 minutes after food was placed on the steam table. Food item not being pureed with adequate and appropriate liquids. Pureed foods were prepared with water. Liquids for pureed foods were not measured. Thickener for pureed foods was not measured. Pureed and mechanical soft foods did not follow policy/procedures of determining number of servings needed to determine the portion size method. Condiments and seasonings used on regular textured foods was not used on puree and mechanical soft foods. DM prepared foods without proper equipment: scale, measuring cups, and measuring spoons. Pureed test tray rendered a bland flavor. These failures could compromise and destroy nutritive value of food and prevent residents who ate food from the kitchen at risk of recovery from illness or injury. Finding included: Observation on 02/10/2025 at 09:25 a.m. during the initial brief tour of the kitchen revealed the following: o Mealtime schedule posted in the entrance of the dining room noted lunch is served at 12 p.m. o The pureed diet food and mechanical soft diet food, which included beef steak with mushrooms and onions, buttered cabbage, and blackeye peas was prepared and was being held in the convection steamer until meal service. o The regular diet meal, which included beef steak with mushrooms and onions, buttered cabbage, and blackeye peas was prepared and being held on the hot food table until meal service. o The 5 pureed diets, 10 mechanical soft diets, and 26 regular diets were prepared without measuring tools, without a count or consideration of portion amounts and sizes to align with dietary needs. Observation on 02/11/2025 at 9:29 a.m., revealed the following: o The veggie cream of tomato soup was prepared and sitting on the heating table and then moved to the convection steamer. o Country gravy was prepared and placed in the convection steamer. o Cubed fully cooked chicken breast pieces were removed from the freezer to begin preparing for lunch. o 96 ounces of canned carrots were prepared for the pureed vegetable item. The puree process did not contain thickener measurements and placed on in the convection steamer. o Regular diet instant mashed potatoes were prepared with milk, butter, and seasonings. Puree instant mashed potatoes were prepared with water and butter. Both foods were prepared without measurements and without portion counts and were placed on the hot food table. o Fully cooked breaded chicken patties were placed in the fryer for immediate cooking and transferred to the convection steamer. o Unmeasured amount of cubed fully cooked unseasoned chicken breast pieces was placed in the oven for 10 minutes to heat up to make soft prior to puree process. o Unmeasured amount of cubed fully cooked unseasoned chicken breast pieces for mechanical soft diet was placed in a deep pan and placed in the convection steamer to heat up. o The cubed fully cooked unseasoned chicken breast pieces were placed in the puree machine, with unmeasured hot water, and unmeasured thickener. Once pureed it was placed in the convection steamer. Observation on 02/112025 at 12:33 p.m. of the survey test tray revealed the following: o Puree carrots temperature reading was 149 degrees, was creamy and bland in flavor. o Puree bread temperature reading was 80 degrees and was sweet in flavor. o Puree mashed potatoes with gravy temperature reading was 150 degrees, flavorful, no lumps, no grit, no peels, creamy, and the right consistency. o Puree chicken temperature was 165 degrees, creamy, pureed well, bland flavor, tasted like chicken soup. During an interview on 02/10/2025 at 11:29 a.m., the DM stated he checks the food temperatures 30 minutes before meal service. He stated the pureed consistency is like pancake batter, smooth and for flavor he will add more butter, cream cheese, or sour cream. If the consistency is too thin, he uses Thickener powder and if too thick uses milk or butter to thin. During an interview on 02/11/2025 at 9:29 a.m., the DM stated he cooked the instant mashed potatoes for puree and regular diet differently, to avoid residents choking on seasoning flakes. He stated all puree consistency should be pancake batter like. And when pureeing you can use water, butter, and sour cream, to gain the consistency you need. During an interview on 02/12/2025 at 2:25 p.m., the DM stated the RD visits two times a month. He stated the RD spends one full day, 9 a.m. - 5 p.m. with kitchen staff and one full day for clinicals to go over resident needs and diets. He stated quality assurance of the kitchen was conducted monthly by the RD. When she visits with him, she provides a consult on puree consistency, reviews, and signs off on menu substitute logs, consults on food storage practices, hand hygiene and hygienic practices, emergency food supply, proper storage practices, rotation of produce, preparing regular, mechanical soft, and puree foods, preparing puree foods and maintaining nutritional value, and food holding times. He stated she provided him with in-service topics monthly, the training materials, sign-in sheets, and training assessments to provide to the dietary staff to confirm their understanding of the different kitchen topics. He stated he will conduct the trainings in English and Spanish for the dietary staff and have them complete the assessment for understanding, which are reviewed by the RD. He also stated his Food Manager Certification program trained him to use the FDA Handbook as a guide. During an interview on 02/12/2025 at 03:21 p.m., the DM stated he had been employed at the facility since 2020. He stated he normally begins preparing meals two hours prior to meal service. He stated he places foods in the convection steamer and hot food table when completing food temp checks 10 - 15 minutes prior to meal service. The DM stated the RD provided him and his staff training on pureeing foods while maintaining nutritional value, to use milk, butter, and sour cream when pureeing, to use water for pureeing bread (later made correction), preparing, and cooking foods according to the menu. He stated the menus and guides were located centrally in the kitchen for all staff. He stated if dietary staff do not adhere to portions, measurements, ingredients listed on the recipe, correct liquids for pureeing could result in poor quality and negatively impact the residents in weight loss concerns. He stated the RD stressed the importance of using milk or other approved liquid for pureeing to maintain flavor and nutritional value. He stated despite his training he will use other ingredients at times for flavor and pureeing foods. He stated he trained his cooks to puree foods with milk or juice. He prepared food early and placed in the convection steamer or hot food table to keep on schedule understanding it could result in poor quality. He stated, measuring and portioning foods ensured residents' diet was followed. He stated he would be conducting in-services with all dietary staff immediately and will get better. During an interview on 02/13/2025 at 01:25 p.m., the ADM stated she has been employed at the facility for a year. She stated dietary staff were trained to use and follow measurements, portions, ingredients, recipes, menus approved by the RD, use appropriate liquids for pureeing, to check food temperatures, to place food in the steam table or on the hot food table no more than 30 minutes prior to meal service, and clean equipment according sanitation standards. The ADM stated on numerous occasions, I feel your questions are noting specific concerns in the kitchen and perhaps speaking to the RD would be helpful. She also stated, I don't feel comfortable answering your questions without reviewing the facility's policies on dietary expectations as I don't want to be giving the wrong answer. She stated the current DM worked closely with the RD, he reported directly to her, and they reviewed monitoring reports, audits, and training topics. She stated that when dietary staff do not follow kitchen practices it could cause concerns for the residents. During an interview on 02/14/2025 at 01:03 p.m., the RD P, Account Manager and Clinical Supervisor of Nutrition Lifestyle stated she was stepping in for the RD that consults and monitors the facility. She stated she just concluded an hour in-service with the DM and dietary staff. She stated the in-service addressed hand hygiene, hair nets, beard guards, following menus, proper puree, food holding, thermometer cleaning, and proper usage for temping foods. She stated several staff were primary Spanish speakers, but used Google translate or had DM to help translate so all receive the same information. She stated the ADM asked her to go over any potential concerns in the kitchen. She stated dietary staff have received training and expected to follow the menus, recipes, prepare meals with measurements, and portion practices, use approved liquids for pureeing. She stated all dietary and non-dietary staff are expected to follow hand hygiene practices and hand washing, gloves, and wear hairnets. She stated that when dietary staff do not follow kitchen practices it can cause concerns for residents and cause illnesses that can be severe. Review of facility's document provided titled QA I Monitor Report dated 02/06/2025 reflected: Dietary staff underwent a monitoring and evaluation of kitchen practices conducted by the RD in general sanitation and cleanliness, dishwashing, tableware sanitation and storage, staff sanitation, food storage, meal service observation, and tray cards. Results of the monitoring were reviewed with the ADM, DM, and dietary staff. Dietary staff were redirected during the evaluation to improve quality and safety ensuring facility practices are achieved. Monitoring areas which staff met expectations: practices appropriate hand washing when cooking and serving food; washes hands or changes gloves when moving from one operation to another; Non-dietary staff are prohibited from entering the kitchen; all dietary staff have a current food handler's certificate; cook can demonstrate knowledge of final cooking temperature and use of a thermometer; foods cooked in a manner to conserve nutritive value, flavor, appearance, and texture; consistencies prepared correctly; portion sizes agree with menus; food service started within 30 minutes after food was placed on the steam table; Menu prepared as written; Recipes followed Monitoring areas that staff did not meet facility expectations and RD recommended for further training and follow-up: i. Hair nets and beard guards not in use, which was corrected during the monitoring. Review of facility's document provided titled QA I Monitor Report dated 01/10/2025 reflected: Dietary staff underwent a monitoring and evaluation conducted by the RD which addressed kitchen practices in general sanitation and cleanliness, dishwashing, tableware sanitation and storage, staff sanitation, food storage, meal service observation, and tray cards. Results of the monitoring were reviewed with the ADM, DM, and dietary staff. Dietary staff were redirected during the evaluation to improve quality and safety ensuring facility practices are achieved. Monitoring areas which staff met expectations: staff practices appropriate hand washing when cooking and serving food; staff washes hands or changes gloves when moving from one operation to another; hair nets and beard guards in use; non-dietary staff are prohibited from entering the kitchen; all dietary staff have a current food handler's certificate; cook can demonstrate knowledge of final cooking temperature and use of a thermometer; foods cooked in a manner to conserve nutritive value, flavor, appearance, and texture; consistencies prepared correctly; portion sizes agree with menus; and food service started within 30 minutes after food was placed on the steam table; Monitoring areas that staff did not meet facility expectations and RD recommended for further training and follow-up: ii. Menu not prepared as written and recipes not followed. i. No sanitation buckets in use. ii. Dietary staff cooking with long acrylic nails - not using gloves when handling food per policy. iii. Recommend current DM educate kitchen staff on taking temperatures on the line (RD demonstrated but language barrier was difficult). iv. Reviewing menu extensions with cooks to prepare all necessary items like breads for puree and gravies and sauces for mechanical soft & puree. Review of facility's document provided titled Quality Assurance Monitor II Tray Line and Test Tray Audit dated 01/10/2025 reflected: Dietary staff underwent an audit conducted by the RD which addressed kitchen practices in meal preparation, tray line preparation, tray line service, meal service, steam table temperatures, and test tray. Audit results were reviewed with the DM and dietary staff and presented to the ADM. Dietary staff were redirected during the audit to improve quality and safety ensuring facility practices are achieved. Audit areas which staff met expectations: standardized menus available and used: menus and extensions available and used: consistencies prepared correctly: recipes in use for mechanically altered food items: food prepared in scheduled time frames items batch cooked when appropriate: food placed on steam table no sooner than 30 minutes prior to service: portion sizes agree with menus: test tray was eye appealing, recipe followed, portion size correct, and item served per menu. Audit areas that staff did not meet facility expectations and RD recommended for further training and follow-up: i. Menu not prepared as written. ii. All items on main menu were not available and not on the steam table. iii. Alternative/therapeutic/fortified menu items were not available and not on the steam table. iv. Puree prepared water. v. Test tray point of service temperature not adequate and test tray flavor was unacceptable. vi. Puree was missing hush puppies, alternative not provided for puree for fish allergy, no lemon butter sauce prepared per menu extension. vii. Staff needing further education on puree preparation. viii. Mac n Cheese was without significant flavor. This places older adults at risk for malnutrition r/t lack of palatability. Please ensure cheese is cheesy and add additional herbs and seasonings to food to enhance flavor. Review of facility's document provided titled Quality Assurance Monitor I Kitchen/Food Service Observation dated 12/10/2024 reflected: Dietary staff underwent a monitoring and evaluation conducted by the RD which addressed kitchen practices in general sanitation and cleanliness, dishwashing, tableware sanitation and storage, staff sanitation, food storage, meal service observation, and tray cards. Results of the monitoring were reviewed with the DM and dietary staff and presented to the ADM. Dietary staff were redirected during the evaluation to improve quality and safety ensuring facility practices are achieved. Monitoring areas which staff met expectations: staff practices appropriate hand washing when cooking and serving food: staff washes hands or changes gloves when moving from one operation to another: hair nets and beard guards in use: non-dietary staff are prohibited from entering the kitchen: all dietary staff have a current food handler's certificate: cook can demonstrate knowledge of final cooking temperature and use of a thermometer: foods cooked in a manner to conserve nutritive value, flavor, appearance, and texture: consistencies prepared correctly: portion sizes agree with menu: food service started within 30 minutes after food was placed on the steam table: menu prepared as written: recipes followed. Monitoring areas that staff did not meet facility expectations and RD recommended for further training and follow-up: None. Review of facility's document provided titled Quality Assurance Monitor VI Cost Control Audit dated 12/10/2024 reflected: Dietary staff underwent an audit conducted by the RD which addressed kitchen practices in inventory, purchases, and food preparation, and meal service. Audit results did not note if reviewed by facility staff, no deficiency's noted by the RD. Audit areas which staff met expectations: approved menus followed daily: standardized recipes followed for each meal: staff provided with a count of all therapeutic and mechanically altered diets to use during meal preparation; correct portion sizes served. Review of facility's document provided titled Food and Nutrition Service Fortified Food in-service dated 12/23/2024 reflected: Foods addressing nutrient deficiencies and wound healing. What are fortified foods. When to use fortified foods. Why fortified foods. When considering fortified foods. Review of facility's Policy titled Fall/Winter 2023-24 Dining Service Menu Guide Revised 2020 reflected: The community RD should review and sign the menu and menu components prior to implementation to ensure state regulations as well as community policies and procedures are met. The following guidelines were used to ensure nutritional adequacy when planning menus. Explanation of Diets General Guidelines i. For safety puree with adequate and appropriate liquid. ii. Importance of following the recipe. iii. Use appropriate measuring and weighing equipment when preparing foods. iv. Never use water to puree a food item. v. Weigh foods required for the standardized recipe. vi. Measure when adding commercial thickener as directed in the recipe.

Based on observations, interviews, and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 2 residents (Resident #5) reviewed for privacy. The facility failed to ensure RN G provided and continued to provide privacy during wound care for Resident #5, by ensuring the door and privacy curtain remained closed throughout the procedure. This failure could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and diminished quality of life. The finding included: Record review of Resident #5's admission record, dated 2/14/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Urinary tract infection, cystitis (inflammation of the bladder), pleural effusion (a collection of fluids around the lungs), chronic heart failure (the heart is unable to pump blood to meet the demands of the body), right above the knee amputation, hypertension (high blood pressure), and anxiety disorder. Record review of Resident #5's admission MDS, dated [DATE], revealed a BIMS score of 15, which indication no cognitive impairment. Further review of the MDS revealed Resident #5 had one unhealed pressure ulcer. Record review of Resident #5's care plan, dated 12/13/2024, revealed the resident had an impairment to skin integrity of the left buttock/coccyx (tailbone) area. The relevant intervention was monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, sign and symptoms of infection, maceration (skin breakdown due to moisture at the cellular level) to the MD. During an observation on 02/13/2025 at 02:03 PM revealed RN G provided wound care to Resident #5. During the wound care, RN G left Resident #5 with exposed buttocks toward the door and opened the privacy curtain to retrieve supplies. While the RN was retrieving the supplies another resident (unknown) opened the room door leaving Resident #5 with exposed buttocks to the hallway. RN left the door and privacy curtain open while she finished the remainder of the wound care. If anybody passed by the hallway to Resident #5's rooms, they would see Resident #5 exposed buttocks. During an interview on 02/13/2025 at 03:04 PM Resident #5 stated she didn't notice that the curtain and the door were opened. She stated it could be embarrassing if someone had seen her exposed backside. During an interview on 02/13/2025 at 02:30 PM RN G stated, she had been trained on resident rights. She stated some rights are residents had the right to privacy, right to refuse care, and right to be informed about care. She stated by not closing the door and the curtain when it was opened, the privacy and dignity of Resident #5 were compromised as anyone passing by the room could have seen Resident #5's exposed body. She stated she was nervous and didn't realize at the time. During an interview on 02/14/2025 at 04:18 PM the DON stated that the staff providing wound care were responsible for ensuring the resident's privacy was maintained. She stated not ensuring the resident's privacy could affect the resident emotionally. The DON stated that she and the ADON monitored the staff to ensure they provided privacy for the residents with daily observations. During an interview on 02/14/2025 at 04:40 PM the ADM stated the residents have the right to privacy. She stated she expected staff to close the door and use the privacy curtains when providing care for the residents. She stated if a door and/or privacy curtain were opened during patient care it could make the resident feel exposed. Record review of undated blank Treatment Nurse Competency Check off revealed step #9. Closed door and pulled privacy curtain and step #20 Maintain resident's dignity during treatment. Record review of policy titled Resident Rights, dated 2001 and revised December 2016, revealed: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: t. privacy and confidentiality.

Based on interview and record review, the facility failed to ensure that the residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 4 (Resident #22) reviewed for quality of care. The facility failed to ensure Resident #22 received adequate physical assessment, including vital signs and lung sounds, prior to and after she received medications through a nebulizer and while on antibiotics for an upper respiratory infection. The failure could place resident at an increased risk for an adverse reaction to medication. Findings include: Record review of Resident #22's admission record, dated 2/14/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebrovascular disease (a condition that affect blood flow to the brain), vascular dementia (a condition affecting thought processes caused by impaired blood flow to the brain), muscle weakness, hypertension (high blood pressure), retention of urine (unable to urinate naturally), and hyperlipidemia (high cholesterol). Record review of Resident #22's quarterly MDS, dated [DATE], revealed a BIMS score of 14 which indicated no cognitive impairment. Record review of Resident #22's Medication Administration Record, dated January 2025, revealed Resident #22 received Azithromycin (an antibiotic) on January 10-14, 2025, for infection. Resident #22's Nursing Medication Administration Record revealed Resident #22 received Ipratropium-Albuterol Inhalation Solution on 01/02/2025, 01/10/2025, 01/12/2025, 01/13/2025, 01/14/2025, 01/15/2025, 01/16/2025, and 01/19/2025. Record review of Resident #22's progress note written by NP L, dated 01/10/2025, revealed Patient is seen in her room. She still has a cough, over 1 week in, has been flu negative, no fever but cough is productive, difficult sleeping. Will treat as URI and start x park[sp?] and prednisone. Assessment and plan 1. Cough: for over a week, productive, taking cough medicine, will treat with zpak and short course of Prednisone. Diagnoses Acute upper respiratory infection, unspecified. Record review of Resident #22's care plan on 02/14/2025 revealed no care plan related to respiratory. Record review of Resident #22's vital signs dated 02/14/2025 revealed no heart rate/pulse, oxygen saturation, respiratory rate, and temperature were documented on 01/02/2025, 01/10/2025, 01/12/2025, 01/13/2025, 01/14/2025, 01/15/2025, 01/16/2025, and 01/19/2025. Record review of Resident #22's nursing progress notes revealed no documented vital signs or lung sounds on 01/02/2025, 01/10/2025, 01/12/2025, 01/13/2025, 01/14/2025, 01/15/2025, 01/16/2025, and 01/19/2025. During an interview and record review on 02/13/2025 at 01:11 PM, the DON stated nebulizer treatments did not require documentation of lung sounds, heart rate, oxygen saturation or respiratory rate. She stated after reviewing Resident #22's chart, there were not any vital signs documented on 01/02/2025, 01/10/2025, 01/12/2025, 01/13/2025, 01/14/2025, 01/15/2025, 01/16/2025, and 01/19/2025. The DON stated vital signs should be assessed and documented when residents were taking antibiotics. She didn't have an answer for how it might affect a resident if an assessment is not performed and documented while a resident is on antibiotics. During an interview on 02/14/2025 at 03:24 PM, LVN C stated the policy for assessment prior to administering a nebulizer treatment included assessing pulse, respiratory rate, oxygen saturation and lung sounds. She stated the nurse administering the medication is responsible for performing the assessment and documentation. LVN C stated residents on antibiotics for a respiratory infection should have temperature and oxygen saturations monitored and documented. She stated the nurse responsible for the resident during that shift is responsible for monitoring these vital signs. She stated she wasn't sure who was responsible for monitoring for completion of assessments. During an interview on 02/14/2025 at 3:48 PM, LVN A stated prior to administering nebulizer treatments they are responsible for raising the head of the bed, checking oxygen saturation and heart rate, and documenting it on a pop-up screen. He stated when a resident is taking antibiotics for a respiratory infection, they should be monitored for side effects and the resident's temperature and oxygen saturation. Record review of undated handheld nebulizer competency provided by the facility revealed Step #8 Performs patient assessment (pulse, breath sounds, respiratory rate, pulse ox), Step # 15 Encourage patient to cough and observe sputum characteristics if cough is productive. Assess breath sounds, RR, and HR, and Step #21 Correctly document all appropriate information into patient's medical records. Record review of facility policy titled Charting and Documentation, dated 2001 and revised July 2017, revealed Policy statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 7. Documentation of procedures and treatments will include care-specific details, including a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting.

Based on interview and record review the facility failed to establish an infection prevention and control program (ICPC) that included, at a minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 5 resident (Resident #22) reviewed for antibiotic stewardship program. The facility failed to follow antibiotic stewardship policy for Resident #22 by not ensuring an infection surveillance was performed per facility policy. This deficient practice could place residents at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased multi drug resistant organisms. Findings include: Record review of Resident 22's admission record, dated 2/14/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebrovascular disease (a condition that affect blood flow to the brain), vascular dementia (a condition affecting thought processes caused by impaired blood flow to the brain), muscle weakness, hypertension (high blood pressure), retention of urine (unable to urinate naturally), and hyperlipidemia (high cholesterol). Record review of Resident #22's quarterly MDS, dated [DATE], revealed a BIMS score of 14 which indicated no cognitive impairment. Record review of Resident #22's Medication Administration Record, dated January 2025, revealed Resident #22 received Azithromycin (an antibiotic) on January 10-14, 2025, for infection. Record review of Resident #22's progress note written by NP L, dated 01/10/2025, revealed Patient is seen in her room. She still has a cough, over 1 week in, has been flu negative, no fever but cough is productive, difficult sleeping. Will treat as URI and start x park[sp?] and prednisone. Assessment and plan 1. Cough: for over a week, productive, taking cough medicine, will treat with zpak and short course of Prednisone. Diagnoses Acute upper respiratory infection, unspecified. Record review of Resident #22's care plan on 02/14/2025 revealed no care plan related to upper respiratory infection. Record review of Resident #22's assessments revealed no infection control surveillance form for the month of January 2025. During an interview on 02/13/2025 at 01:11 PM, the DON reviewed Resident #22's chart and stated Resident #22 was started on antibiotics on January 10, 2025, for a presumed URI after NP L assessed her. The DON stated the infection surveillance form was not completed because the infection didn't meet McGeer criteria (a tool designed to support facility healthcare-associated infection surveillance). She stated, she didn't have a true infection, only a presumptive infection. During an interview on 02/14/2025 at 03:24 PM, LVN C stated new orders received for antibiotics needed to have an infection surveillance form completed. She stated the infection surveillance form indicated if the antibiotic was appropriate. She stated if the resident didn't meet the criteria for antibiotics according to the infection surveillance form, then the DON would need to be notified. LVN C stated she didn't know of any instance that completing an infection surveillance form would not be done when starting an antibiotic. She stated the form was completed to prevent giving antibiotic when they are not needed. During an interview on 02/14/2025 at 03:48 PM, LVN A stated the nurse completing the antibiotic order was responsible for the infection surveillance form. LVN A stated the infection surveillance should always be completed and he was not aware of any situation that it wouldn't be completed. He stated he wasn't sure if an infection surveillance form was completed for Resident #22 in January. LVN A stated he wasn't sure of an effect to the resident if the surveillance form was not completed. Record review of the Infection control trending per hallway for January 2025 revealed no infection monitored for Resident #22's room for the month. Record review of Infection Surveillance Monthly Report January 2025, dated 02/10/2025, revealed Resident #22 was not listed under Respiratory Infection Category. Record review of the Infection Prevention and Control Binder revealed ADON as Infection Preventionist Coordinator with the DON and LVN C as alternate infection preventionists. Record review of the facility's policy titled Antibiotic Stewardship Review and Surveillance of Antibiotic Use and Outcomes, dated 2001 and revised December 2016, revealed Policy statement: Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Policy Interpretation and Implementation: 1. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the infection preventionist (IP), or designee. 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics . 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. Based on interview and record review the facility failed to establish an infection prevention and control program (ICPC) that included, at a minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 5 resident (Resident #22) reviewed for antibiotic stewardship program. The facility failed to follow antibiotic stewardship policy for Resident #22 by not ensuring an infection surveillance was performed per facility policy. This deficient practice could place residents at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased multi drug resistant organisms. Findings include: Record review of Resident 22's admission record, dated 2/14/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebrovascular disease (a condition that affect blood flow to the brain), vascular dementia (a condition affecting thought processes caused by impaired blood flow to the brain), muscle weakness, hypertension (high blood pressure), retention of urine (unable to urinate naturally), and hyperlipidemia (high cholesterol). Record review of Resident #22's quarterly MDS, dated [DATE], revealed a BIMS score of 14 which indicated no cognitive impairment. Record review of Resident #22's Medication Administration Record, dated January 2025, revealed Resident #22 received Azithromycin (an antibiotic) on January 10-14, 2025, for infection. Record review of Resident #22's progress note written by NP L, dated 01/10/2025, revealed Patient is seen in her room. She still has a cough, over 1 week in, has been flu negative, no fever but cough is productive, difficult sleeping. Will treat as URI and start x park[sp?] and prednisone. Assessment and plan 1. Cough: for over a week, productive, taking cough medicine, will treat with zpak and short course of Prednisone. Diagnoses Acute upper respiratory infection, unspecified. Record review of Resident #22's care plan on 02/14/2025 revealed no care plan related to upper respiratory infection. Record review of Resident #22's assessments revealed no infection control surveillance form for the month of January 2025. During an interview on 02/13/2025 at 01:11 PM, the DON reviewed Resident #22's chart and stated Resident #22 was started on antibiotics on January 10, 2025, for a presumed URI after NP L assessed her. The DON stated the infection surveillance form was not completed because the infection didn't meet McGeer criteria (a tool designed to support facility healthcare-associated infection surveillance). She stated, she didn't have a true infection, only a presumptive infection. During an interview on 02/14/2025 at 03:24 PM, LVN C stated new orders received for antibiotics needed to have an infection surveillance form completed. She stated the infection surveillance form indicated if the antibiotic was appropriate. She stated if the resident didn't meet the criteria for antibiotics according to the infection surveillance form, then the DON would need to be notified. LVN C stated she didn't know of any instance that completing an infection surveillance form would not be done when starting an antibiotic. She stated the form was completed to prevent giving antibiotic when they are not needed. During an interview on 02/14/2025 at 03:48 PM, LVN A stated the nurse completing the antibiotic order was responsible for the infection surveillance form. LVN A stated the infection surveillance should always be completed and he was not aware of any situation that it wouldn't be completed. He stated he wasn't sure if an infection surveillance form was completed for Resident #22 in January. LVN A stated he wasn't sure of an effect to the resident if the surveillance form was not completed. Record review of the Infection control trending per hallway for January 2025 revealed no infection monitored for Resident #22's room for the month. Record review of Infection Surveillance Monthly Report January 2025, dated 02/10/2025, revealed Resident #22 was not listed under Respiratory Infection Category. Record review of the Infection Prevention and Control Binder revealed ADON as Infection Preventionist Coordinator with the DON and LVN C as alternate infection preventionists. Record review of the facility's policy titled Antibiotic Stewardship Review and Surveillance of Antibiotic Use and Outcomes, dated 2001 and revised December 2016, revealed Policy statement: Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Policy Interpretation and Implementation: 1. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the infection preventionist (IP), or designee. 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics . 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form.

Based on observations, interviews, and record reviews 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 for 1 of 5 residents (Resident #5) reviewed for infection control. 1. The facility failed to ensure RN G and CNA H followed enhanced barrier precautions when they provided wound care for Resident #5 on 02/13/2025. 2. The facility failed to ensure RN G followed infection control precautions when she performed wound care on Resident #5. These failures could place residents at risk for cross contamination and infection. Findings included: Record review of Resident #5's admission record, dated 2/14/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Urinary tract infection, cystitis (inflammation of the bladder), pleural effusion (a collection of fluids around the lungs), chronic heart failure (the heart is unable to pump blood to meet the demands of the body), right above the knee amputation, hypertension (high blood pressure), and anxiety disorder. Record review of Resident #5's admission MDS, dated [DATE], revealed a BIMS score of 15, which indication no cognitive impairment. Further review of the MDS revealed Resident #5 had one unhealed pressure ulcer. Record review of Resident #5's care plan, dated 12/13/2024, revealed the resident had an impairment to skin integrity of the left buttock/coccyx area. The relevant interventions were follow facility protocols for treatment of injury and monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, sign and symptoms of infection, maceration (skin breakdown due to moisture at the cellular level) to the MD. There was no mention of enhanced barrier precautions in the care plan. Record review of Resident #5's physician's orders, dated 02/14/2025, revealed Stage III pressure wound to L buttock: cleanse with NS, pat dry, apply collagen, skin prep peri wound, apply dry dressing T-Th-Sat and prn until resolved and enhanced barrier precautions (gown and glove) for high contact direct care every shift. During an observation on 02/13/2025 at 02:03PM of wound care for Resident #5 revealed CNA H assisted RN G with positioning the resident in bed. CNA H washed hands and applied gloves prior to assisting resident but did not wear a gown. RN G washed hands and put on gown but did not secure it with the waist tie when donning (to apply) it. During wound care RN G cleansed the wound with NS and patted dry with wet gauze then proceeded to place the dirty gauze on clean supplies field next to the clean dressing. She then took off her gloves, sanitized her hands, applied new gloves, picked up the clean dressing and applied it to Resident #5's wound. During an interview on 02/13/2025 at 02:27 PM CNA H stated he had been trained on enhanced barrier precautions and infection control policies. He stated he should have been wearing a gown when providing care to Resident #5, but he forgot to put it on. He stated not wearing a gown for a resident who is on enhanced barrier precautions could cause an infection for the resident. During an interview on 02/13/2025 at 02:30 PM RN G stated she had been trained on enhanced barrier precautions and infection control policies. She stated she didn't tie the gown around the waist because it didn't have a tie around the waist. She stated the gown should have been tied. RN G stated the gauze used to pat dry the wound should have been thrown directly in the trash. She stated the gown is used as a protection for the resident to prevent infection and putting the dirty gauze down on the clean field could contaminate the new dressing. During an interview on 02/14/2025 at 04:18 PM the DON stated she and the ADON were responsible for ensuring staff use enhanced barrier precautions for residents that have wounds. She stated they were constantly performing visual spot checks. She stated that all staff were to wear gown and gloves when providing any care to Resident #5. She stated she spoke with CNA H and he told her he didn't realized he was going to be providing care to the resident when he went in the room and he should have worn a gown. The DON stated she also spoke with RN G and RN G stated she was nervous and made some mistakes due to nerves. She stated RN G should have secured her gown with a tie around the waist prior to providing care to Resident #5. The DON stated enhanced barrier precautions were used to prevent transmission of infection to or from the resident that required it. She stated RN G should have put the gauze in the trash after using it and not next to the clean dressing. She stated by putting the dirty gauze next to the clean dressing it could have contaminated the clean dressing. During an interview on 02/14/2025 at 04:40 PM the ADM stated she had been trained on enhanced barrier precautions last week. She stated staff should use Enhanced Barrier Precautions for any resident that has a wound, ostomy (surgical opening in the abdomen), or dialysis. She stated that anytime staff was to provide care to residents with these conditions it was required to wear a gown and gloves to prevent the spread of infection to the resident. She stated the gown should be secured with a tie at the waist. The ADM stated the DON and ADON were responsible for ensuring nursing staff wear the correct PPE but ultimately it was her responsibility. Record review of undated facility provided document titled Treatment Nurse Competency check off revealed 6. Gathered all needed supplies for treatment, including pieve[sp?] of wax paper / barrier for over bed table, and set up items maintaining clean field. 7. Has plastic bag to dispose of soiled / used supplies appropriately, may tape plastic trash bag to over bed taible[sp?]. Note: a red bag is not necessary for handling soiled dressings at bedside. 18. If any area was contaminated, start over. Record review of undated facility provided document titled Donning and Doffing PPE revealed Donning (to apply) PPE 2. Gown *Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back *Fasten in back of neck and waist. Record review of facility policy titled Enhanced Barrier Precautions in Nursing Homes Algorithm, dated 06/2024, revealed Enhanced barrier precautions implementation In addition to following standard precautions, gown and gloves should be worn during the following high-contact resident care activities: *Dressing *Bathing/Showering *Transferring *Providing Hygiene *Changing linens *Changing briefs or assisting with toileting * Device care or use *Wound care.

Based on observation, interview, and record review, the facility failed to properly store and label biologicals for one (Resident #1) of five residents reviewed for improper medication storage, in that: The facility failed to remove Resident #1's narcotics (Hydrocodone) from the medication cart when it was discontinued July of 2023 which resulted in a medication diversion on 03/09/24. This noncompliance was identified as PNC. The deficient practice began on 03/09/24 and ended on 03/12/24. The facility had corrected the noncompliance before the survey began. This failure could place residents whose narcotics have been discontinued at risk of receiving discharged discontinued medication, medication errors, and drug diversion. 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 unspecified dementia, repeated falls, scoliosis (curvature of the spine or back bone), delusional disorders, and major depressive disorder. Review of Resident #1's quarterly MDS assessment, dated 01/01/24, reflected a BIMS of 9, indicating a moderate cognitive impairment. Section J (Health Conditions) reflected she was not receiving a scheduled pain medication regimen. Review of Resident #1's quarterly care plan, dated 01/01/24, reflected she was at risk for pain related to multiple issues with an intervention of administering pain medications as ordered by the physician. Review of Resident #1's physician order, dated 06/01/23, reflected the following: Hydrocodone-Acetaminophen Oral Tablet 5.325 MG - give 1 tablet by mouth every 6 hours as needed for pain. Review of Resident #1's discontinued orders , on 04/04/24, reflected her order for Hydrocodone was discontinued on 07/05/23. Review of Resident #1's Controlled Substance Administration Record, on 04/04/24, reflected she was administered the discontinued Hydrocodone on 09/27/23 and 11/30/23. Review of the facility's Investigation Summary, dated 03/09/24, reflected the following: Summary: On the morning of 3/9/24 during the narcotic count of the 100 Hall Nurse Cart between the off-going 100 Hall Charge Nurse and on-coming nurse, they observed a blister pack of hydrocodone/APAP TAB 5-325 MG altered. Two of the doses, 27 and 28, appeared to opened at some point with two different medications inserted and then taped closed on the backside of the pack. The medication is a PRN ordered for [Resident #1]. Per the narcotic sheet, the last dose was administered in November 20, 2023. The other remaining medications in the blister pack were secure and untampered. The nurses reported their observance to the DON. [Resident #1] was assessed for pain and none was noted. As it was ordered as needed she did not miss a scheduled dose and the remaining supply was more than sufficient to meet any pain management need. Per review of records and assessment, the resident did not have any unmet pain management needs nor experience a negative impact due to the incident. Facility administration reported the incident to the (police department), [case number] . The responding officer and Administrator verified the two substituted medications were (medications). Facility leadership notified the resident representative, Medical Director, and HHSC via self-report. Facility Administration initiated an investigation by auditing all narcotics against the narcotic sheets for each of the medication carts in use. No other blister packs were altered and all medications were accounted for. Per audit by the DON, Consulting Pharmacist, and Regional Clinical Nurse, it was identified that the order had been discharged in July 2023, however the medication remained on the cart in error. As it was administered after the order had been discharged , it constitutes a med error and has since been addressed accordingly. Facility leadership interviewed all current staff members who had access to the nurses cart. All staff interviewed denied removing the medications nor were aware of when or how the blister pack was manipulated. Nursing staff were in-serviced on medication administration protocol, policy to waste medication if erroneously/accidentally popped from blister pack, and prompt removal of discharged medications from the medication carts. Clinical leadership established a performance improvement plan to monitor for compliance. Immediate response: Assessed resident for pain and/or adverse effects; none noted Secured blister pack Notified Resident Representative Notified Medical Director Notified (police department) Case Notified HHSC via self-report Initiated investigation; No observations of other tampered medication Actions: 3/9/24 - Admin checked narcotics against narc sheets on all carts and verified integrity of packaging. No other issues noted. 3/12/24 - DON, Pharmacy Consultant, Regional Nurse conducted additional audits; Checked active orders against narcotics on carts and against narcotic sheets. Identified [Resident #1]'s hydrocodone was DC'd and med should have been removed from cart. Checked integrity of medication packaging. Observed other taped meds on blister packs and confirmed medication was actual med. Inserviced staff to waste meds instead of attempting to save them and resecure in packaging. Conclusion: Confirmed. The Hydrocodone blister pack was clearly tampered with and other medications were placed in the spaces for the two missing doses. As the order for the medication was discharged and the medication should have been removed, there was no misappropriation of resident property. There is no conclusive evidence to identify a person responsible for tampering with the blister pack. As such, the investigation provided opportunity to review current practices and provide education to nursing staff regarding medication administration protocols and overall medication management policies. Nursing leadership created a PIP to audit and track compliance. Review of the facility's PIP, dated 03/10/24, reflected the following: Observation: A narcotic blister pack was not removed from the medication cart timely after the medication was discharged . Goal/Objective: Timely removal of DC'd narcotics from medication carts Actions: Educate Nurses and CMAs of policy and procedure to remove DC narcotics from cart once DC'd from patient MAR. Responsible Party: DON/ADON Date Completed: 3/11/24 Goal/Objective: Monthly, random audits of active narcotic orders against narcotics on all medication carts. Responsible Party: DON or Designee Date Completed: March, 2024; April 2024; May 2024 Comments: DON/Designee to updated on findings each month and report in QAPI x3 months. Review of the facility's self-report to HHSC, dated 03/10/24, reflected the medication discrepancy was reported in a timely manner. Review of an in-service entitled Narcotics/Count/Discrepancies/Drug Diversion, dated 03/11/24 and conducted by the DON, reflected nurses and medication aides from all shifts were educated on the following: - Ensure you always have a correct count of narcotic before you take keys from ongoing nurse or MA. - Pay attention to the back of each blister card. - If a medication has been discontinued, pull it out of the cart and give to DON (only when you see her in person). - If a resident is not using a PRN or not needing it, notify NP if you can discontinue. - All discontinued orders: you must pull the blister pack and give to DON in person (with a co-signature) Review of an in-service entitled Blister Packs, dated 03/12/24 and conducted by the DON, reflected nurses and medication aides from all shifts were educated on the following: - If a blister pack gets torn or breaks, you must waste the pill inside. - No tape allowed if it is torn, you must waste it always have a witness with you. - You must be looking at (EMR) for your order first. During an observation and interview on 04/04/24 at 11:02 AM revealed the DON chose three random narcotic blister packs from a medication cart for three different residents. The medications were reviewed against the resident's orders and matched accordingly. A count of the blister packs was checked versus the narcotic count sheet. Blister packs were observed to not have any signs of tampering. She stated it was the nurse's responsibly to ensure narcotics were taken off the medication carts if there was an order for discontinuation. During an observation and interview on 04/04/24 at 11:18 AM revealed LVN A choosing three random narcotic blister packs from a medication cart for three different residents from a different medication cart. The medications were reviewed against the resident's orders and matched accordingly. A count of the blister packs was checked versus the narcotic count sheet. Blister packs were observed to not have any signs of tampering. She stated before administering a narcotic the most important thing was to ensure the resident had an order and the dosage matched. She stated when doing a narcotic count at the beginning and end of her shift, she ensured the numbers matched and the blister packs were intact. During an interview on 04/04/24 at 12:26 PM, LVN B stated when he was conducting a narcotic count at the beginning and ending of each shift, he was ensuring the narcotic log matches the blister pack, looking to see if anything looked suspicious, looked at back of the blister pack to ensure it had not been tampered with, and looking to ensure no random pills had popped out in the cart. He stated before administering any medications to a resident, he made sure there was an order for it in the resident's EMR. He stated if a narcotic was to get discontinued by the NP, he would take the blister pack and count sheet from the cart and take them to the DON and they both would do a count a sign off. During an interview on 04/04/24 at 2:10 PM, LVN C stated when she was doing a narcotic count, she was making sure the counts matched, would turn the blister pack around to ensure it had not been tampered with. She stated it if looked off she would notify the DON immediately. She stated before she administered medications, she ensured it matches with the resident's order. She stated if there was not an order in the chart, she would call the doctor. She stated if a narcotic got discontinued, she would pull the medication and the count sheet and take them to the DON to count and sign off. Review of the facility's Controlled Substances Policy, Revised November of 2022, reflected the following: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. . 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d. Destruction, waste and return to pharmacy records.

Based on interview and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 of 1 (Resident #1) residents reviewed for discharge rights. The facility failed to provide their bed hold policy to Resident #1 or her RP, in writing, upon Resident #1's discharge from the facility on 1/03/2024. This failure placed residents at risk of being improperly discharged . Findings included: A record review of Resident #1's face sheet dated 2/06/2024 reflected a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (paralysis of the body), vascular dementia (cognitive decline), epilepsy (seizure disorder), atrial fibrillation (irregular heartbeat), dysphagia (difficulty swallowing), apraxia (neurological motor planning disorder), disorder of brain, hypertension (high blood pressure), type 2 diabetes (uncontrolled blood sugar), and cerebral infarction (stroke). A record review of Resident #1's MDS assessment type titled None of the above dated 1/03/2024 reflected she had severely impaired cognitive skills for daily decision making. A BIMS score, which is used to determine the severity of cognitive loss, was not reflected . Resident #1's MDS assessment reflected she had been discharged to the hospital and her return to the facility was anticipated. Section GG reflected Resident #1 utilized a wheelchair and was dependent on staff for all ADLs. A record review of Resident #1's care plan last revised on 1/08/2024 reflected she had impaired mobility and dementia. Resident #1's discharge goals, discharge preferences and discharge plans were not documented in her care plan. A record review of a written discharge notice addressed to Resident #1's family member dated 12/11/2023 reflected Resident #1 was being discharged from the facility on 1/09/2024 for non-payment and Medicaid ineligibility. The letter reflected, The facility staff will work with you to make preparations needed to ensure a safe and orderly transition and We have provided, and will continue to provide, assistance with placement in another community or at a home, if you so desire. A record review of Resident #1's physician discharge summary dated 1/08/2024 reflected Resident #1 was discharged to the hospital on 1/03/2024 for evaluation and treatment. A record review of Resident #1's progress note dated 12/06/2023 authored by the Administrator reflected she had spoken to Resident #1's family member advising of the anticipated discharge date of [DATE] due to non-payment and failure to qualify for Medicaid. This progress note reflected the following: Educated on date, location, DME to order, and confirmation to refer for home health services. [Resident #1's family member] verbalized understanding and provided updated address for communication and DC location. Understood ability to appeal DC actions or bring account to current to pause DC procedures. A record review of written correspondence from Resident #1's family to an HHSC surveyor dated 2/08/2024 reflected Resident #1 had been discharged from the hospital to a different nursing facility on 1/12/2024. During an interview on 2/05/2024 at 11:22 a.m., Resident #1's family stated Resident #1's Medicaid had been denied for the first time in eight years, the facility was not willing to work with them on payment, and there was no communication. Resident #1's family said Resident #1's Medicaid was pending, and the facility would not allow her to return after her hospitalization due to her Medicaid-pending status. Resident #1's family stated Resident #1 went to a new facility after being discharged from the hospital and that facility had been making attempts to fix Resident #1's issue with Medicaid. During an interview on 2/06/2024 at 12:32 p.m., the BOM stated she had provided several discharge notices to Resident #1's family for non-payment since June of 2023, and the most recent notice was given in December of 2023. The BOM stated Resident #1 was denied Medicaid due to her income being too high, and she would have needed to have a qualified income trust. The BOM stated she had communicated that to Resident #1's RP. The BOM stated Resident #1's RP applied for Medicaid himself, without the facility's help, per his wishes, and that usually the facility preferred to handle the applications to help catch things. During an interview on 2/07/2024 at 1:40 p.m., the Administrator stated she was not sure whether the facility's bed hold policy was communicated to Resident #1 or Resident #1's RP at the time Resident #1 was transferred to the hospital . During an interview on 2/07/2024 at 1:59 p.m., the SW stated the discharge process began the day a resident received a discharge notice. The SW stated she was not aware Resident #1 was given a discharge notice and correct that there was not much she could have done to ensure a safe discharge if she was unaware of the facility-initiated discharge. The SW stated Resident #1 went to the hospital and from there, the hospital handled her discharge. The SW stated she did not know why Resident #1 had not returned to the facility. During an interview on 2/06/2024 at 2:34 p.m., Resident #1's family stated no the facility had not provided a copy of their bed hold policy. During an interview on 2/06/2024 at 2:59 p.m., the DON stated she could not answer as to what the policy was for communication of the facility's bed hold policy to residents and their representatives. The DON stated the Administrator could answer better. The DON stated there was a bed hold for when residents wanted to come back, and it's related a lot to the business office. During an interview on 2/06/2024 at 4:30 p.m., the Administrator stated Resident #1 was not permitted to be readmitted to the facility after being hospitalized due to Resident #1 being given a 30-day discharge notice for non-payment. The Administrator did not clarify whose responsibility it was to issue a copy of the facility's bed hold policy to residents when they were discharged . A record review of the facility's undated document titled Bed Hold Procedure reflected the following: PURPOSE: To inform the resident/responsible party of the facility Bed Hold Policy and to give the resident/responsible party the option to hold the bed for the resident if he/she should have a hospital stay or leave on pass. POLICY: All residents/responsible parties must be informed and given the option to pay for bed hold if the resident should have a hospital stay or leave on pass. Every resident/responsible party must complete the Bed Hold Policy form at the time of admission. The Bed Hold Policy Initiation must be completed each time ethe Bed Hold is initiated. PROCEDURE: 1. Review with the resident/responsible party the Bed Hold Policy. Explain the facility's bed hold charges upon admission. 2. Inform the resident/responsible party that each time the resident is admitted to the hospital or leaves from the facility, they must sign or give verbal approval to a facility representative to either hold or release the bed. 3. If the resident/responsible party chooses to hold the bed, write in the resident's name and the daily amount of the bed hold charge. Have them initial their choice. 4. If the resident/responsible party chooses not to hold the bed, fill in the resident's name and have them initial their choice. 5. Have the resident/responsible party sign and date the Bed Hold Policy form.

Based on interview and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 of 1 (Resident #1) residents reviewed for discharge rights. The facility failed to document in Resident #1's chart actions made to ensure a safe and orderly discharge, and to find alternate placement for Resident #1. This failure placed residents at risk of being improperly discharged . Findings included: A record review of Resident #1's face sheet dated 2/06/2024 reflected a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (paralysis of the body), vascular dementia (cognitive decline), epilepsy (seizure disorder), atrial fibrillation (irregular heartbeat), dysphagia (difficulty swallowing), apraxia (neurological motor planning disorder), disorder of brain, hypertension (high blood pressure), type 2 diabetes (uncontrolled blood sugar), and cerebral infarction (stroke). A record review of Resident #1's MDS assessment type titled None of the above dated 1/03/2024 reflected she had severely impaired cognitive skills for daily decision making. A BIMS score, which is used to determine the severity of cognitive loss, was not reflected . Resident #1's MDS assessment reflected she had been discharged to the hospital and her return to the facility was anticipated. Section GG reflected Resident #1 utilized a wheelchair and was dependent on staff for all ADLs. A record review of Resident #1's care plan last revised on 1/08/2024 reflected she had impaired mobility and dementia. Resident #1's discharge goals, discharge preferences and discharge plans were not documented in her care plan. A record review of a written discharge notice addressed to Resident #1's family member dated 12/11/2023 reflected Resident #1 was being discharged from the facility on 1/09/2024 for non-payment and Medicaid ineligibility. The letter reflected, The facility staff will work with you to make preparations needed to ensure a safe and orderly transition and We have provided, and will continue to provide, assistance with placement in another community or at a home, if you so desire. A record review of Resident #1's progress notes dated 12/06/2023-1/03/2024 reflected no documentation of home health referrals, durable medical equipment requested or ordered, attempts to find alternate placement, or communications with the hospital in which Resident #1 was transferred to. There were no social services notes documented in Resident #1's progress notes from 12/06/2023-1/03/2024. A record review of Resident #1's physician discharge summary dated 1/08/2024 reflected Resident #1 was discharged to the hospital on 1/03/2024 for evaluation and treatment. The social service discharge summary signed by the SW on 1/08/2024 reflected no referrals were made to home health agencies, meals-on-wheels, or senior citizen agencies. The nursing discharge summary signed by the ADON on 1/08/2024 reflected Resident #1's reason for discharge was hospitalization -financial reasons were not indicated as the reason for discharge. A record review of Resident #1's progress note dated 12/06/2023 authored by the Administrator reflected she had spoken to Resident #1's family member advising of the anticipated discharge date of [DATE] due to non-payment and failure to qualify for Medicaid. This progress note reflected the following: Educated on date, location, DME to order, and confirmation to refer for home health services. [Resident #1's family member] verbalized understanding and provided updated address for communication and DC location. Understood ability to appeal DC actions or bring account to current to pause DC procedures. A record review of written correspondence from Resident #1's family to an HHSC surveyor dated 2/08/2024 reflected Resident #1 had been discharged from the hospital to a different nursing facility on 1/12/2024. During an interview on 2/05/2024 at 11:22 a.m., Resident #1's family stated Resident #1's Medicaid had been denied for the first time in eight years, the facility was not willing to work with them on payment, and there was no communication. Resident #1's family stated Resident #1 was a quadriplegic, had dementia and was non-verbal. Resident #1's family stated had Resident #1 not gone to the hospital unexpectedly to get a feeding tube, the facility would have dropped Resident #1 off at their home where they would have needed to refuse her due to not being able to take care of her. Resident #1's family said Resident #1's Medicaid was pending, and the facility would not allow her to return after her hospitalization due to her Medicaid-pending status. Resident #1's family stated Resident #1 went to a new facility after being discharged from the hospital and that facility had been making attempts to fix Resident #1's issue with Medicaid. During an interview on 2/06/2024 at 12:32 p.m., the BOM stated she had provided several discharge notices to Resident #1's family for non-payment, and the most recent notice was given in December of 2023. The BOM stated Resident #1 was denied Medicaid due to her income being too high, and she would have needed to have a qualified income trust. The BOM stated she had communicated that to Resident #1's RP. The BOM stated Resident #1's RP applied for Medicaid himself per his wishes, and that usually the facility preferred to handle the applications to help catch things. During an interview on 2/07/2024 at 1:59 p.m., the SW stated the discharge process began the day a resident received a discharge notice. The SW stated the discharge process was an effort involving therapy, social services, and nursing. The SW stated the process was documented in the physician's discharge note and the discharge summary. The SW stated she started the discharge summary then Medical Records started the physician discharge note. The SW stated she was not aware Resident #1 was given a discharge notice and correct that there was not much she could have done to ensure a safe discharge if she was unaware of the facility-initiated discharge. The SW stated Resident #1 went to the hospital and from there, the hospital handled her discharge. The SW stated she did not know why Resident #1 had not returned to the facility. The SW stated she had not made any attempt to find alternate placement for Resident #1 because Resident #1 had gone to the hospital. The SW stated if residents were not given alternate placement or if they were not safe to be at home, her assumption was that without having the proper care, they would return to the hospital. The SW stated she did not know why she was not made aware of Resident #1's facility-initiated discharge and said yes she would expect that information to have been communicated to her. During an interview on 2/06/2024 at 2:34 p.m., Resident #1's family stated after Resident #1 went to the hospital on 1/03/2024. Resident #1's famly stated a case worker from the hospital called him and told him that Resident #1 was no longer allowed at the facility, but did not say why. Resident #1's family stated the Administrator had told him Resident #1 was not allowed back to the facility due to non-payment. Resident #1's family stated that at that time, Resident #1's Medicaid application was pending. Resident #1's family stated the facility did not try to ensure a safe discharge or locate alternate placement, and they made the hospital do it. Resident #1 stated he would expect the discharge planning to occur a few weeks prior to the schedule discharge date . During an interview on 2/06/2024 at 2:59 p.m., the DON stated We usually make sure they have home health, equipment, and communicate with the family. The DON stated We talk to the family and the family chooses what they want as far as alternate placement. The DON stated they would consult with the MPOA to find alternate placement. The DON stated no Resident #1 was not able to care for herself. The DON stated in order to obtain the correction information as to why Resident #1 did not return to the facility after being hospitalized , the HHSC surveyor would need to speak with the Administrator. The DON stated she thought in the morning meeting that the Administrator and SW mentioned they would set up home health for Resident #1. When asked what could happen if a resident was discharged unsafely or without attempts to find alternate placement, the DON stated she could not answer that because usually they tried to ensure discharges were safe. During an interview on 2/06/2024 at 4:30 p.m., the Administrator stated Resident #1 was not permitted to be readmitted to the facility after being hospitalized due to Resident #1 being given a 30-day discharge notice for non-payment. The Administrator stated Resident #1 was discharged acutely due to a UTI. The Administrator stated communications for Resident #1's discharge planning were verbal between herself and Resident #1's family. The Administrator stated she thought Resident #1's family was going to come by the facility and pay the balance prior to the execution of the 30-day notice, and so Resident #1's discharge was not anticipated . A record review of the facility's policy titled Transfer or Discharge, Facility-Initiated dated October 2022 reflected the following: Policy Statement Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Policy Interpretation and Implementation I. Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: e. the resident has failed, after reasonable and appropriate notice, to pay for ( or to have paid under Medicare or Medicaid) a stay at this facility. (1) Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. 2. Transfer and discharge includes movement of a resident from a certified bed in the facility to a noncertified bed in another part of the facility, or to a non-certified bed outside the facility. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. Specifically: a. transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility; and b. discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. Facility-Initiated Transfer or Discharge I. Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. Non-Payment as a Basis for Discharge 1. Non-payment for a stay in the facility occurs when the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility and also may apply: a. when the resident has not submitted the necessary paperwork for third party (including Medicare/Medicaid) payment; or b. after the third party payer (including Medicare or Medicaid) denied the claim and the resident refused to pay for his/her stay. 2. The facility will notify the resident of their change in payment status, and ensure the resident has the necessary assistance to submit any third party paperwork. 3. In situations where a resident representative has failed to pay, the facility may discharge the resident for nonpayment; however, if there is evidence of exploitation or misappropriation of the resident's funds by the representative, the facility will take steps to notify the appropriate authorities on the resident's behalf, before discharging the resident. Notice of Transfer or Discharge (Planned) I. Except as specified below, the resident and his or her representative are given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility. 2. The resident and representative are notified in writing of the following information: e. The Notice of Facility Bed-Hold and policies; 5. For significant changes, such as a change in the transfer or discharge destination, a new notice will be given that clearly describes the change(s) and resets the transfer or discharge date in order to provide 30-day advance notification and permit adequate time for discharge planning. Notice of Transfer or Discharge (Emergent or Therapeutic Leave) I. When residents who are sent emergent [NAME] to an acute care setting, these scenarios are considered facility initiated transfers, NOT discharges, because the resident's return is generally expected. 2. Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility. Residents who are sent to the acute care setting for routine treatment/planned procedures are also allowed to return to the facility. 5. Notice of Facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer. 7. Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. Notice of Discharge after Transfer I . If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility (not at the time the resident was transferred to acute care). 2. If the facility does not permit a resident's return to the facility ( i.e., initiates a discharge) based on inability to meet the resident's needs, the facility will notify the res ident, and/or his or her representative in writing of the discharge, including notification of appeal rights. Orientation for Transfer or Discharge (Planned) I. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. 2. A member of the interdisciplinary team will review the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. 3. Sufficient preparation and orientation for the resident prior to an immediate facility-oriented transfer or discharge includes explaining to the resident where he/she is going and why, and taking steps to minimize his/her anxiety or depression (e.g., working with the resident, representative, or family to ensure that the resident's be longings will be taken care of and transferred to the new location as needed/requested. And ensuring that staff recognize characteristic resident reactions identified during assessment and care planning). 5. Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. Documentation of Facility- Initiated Transfer or Discharge 4. If the facility determines that the resident cannot return to the facility, the medical record will indicate that the facility made efforts to: a. determine if the resident still requires the services of the facility and is eligible for Medicare skilled nursing facility or Medicaid nursing facility services; b. ascertain an accurate status of the resident's condition, which can be accomplished via communication between hospital and facility staff and/or through visits by facility staff to the hospital; c. find out from the hospital the treatments, medications, and services the facility would need to provide to meet the resident's needs upon returning to the facility. If the facility is unable to provide the treatments, medications, and services needed, the facility may not be able to meet the resident's needs: and d. work with the hospital to ensure the resident's condition and needs are within the facility's scope of care, based on its facility assessment, prior to hospital discharge.

Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 3 (100, 300, and 400 hallway medication cart) of 5 medication carts reviewed for medication storage. LVN E failed to ensure that the Medication Cart for the 100 Hallway was not left unattended and unlocked. RN A failed to ensure that the Medication Cart for the secured 300 Hallway was not left unattended and unlocked. MA F failed to ensure that the Medication Cart for the 400 Hallway was not left unattended and unlocked. These failures could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed and over-the-counter medications. Findings included: Observation on 12/19/2023 at 10:16 AM revealed that the 100 Hallway Medication Cart (a large rolling cart with an outer lock which was used to store medications and supplies for medication administration for multiple residents; it also contained an inner locked compartment which stored controlled substances) was unsecured and unattended in the hallway outside a resident's room, which had a closed door. At 10:17 AM, LVN E exited the resident's room and secured the cart before turning it away from the door. Interview on 12/19/2023 at 10:18 AM, LVN E stated that she thought she secured the 100 Hallway Medication Cart before entering the resident's room. LVN E stated the cart may not have locked because of a drawer that sticks at times preventing it from locking. LVN E stated that the medication cart was to be always secured when not in direct view. LVN E stated that failure to secure the cart could allow a resident access to medications within the cart resulting in allergic reactions and drug interactions. Observation on 12/19/2023 at 2:28 PM, revealed that the 300 Hallway Medication Cart was unsecured and unattended in the 300 hallway just off the large gathering area for residents within the facility's secure unit. RN A was observed in the gathering area providing residents with drinks and snacks. While the medication cart was unsecured and unattended, four residents passed within arm's reach of the unsecured medication cart. At 2:41 PM, RN A opened the bottom left drawer of the medication cart and retrieved a straw for a resident. RN A pushed the drawer closed and pushed the cart lock to secure it, but it did not lock. RN A pushed the drawer in again and was then able to secure the cart. The 300 Medication Cart contained prescription and over-the-counter medications. Interview on 12/19/2023 at 2:45 PM, RN A stated that she retrieved a pair of gloves from the cart prior to the state surveyor entry into the secure unit and failed to secure the medication cart. RN A stated that the medication cart was to be always locked when not in direct view. RN A stated that failure to secure the medication cart could result in a resident gaining access to medications within the cart leading to allergic reactions, drug interactions, overdose, and / or resident illness. Observation on 12/20/2023 at 8:18 AM, MA F left the 400 Hallway Medication Cart unsecured and unattended in the 400 hallway as she provided care for a resident. MA F returned to the 400 Hallway Medication Cart at approximately 8:22 AM and locked the medication cart after obtaining medications for another resident. Interview on 12/21/2023 at 8:27 AM, RN C stated that medication carts were to be kept locked when not in use. RN C stated that a resident could access medications in the unlocked cart resulting in possible allergic reaction. RN C stated that some residents have dementia and may not have awareness that what they were doing could hurt them. Interview on 12/21/2023 at 12:20 PM, MA F stated that she was trained to keep her medication cart locked when she is away from it, even if only for a short time. MA F stated that the medication cart should be locked when they are in the hallways, if it was not being used. MA F stated that a resident could get into the medication cart and take medications out that could be harmful to them. Interview on 12/21/2023 at 2:40 PM, the DON stated that the medication carts were to be always locked. The DON stated that RN A notified her of the failure on 12/19/2023 to secure the 300 Hallway Medication Cart, which she stated cannot occur. The DON stated that failure to secure medication carts could result in a resident gaining access to medications which could be ingested or applied resulting in possible allergic / drug reactions. The DON stated that failure to secure the medication carts also posed a risk of drug diversion. The DON was unable to recall the last in-service that was provided to staff for medication storage. Interview on 12/21/2023 at 3:41 PM, the ADMINISTRATOR stated that medication carts in the facility were to be always locked to prevent residents from gaining access. The ADMINSTRATOR was advised of observations and stated that an immediate in-service needed to be completed for medication storage due to risk of drug diversion. Review of facility in-service for Narcotics on 4/14/2023, all shifts and new hires, which was conducted by the DON revealed, Objectives of the Inservice: *Narcotics will stay in lock box at all times. The signature sheet indicated that both RN A and LVN F were in attendance. Review of the facility's Identifying Exploitation, Theft, and Misappropriation of Resident Property Policy, dated April 2021 revealed, 5. Examples of misappropriation of resident property include: f. drug diversion (taking the resident's medication). Review of facility's undated Delivery, Receipt, and Storage of Medication Policy revealed, 6.3 Storage of Medication, The facility should ensure that only authorized facility staff should have access to the medication storage areas. Authorized facility staff should include nursing staff and those authorized to administer medications. Scheduled medications should be stored in a separate locked area within the medication carts or medication room. The facility should ensure the medications requiring refrigeration are stored appropriately, and the food is not stored with refrigerated medications. Topical medications should be stored separately from oral medications.

Based on observation, interview, and record review the facility failed to ensure all residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 5 of 8 (Resident #35, Resident #55, Resident #52, Resident #27 and Resident #108) residents reviewed for activities of daily living. 1. The facility failed to ensure Resident #35 received regular showers or baths. 2. The facility failed to ensure Resident #55 and Resident #52 received nail care. 3. The facility failed to ensure Resident #27 and Resident #108 received a shave. These failures placed residents at risk of not receiving help with activities of daily living. Findings included: 1. A record review of Resident #35's face sheet dated 12/21/2023 reflected an [AGE] year-old male admitted on [DATE] with diagnoses of heart failure, gastro-esophageal reflux disease (acid reflux), peripheral vascular disease (circulation disorder), Alzheimer's disease (type of dementia), and atrial fibrillation (irregular heartbeat). A record review of Resident #35's MDS assessment dated [DATE] reflected a BIMS score of 13, which indicated cognition was intact. Section G reflected Resident #55 had total dependence and required two+ persons physical assist with toilet use and transfers. ADL assistance for bathing was not reflected in Resident #35's MDS assessment. A record review of Resident #35's care plan last revised on 12/11/2023 reflected he required extensive assistance by 1-2 staff with bathing. A record review of Resident #35's physician order dated 11/07/2023 reflected he was discharged from hospice services. A record review of Resident #35's bathing record titled ADL - Bathing dated 11/22/2023-12/20/2023 reflected he had received a shower or bath on 11/29/2023 and on 12/11/2023. There were three documented refusals on 11/27/2023, 12/01/2023, and 12/04/2023. A record review of Resident #35's progress notes dated 10/29/2023-12/202/23 reflected no documents showers, baths, or refusals of baths. A record review of Resident #35's progress note dated 12/09/2023 reflected he had tested positive for COVID-19. During an observation and interview on 12/19/2023 at 11:10 a.m., Resident #35 was observed sitting in his wheelchair in his room. Resident #35 stated hospice gave him his last bath, then the day after that the facility gave him another bath, but he had not received a shower or bath since then. Resident #35 could not recall the timeframe for when he had last been bathed. Resident #35 stated hospice had not been by to see him in a while. During an interview on 12/19/2023 at 11:14 a.m., RN C stated Resident #35 was admitted to the facility on hospice but due to his improvement in health, he had been discharged from hospice. RN C stated Resident #35 was discharged from hospice about three weeks prior. During an interview on 12/20/2023 at 8:50 a.m., RN C stated she was familiar with Resident #35, he [NAME] never refused anything from me ever and he lets me do everything. RN C stated the CNAs documented baths/showers and they had their own tab on the electronic records system. RN C stated the facility did not do shower sheets and yes the documentation for baths and showers were all electronic. RN C stated when Resident #35 was on hospice, he had the same hospice aide come in to provide showers for him. RN C stated, he could have missed some during Covid and that's the only reason I can see as to why Resident #35 would have missed showers/baths. RN C stated she thought staff knew Resident #35 was off hospice and she was pretty sure staff knew Resident #35 had not been receiving showers from hospice. RN C stated maybe staff were worried about Resident #35 being on droplet isolation. RN C stated she had never known him to refuse a shower except for one time a few weeks prior. RN C stated when residents refused showers, they were supposed to tell a charge nurse, and the CNAs needed to mark refusals in their electronic records system. RN C stated Resident #35 received showers on the afternoon shift, she was not familiar with the aides, and did not know why they would not have documented on the 2:00-10:00 p.m. shift because she left work at 2:00 p.m. An observation on 12/21/2023 at 8:42 a.m. revealed the shower schedule for the 100-hall was posted on the inside door of the shower room. The shower schedule reflected Resident #35 was to receive showers on Mondays, Wednesdays, and Fridays on the 2:00 p.m.-10:00 p.m. shift. A note by Resident #35's name reflected no longer hospice, we have to shower him. 2. A record review of Resident #55's face sheet dated 12/21/2023 reflected a [AGE] year-old female admitted on [DATE] with unspecified dementia, dehydration, COVID-19, subsequent encounter for closed fracture with routine healing, and thrombocytosis (elevated blood platelets). A record review of Resident #55's MDS assessment dated [DATE] reflected a BIMS score of 13, which indicated cognition was intact. Section G reflected Resident #55 required extensive assistance and a two+ persons physical assist with bed mobility, transfer, and toilet use. ADL assistance required for personal hygiene was not reflected. A record review of Resident #55's care plan last revised on 12/05/2023 reflected she had an ADL self-care performance deficit related to immobility. Interventions included that staff were to check nail length and trim and clean on bath day and as necessary. A record review of Resident #55's progress notes dated 11/21/2023-12/21/2023 reflected no documented attempts or refusals to perform nail care. A record review of Resident #52's face sheet dated 12/21/2023 reflected an [AGE] year-old male admitted on [DATE] with diagnoses of Alzheimer's disease (type of dementia), unspecified glaucoma (damaged optic nerve), unspecified severe protein-calorie malnutrition, and hypertension (high blood pressure). A record review of Resident #52's MDS assessment dated [DATE] reflected a BIMS score of 8, which indicated moderately impaired cognition. Section G reflected Resident #52 required supervision and a one-person physical assist with bed mobility. ADL assistance required for personal hygiene was not reflected. A record review of Resident #52's care plan last revised on 10/09/2023 reflected he had ADL self-care performance deficit related to advanced dementia and mobility issues. Interventions reflected Resident #52 required substantial assistance by one staff with bathing. A record review of Resident #52's progress notes dated 11/23/2023-12/18/2023 reflected no documented attempts or refusals for nail care. During an observation and interview on 12/20/2023 at 8:23 a.m., Resident #52 was observed lying in bed. Resident #52's nails were long and with dirt underneath. Resident #52 was non-interviewable and said, I don't care where they're at anymore. During an observation and interview on 12/20/2023 at 8:26 a.m., Resident #55 was observed lying in bed with a family member present. Resident #55 stated the care was okay and then closed her eyes. Resident #55's family member stated she had been in the facility since October of 2023 after having a fall and was there for rehabilitation. Observed Resident #55's fingernails to be very long and Resident #55's family member stated we haven't gotten around to asking about that-whether they could be trimmed. Resident #55's family member stated he thought Resident #55's fingernails looked long and that Resident #55 did not like to keep them that long when she took care of them herself. Resident #55's family member stated Resident #55 had planned to go to the nail salon to get her fingernails done before she fell in October of 2023. Resident #55's family member stated Resident #55's nails had not been trimmed since September of 2023. During an observation and interview on 12/21/2023 at 3:36 p.m., Resident #55's fingernails were observed to still be long. Resident #55's family member stated he had seen someone who looked like a nail person, he was going to ask about getting Resident #55's nails done, but he forgot to mention it. During an interview on 12/21/2023 at 8:28 a.m., CNA G stated nail care was supposed to be done by the CNAs during showers because nails got wet and were easier to clip. CNA G stated for the residents with diabetes, nurses clipped their nails, but Resident #55 and Resident #52 were not diabetic. CNA G stated he did not know when Resident #55's or Resident #52's nails were last trimmed because they were scheduled for showers in the afternoon, and he worked mornings. During an observation and interview on 12/21/2023 at 8:31 a.m., CNA G was observed entering Resident #52's room. CNA G observed Resident #52's fingernails and stated, there's some dirt there and they need to be trimmed. During an observation and interview on 12/21/2023 at 8:34 a.m., CNA G was observed entering Resident #55's room. CNA G observed Resident #55's fingernails and said, they look like press on nails, this one is really big, it needs to be clipped, and she shouldn't have press on or long nails because she could scratch herself. CNA G stated, they should be clipped. An observation on 12/21/2023 at 8:42 a.m. revealed the shower schedule for the 100-hall was posted on the inside door of the shower room. The schedule reflected Resident #52 and Resident #55 were to receive showers on Mondays, Wednesdays, and Fridays on the 2:00-10:00 p.m. shift. 3. A record review of Resident #27's face sheet dated 12/21/2023 reflected a [AGE] year-old female admitted [DATE] with diagnoses of unspecified dementia, chronic atrial fibrillation (irregular heartbeat), major depressive disorder (depression), anxiety disorder, hypertension (high blood pressure), hypothyroidism (disorder of thyroid gland), sick sinus syndrome (abnormal heart rhythm), and malignant neoplasm of unspecified part of unspecified bronchus or lung (abnormal lung growth). A record review of Resident #27's MDS assessment dated [DATE] reflected a BIMS score of 13, which indicated cognition was intact. Section G reflected Resident #27 required extensive assistance and a two+ persons physical assist with personal hygiene including shaving. A record review of Resident #27's care plan last revised on 12/05/2023 reflected she had an ADL self-care performance deficit related to generalized debility and dementia. Interventions reflected Resident #27 required extensive assistance by one staff with personal hygiene. A record review of Resident #108's face sheet dated 12/21/2023 reflected an [AGE] year old female admitted on [DATE] with diagnoses of malignant neoplasm of bladder (bladder cancer), secondary malignant neoplasm of bone (bone cancer), hypertension (high blood pressure), and muscle weakness. A record review of Resident #108's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 9, which indicated moderately impaired cognition. Section GG reflected Resident #108 required moderate assistance with personal hygiene including shaving. A record review of Resident #108's care plan last revised on 12/15/2032 reflected she had an ADL self-care performance deficit related to assessment. Interventions reflected Resident #108 required extensive assistance of one staff for personal hygiene. During an observation and interview on 12/19/2023 at 9:52 a.m., Resident #108 was observed lying in bed. Resident #108 stated staff were rushed, haphazard, and did not have time. Resident #108 was observed to have chin hair and stated staff had not offered her a shave since she came to the facility. Resident #108 stated a friend of hers trimmed her facial hair for her. Resident #108 stated if staff offered her a shave, absolutely she would accept it. An observation on 12/19/2023 at 1:00 p.m. revealed Resident #27 was sitting in the dining room. Resident #27 was observed to have facial hair on her chin. During an interview on 12/19/2023 at 3:12 p.m., Resident #27 stated of course she would like to have her facial hair trimmed if staff offered. Resident #27 stated she had been at the facility for three years and staff had never offered to trim her. Resident #27 stated yes she used to trim her facial hair herself when she lived at home. Resident #27 stated she had never asked staff for a trim, but she would say yes if they had. Resident #27 stated she had more liberty with her hands in the past, and she could no longer move her hands around. An observation on 12/20/2023 at 3:24 p.m. revealed Resident #27 still had hair on her chin. During an interview on 12/21/2023 at 8:37 a.m., CNA G stated the CNAs took care of facial hair on women during showers. CNA G stated [Resident #27] is a morning shower. During an observation and interview on 12/21/2023 at 8:39 a.m., CNA G was observed entering Resident #27's room. CNA G stated, to be honest, she has a little chin hair. CNA G stated he did not know when the last time was that Resident #27 received a shave. CNA G stated Resident #27 had COVID-19 and during that time she received bed baths. CNA G stated some CNAS don't like to do their jobs and said some staff did not want to go into the rooms of residents with COVID-19. CNA G stated yes it could have been missed between Resident #27 having COVID-19 and receiving bed baths. During an interview on 12/21/2023 at 8:41 a.m., CNA G stated Resident #108 received showers on the 2:00-10:00 p.m. shift. He did not know when the last time her shower was but, I know she requested one this morning. During an observation and interview on 12/21/2023 at 8:43 a.m., CNA G was observed entering Resident #108's room and he said, you can see that she still has whiskers. An observation on 12/21/2023 at 8:42 a.m. revealed the shower schedule for the 100-hall was posted on the inside door of the shower room. The schedule reflected Resident #55 was to receive showers on Mondays, Wednesdays, and Fridays between 6:00 a.m.-1:00 p.m. and Resident #108 was to receive showers on Tuesdays, Thursdays, and Saturdays on the 2:00-10:00 p.m. shift. During an interview on 12/21/2023 at 2:41 p.m., the DON stated showers should be done on time. The CNAs did nail care on Sundays, and for women with facial hair, she asked families for permission to shave. The DON stated showers, nail care, and shaving was done by the CNAs, except for diabetic residents. She stated nurses checked diabetic residents nails. The DON stated women were shaved on shower days as needed only if families requested staff to shave the resident. The DON stated showers were three days a week and nail care was done anytime it was needed. The DON stated Resident #108 was new with us and she had not yet requested permission from the family to shave her facial hair. The DON stated family had not notified the facility that Resident #108 had a special area that needed to be shaved. The DON stated Resident #27 was alert and orientated so she would tell us if she wanted to be shaved. The DON stated the CNAs were monitored to ensure they provide care via the ADL report. The DON stated, we all do monitor the CNAs, including the MDS Coordinator, and management. When asked how staff were trained on providing showers, nail care, and shaves for women, the DON stated, there is not a specific day because shower days are shower days. The DON stated yes she meant that those areas should be monitored during shower days. The DON stated if the residents did not receive showers, it could affect their well-being, health, and it could be an infection control issue as well as a skin issue. The DON stated not having nail care was a hygiene issue. The DON stated Resident #108 and Resident #27 could communicate whether they wanted a shave and that she had not had a chance to see them that week. The DON stated having unwanted facial hair was a body image and dignity issue and I won't allow it. The DON stated she had not seen Resident #52 and Resident #55's nails that week either. During an interview on 12/21/2023 at 3:47 p.m., the Administrator stated her expectation for showers, nail care, and shaves for female residents was people who request it get it done. The Administrator stated shaving for women was ad hoc and for men, it was part of their regimen. The Administrator stated the CNAs provided the ADL care, showers were three times a week, and nail care was offered weekly or as needed. The Administrator stated if a female resident came in and they knew they needed a shave, they would request it. The Administrator stated if there was heavy facial hair presence she would expect staff to offer them a shave. The Administrator stated the CNAs were monitored via the point of care tab on their electronic medical records system. The Administrator stated they could pull a report indicating performance, that observation was another way, and we do room rounds. The Administrator stated management staff rounded on residents everyday Monday-Friday to check ADLs. The Administrator stated staff were trained on providing ADLs through school and competency checks. The Administrator stated she was not sure if there was a staff ADL box that had a place to check off for facial hair and nail care. She said it was not built into their routine. The Administrator stated for Resident #35,this is not a family that wouldn't let him have showers. The Administrator stated if showers were not documented, she would have to have a conversation with the caregiver. If Resident #35 had not received a shower, she would have learned about it through his family. When asked how having long fingernails could affect residents, the Administrator stated, I would ask them if they like them. The Administrator stated if residents did not receive showers as often as they wanted, their needs would not be met. For women with unwanted facial hair, the Administrator said, I would want residents to be confident enough to ask. A record review of the facility's untitled in-service training dated 10/02/2023 reflected nursing staff were trained to check fingernails as residents scratch thin skin can cause skin tears. A record review of the facility's policy titled Activities of Daily Living (ADLs), Supporting dated March 2018 reflected the following: Policy Statement Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy Interpretation and Implementation 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) 4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. 7. The resident's response to interventions will be monitored, evaluated, and revised as appropriate.

Based on observation, interview and record review, the facility failed to ensure all residents had a right to be treated with respect and dignity for three of eight (Resident #3, Resident #46, and Resident #158) residents reviewed for dignity. The facility failed to ensure Resident #3, Resident #46 and Resident #158 were not referred to as feeders. This failure placed residents at risk of not being treated with dignity. Findings included: A record review of Resident #3's face sheet dated 12/20/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, major depressive disorder (depression), thyrotoxicosis (too much thyroid hormone), hyperlipidemia (high cholesterol), cerebral palsy (movement disorder), hypertension (high blood pressure), dysphagia (difficulty swallowing), and muscle weakness. A record review of Resident #3's MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated severely impaired cognition. This assessment reflected Resident #3 required extensive assistance and a one-person physical assist with eating. A record review of Resident #3's care plan last revised on 12/19/2023 reflected she had ADL self-care performance deficit related to limited mobility, high muscle tone/spasticity related to cerebral palsy diagnosis, deconditioning and weakness occurring with aging, and chronic ill health. A record review of Resident #46's face sheet dated 12/20/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease with early onset (type of dementia), aphasia (difficulty communicating), occlusion (blockage) and stenosis (narrowing) of left carotid artery, and hypertension (high blood pressure). A record review of Resident #46's MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severely impaired cognition. This assessment reflected Resident #46 required extensive assistance and a one-person physical assist with eating. A record review of Resident #46's care plan last revised on 10/10/2023 reflected she had an ADL self-care performance deficit related to progression of dementia. A record review of Resident #158's face sheet dated 12/20/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of senile degeneration of brain, down syndrome (genetic disorder associated with physical growth delays, characteristic facial features and mild to moderate developmental and intellectual disability, and dementia). A record review of Resident #158's MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severely impaired cognition. Resident #158's functional abilities for eating was not yet completed. A record review of Resident #158's care plan last revised on 12/20/2023 reflected he was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. During an observation and interview on 12/19/2023 at 12:38 p.m., Resident #3 was observed lying in bed with a meal tray by her side. CNA L stated, she's a feeder and stated she would feed Resident #3. During an interview on 12/19/2023 at 1:13 p.m., RN C stated, our other two feeders are in the dining room. An observation on 12/20/2023 at 8:49 a.m. revealed Resident #158 was lying in bed sleeping. During an interview on 12/20/2023 at 1:22 pm., LVN E stated she used the word feeder to refer to residents who needed help eating. LVN E stated she thought she had learned that term through a training at the facility. During an interview on 12/20/2023 at 2:27 p.m., CNA H stated Resident #158 was a feeder and she had learned that term while working in the facility. An observation on 12/20/2023 at 2:34 p.m. revealed Resident #46 was lying in bed making incomprehensible noises. Resident #46 was non-interviewable. During an interview on 12/20/2023 at 2:36 p.m., RN B stated Resident #46 was a feeder and said she learned the term way back at another facility. During an interview on 12/21/2023 at 2:53 p.m., The DON stated she had started an in-service on how to refer to residents who needed assistance with eating because I figured out what you were talking about. The DON stated staff got into the habit of using the word feeder and said they should instead use total assist. The DON stated the term feeder was not supposed to be used by the staff. The DON stated she thought staff were trained on resident rights and dignity via computer-based trainings. The DON stated staff were monitored for resident rights and dignity through interviews and rounding by management staff. The DON stated prior to 12/20/2023, staff had not been trained specifically on not using the term feeder. The DON stated, it's just not nice to say and said that was why they completed an in-service. During an interview on 12/21/2023 at 3:47 p.m., the Administrator stated she expected staff to refer to residents with appropriate language that showed respect. The Administrator stated they had been in-servicing staff on appropriate language as of yesterday (12/20/2023). The Administrator stated staff were trained on resident rights and dignity via computer-based trainings. The Administrator stated herself and the DON monitored staff for resident rights and dignity. If residents were referred to as feeders, it was not the most dignified way to refer to them. A record review of the facility's policy titled Resident Rights dated December 2016 reflected the following: Policy Statement Team members shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity

Based on observation, interview, and record review the facility failed to provide a sanitary environment to help prevent the transmission of communicable diseases and infections for three of seven residents (Resident #7, Resident #12, and Resident #14) observed while receiving direct resident care by facility staff. The facility failed to disinfect a wrist blood pressure cuff and a Hoyer lift (a manual or electronic metal frame with wheels and a sling-fastening device that is used to lift residents out of bed or a chair to be transferred to another bed or chair) before and after use on Resident #7. Failure to disinfect reusable resident-care items could affect all residents who required a blood pressure check or required use of a transfer assistive device, in the form of a Hoyer lift, by promoting the spread of potential pathogens contained on those items. Record review completed on 12/20/2023 of Resident #7's current face sheet revealed an elderly resident admitted on [DATE] with diagnoses of chronic pain, hypertension (high blood pressure), history of falls, anxiety, and depression. Record review completed on 12/20/2023 of Resident #7's Physician Orders reflected that Resident #7 had an active (current) order from facility medical provider for Losartan and Hydralazine, used to treat hypertension (high blood pressure). Facility medical provider added to the Losartan order to hold for systolic blood pressure (the top number in a blood pressure reading) less than 110. It is the standard of care in healthcare and nursing facility settings to obtain a current blood pressure prior to giving a blood pressure medication. Record review completed on 12/20/2023 of Resident #7 Physician Orders reflected that resident is to receive Losartan 100 mg by mouth daily. Record review completed on 12/20/2023 of Resident #12's current face sheet revealed an elderly resident admitted on [DATE] with diagnosis of hypertension (high blood pressure), cardiac arrhythmia (irregular heartbeat), chronic pain, and benign prostatic hyperplasia (in men, enlarged prostate gland which can make it difficult to urinate). Record review completed on 12/20/2023 of Resident #12's Physician Orders reflected that Resident #12 had an active (current) order from facility medical provider for Valsartan 160 mg two tabs once daily by mouth. Additionally, the facility medical provider order stated to hold the Valsartan if systolic blood pressure (the top number in a blood pressure reading) is less than 120. It is the standard of care in healthcare and nursing facility settings to obtain a current blood pressure prior to giving a blood pressure medication. Record review completed on 12/20/2023 of Resident #14's face sheet reflected an elderly hospice resident initially admitted to the facility on [DATE]. Resident #14 had a history of anxiety, depression, limited range of motion, and severe cognitive deficit among other diagnoses. Record review completed on 12/20/2023 reflected that current Minimum Data Set assessment (a medicare-required assessment) indicated that Resident #14 had severe cognitive deficit and was dependent on two staff for his transfers from bed to wheelchair. MA F was observed during the medication administration facility task aspect of an annual survey on 12/20/2023 at 08:15 AM for Resident #7, followed by Resident #12 at approximately 08:25 AM. MA F was observed as she obtained the wrist blood pressure cuff (an electronic cuff that velcros around the wrist and is used to obtain a blood pressure) from a drawer in her medication cart as she prepared to give Resident #7 her morning medications. MA F stated that she would check the blood pressure on Resident #7 before she prepared the medications for Resident #7. MA F proceeded into the room of Resident #7 and explained what she was going to do and checked the blood pressure for Resident #7. After she checked the blood pressure for Resident #7, MA F returned to her medication cart, opened the drawer, and dropped the blood pressure cuff back into her cart. MA F had not wiped down the wrist blood pressure cuff with a sanitation wipe or other cleansing product before or after she checked the blood pressure on Resident #7. MA F was observed as she prepared to provide medications to Resident #12. As the medications for Resident #12 were reviewed, MA F stated that Resident #12 needed his blood pressure checked before his medications were given. MA F removed the same wrist blood pressure cuff that she had used on Resident #7 from the drawer of her medication cart. MA F entered Resident #12's room and applied the cuff to his wrist. MA F proceeded to check his blood pressure and then removed the wrist cuff. MA F returned the wrist blood pressure cuff to a drawer in her medication cart. MA F had not wiped down the wrist blood pressure cuff with a sanitation wipe or other cleansing product before or after she checked the blood pressure on Resident #12. Sanitizing products were not observed to be located on MA F's medication cart, other than hand sanitizer. CNA I and CNA J were observed providing care to Resident #14 on 12/20/2023 at 11:16 AM. CNA I and CNA J prepared to transfer Resident #14 into his wheelchair for lunch. Resident #14 required the use of a Hoyer lift as an assistive device to get from the bed to his wheelchair. CNA J rolled the Hoyer lift that had been parked in the hall into Resident #14's room. The Hoyer lift was not observed to have been wiped off with a sanitizing cloth or other sanitizing device prior to being rolled into Resident #14's room. The Hoyer lift had been observed parked in the resident hall during the morning hours prior to being used in Resident #14's room. During the observation on 12/20/2023 at 11:16 AM, incontinent care was provided in bed for Resident #14 prior to use of the Hoyer lift. Once Resident #14 had been provided incontinent care and the staff dressed him, his personal sling was placed underneath his body, and connected to the Hoyer lift. Resident #14 was observed as he was transferred to his wheelchair. CNA J was observed as she rolled the Hoyer lift into the hall, parked it, and re-entered Resident #14's room. CNA I and CNA J were observed to remove their gloves and wash their hands after Resident #14 was sitting in his chair and the Hoyer lift was rolled out of the room. CNA J was not observed to have wiped down the Hoyer lift with a sanitizing wipe or other sanitizing device after it was used for Resident #14. CNA I proceeded to take Resident #14 to the dining room as CNA J proceeded to help other residents. An interview was conducted with CNA I on 12/21/2023 at 08:40 AM. CNA I stated that the Hoyer lift was cleaned with a spray solution and wiped down between residents. CNA I stated that the rooms with Covid positive residents were wiped down with the sanitizing wipes in the purple-top container. CNA I referenced a purple-top container of sanitizing wipes that were located in the proximity of the interview. An interview was conducted with MA F on 12/21/2023 at 12:20 PM. MA F stated that the facility had instructed her to clean reusable wrist blood pressure cuffs with the alcohol prep pads (small single-use alcohol pads in a foil package that are commonly seen in a healthcare setting). An interview was conducted with the DON, identified as the facility Infection Preventionist, on 12/21/2023 at 3:42 PM in reference to methods of ensuring clean equipment was used with residents. The DON stated that the facility reusable equipment which included the Hoyer lifts and blood pressure cuffs were cleaned with the purple-top sanitizing wipes. The DON stated that all of the carts for nurses, medication aides, and wound care supplies have a container of purple-top wipes on or in them. The DON stated that staff are instructed to clean the Hoyer lift and any reusable resident equipment before and after each resident use. Record review of the facility Coronavirus Disease Prevention and Control policy dated March 2020 stated that infection prevention and control measures are based on established guidelines governing all communicable diseases and that facility leadership and the clinical team are implementing all reasonable measure to protect the health and safety of residents. The policy further stated that infection prevention and control supply needs will be maintained, including surplus for: soap and paper towels, alcohol-based sanitizer, and cleaning supplies with disinfectants that are EPA hospital-registered disinfectants effective against human coronaviruses.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that meets a resident's medical, nursing, mental, and psychosocial needs for two of two residents (Resident #55 and Resident #33) reviewed for pressure ulcers. 1. Resident #55 had three wounds which did not appear on the most recent comprehensive are plan last revised on 12/05/2023. 2. Resident #33 had a right buttock Stage II Pressure Ulcer (partial thickness skin and underlying tissue loss) which was not included in the comprehensive Care Plan revised on 12/20/2023. These failures could place residents at risk for pain from the wound, pain from any debridement procedures (sharp instrument or chemical excision of dead tissue often used to promote healing of pressure ulcers) and pain from the wound care required to promote healing. Residents with a pressure ulcer without an appropriate plan of care and interventions in place are at increased risk for infection, increasing dimensions/worsening of current ulcers, difficulty obtaining comfort in common positions (sitting, heels touching a bed mattress), increased financial expenditure for supplies and wound care consultation, and increased burden of care at discharge when obtaining supplies, specialist consultations/treatment, skilled wound care providers are needed at discharge. The record review on 12/20/2023 of Resident #55 current face sheet revealed a [AGE] year-old female resident who initially admitted to the facility on [DATE]; the face sheet indicated that the primary initial diagnosis for Resident #55 included fracture of left femur. The record review of other diagnoses listed on face sheet included orthopedic aftercare and dementia. The record review of the MDS assessment (an assessment required by Medicare/Medicaid for a nursing facility to complete on admission, periodically, and when there is a change in condition on each resident) dated 12/08/2023 reflected that Resident #55 had a quantity of one pressure ulcer. The MDS dated [DATE] reflected that the one pressure ulcer was an unstageable pressure ulcer. Further record review of the MDS reflected that the site of one pressure ulcer was on one of Resident #55's feet (it is not specified whether it is left foot or right foot). A record review of the MDS (Medicare/Medicaid assessment) dated 12/08/2023 reflected that Resident #55 required extensive assistance of two or more persons for bed mobility, transfers from bed to chair, and toilet use. The record review of the MDS reflected that Resident #55 had a pressure reduction device for her bed (a low air loss and/or alternating air pressure mattress system which helped to prevent skin breakdown) and dressings applied to her feet three times weekly. A record review of the care plan revised on 12/05/23 reflected that Resident #55 had potential/actual impairment to skin integrity related to immobility; the goal had been established that Resident #55 would maintain or develop clean and intact skin by the review date. The record review of the interventions, revised on 12/06/2023 included: treatment administered as ordered by physician, weekly treatment documentation which included measurements of wounds, documentation of notable changes/observations, and documentation of exudate (drainage). The remaining additional interventions included observation of dressing to left heel every shift, dressing changes to left heel with recorded observations of the site three times weekly, and identified and documented causative factors that could be eliminated or resolved. A record review of the Centers for Medicare Services form 802, Resident Matrix, dated 12/19/2023, reflected that there were no Stage IV pressure ulcers on any residents in the facility. The record review of the Centers for Medicare Services form 802 reflected that Resident #55 had a Stage II pressure ulcer and an unstageable pressure ulcer. A record review of the active Physician's Orders reflected that wound care treatments were ordered daily on 12/20/2023 on the Stage II left ischium wound, daily on the Stage IV sacrococcygeal Pressure Ulcer as ordered on 12/14/2023, and daily on the bilateral heel deep-tissue injuries, as ordered on 11/29/2023. A record review of the weekly nurses' skin assessments from 10/18/2023 through 12/20/2023 reflected that the pressure ulcers and the deep-tissue injuries were not addressed on the weekly nurses' skin assessments. The record review of the Wound Care Physician's Notes dated 12/20/2023 reflected that the sacrococcygeal area had a Stage IV pressure ulcer measuring 8.5 cm x 5.0 cm x 1.0 cm (length x width x depth), that the left ischium had a Stage 2 pressure ulcer measuring 0.6 cm x 0.8 cm x 0.1 cm (length x width x depth). The record review of the Wound Care Physician's Notes dated 12/20/2023 reflected that the heels had deep-tissue injuries; the right heel wound measured 3.0 cm x 3.5 cm x 0 cm and the left heel wound measured 2.0 cm x 1.5 cm x 0 cm. An interview with the DON on 12/19/2023 at 2:14 PM revealed that there was one resident with a Stage IV Pressure Ulcer in the facility. The DON stated that Resident #55 had a Stage IV Pressure Ulcer to the sacrococcygeal area. The DON stated that she changed the dressing on Resident #55 daily and functioned as the wound care nurse for the more serious facility wounds. The DON stated that Resident #55's Stage IV sacrococcygeal pressure ulcer had been facility-acquired and formed not long after Resident #55 was admitted (on October 18, 2023). An observation of wound care was conducted on 12/20/2023 at 09:11 AM, performed on Resident #55 by the DON. A deep-tissue injury was observed to both heels and were treated as ordered by the physician on 12/20/2023. A Stage II left ischium pressure ulcer was observed and treated as ordered by the physician on 12/20/2023. A Stage IV sacrococcygeal pressure ulcer was observed and treated as ordered by the physician on 12/20/2023. The wound care measurements appeared consistent with the measurements documented on the Wound Care Physician Notes dated 12/20/2023. An interview with the DON on 12/20/2023 at 09:11 AM revealed that the Wound Care Physician had seen Resident #55 and performed a debridement procedure (removal of dead tissue within the pressure ulcer site using a sharp instrument; the area was first numbed with a topical anesthetic spray) earlier that morning. An interview with the DON was conducted on 12/21/2023 at 1:38 PM. The DON was asked how current staff and/or new staff and/or agency staff were made aware of the interventions required for Resident #55. The DON stated that the report was given orally at shift change and a kardex (a nursing tool which involved a summary of care interventions and medical information which is kept current and updated each shift) was not used. An interview with the DON was conducted on 12/21/2023 at 2:23 PM. The DON stated that care plans were updated quarterly. For issues that had arisen that needed to be care-planned prior to a quarterly update, a morning meeting had been held which included the MDS Coordinator (the nurse who documented the Medicare required assessment findings and had the main facility responsibility to make certain the care plan was kept current). The DON stated that while the Wound Care Physician orders were updated, the care plan should have been. The DON stated that a lot of care had been provided for Resident #55 and it should have been care-planned. The DON stated that the interventions that Resident #55 received that should have been care-planned included: Resident #55 had been turned every two hours when in bed, had been provided a special wheelchair cushion (which reduced pressure to the area of the Stage IV Pressure Ulcer), had been provided an air mattress (a mattress which reduced pressure to the sacrococcygeal, heels, and the left buttock pressure ulcer sites), had received a dietary consultation (to ensure that Resident #55 was getting proper caloric intake, nutrients, and protein for wound healing), had received daily wound care by the DON and other nurses, and had been seen weekly by a Wound Care Physician. An interview was conducted with the MDS Coordinator on 12/21/2023 at 2:45 PM and the MDS Coordinator stated that she has requested that nursing staff notify her within three days when there was a change in a resident that needed to be care-planned. The MDS Coordinator stated that she would wait to care plan a wound if a Wound Care Physician would be seeing the resident, so that the correct type of wound and correct staging of the wound was included in the care plan. The MDS Coordinator stated that she was not made aware of the progression of Resident #55's pressure wounds. The MDS Coordinator stated that any licensed nurse could have updated the care plan. The MDS Coordinator stated that an inaccurate care plan could have caused problems with completion of Activities of Daily Living, pain, mobility issues, and progression of the wound. A record review of Resident #33's face sheet dated 12/21/2023 reflected a [AGE] year-old male readmitted on [DATE] with diagnoses of ileus (gut paralysis), type 2 diabetes (uncontrolled blood sugar), hypertension (high blood pressure), hyperlipidemia (high cholesterol), dysphagia (difficulty swallowing), adult failure to thrive, squamous cell carcinoma of skin, scalp and neck (skin cancer), and COVID-19. A record review of Resident #33's MDS assessment dated [DATE] reflected a BIMS score of 10, which indicated moderately impaired cognition. Section M of Resident #33's MDS assessment reflected he had on unhealed stage 2 pressure ulcer. A record review of Resident #33's care plan last revised on 12/20/2023 reflected he had a resolved stage 4 sacral pressure injury. The care plan reflected the following: RESOLVED 5/17/21: Sacrum r/t Stage 4 Pressure Ulcer Date Initiated: 10/31/022 Revision on: 08/31/2023 Resident #33's care plan did not reflect his current wound. A record review of Resident #33's wound care assessment titled Weekly Wound Progress authored by LVN E dated 11/29/2023 reflected he had a stage 2 pressure ulcer to his right buttock measuring 1.0 x 1.5 x 0.1 cm. A record review of Resident #33's wound care assessment titled Weekly Wound Progress authored by the DON dated 12/06/2023 reflected he had a stage 2 pressure ulcer to his right buttock measuring 1.5 x 1.0 x 0.1 cm. A record review of Resident #33's wound care assessment titled Weekly Wound Progress authored by the DON dated 12/13/2023 reflected he had a stage 2 pressure ulcer to his right buttock measuring 1.2 x 1.7 x 0.1 cm. A record review of Resident #33's wound care assessment titled Weekly Wound Progress with an unknown author dated 12/20/2023 reflected he had a stage 2 pressure ulcer to his right buttock measuring 2.3 x 1.5 x 0.1 cm. During an observation and interview on 12/19/2923 at 10:09 a.m., Resident #33 was observed lying in bed. Resident #33 stated he had a small wound on his bottom that he got while in the facility. Resident #33 stated the wound had been getting better and the wound care physician followed him. During an interview on 12/21/2023 at 3:16 p.m., the MDS Coordinator stated she had worked at the facility for one year and it was her responsibility as well as other nurses' responsibility to revise care plans. The MDS Coordinator stated other nurses should know it was also their responsibility. The MDS Coordinator stated of course it could affect residents' ADLs if wounds were not care planned. The MDS Coordinator stated if the staff went in to do a resident assessment and they were unaware of a wound, it could cause pain or mobility issues. The Administrator was interviewed on 12/21/2023 at 3:30 PM. The Administrator stated that the MDS Coordinator, the Social Worker, and the Activities Director have updated the care plans. The Administrator stated that the care plans and any needed updates were discussed in the Monday through Friday morning clinical meetings. The Administrator stated that many care plan issues have been reviewed during Quality Assurance Performance Improvement meetings. The Administrator stated that the care plans are a tool used as resident care was provided. A record review of the Pressure Ulcers/Skin Breakdown Clinical Protocol Policy dated 04/2018 reflected that the physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. A record review of the Pressure Ulcers/Skin Breakdown Clinical Protocol Policy dated 04/2018 reflected that the nurse shall describe and document/report the following: full assessment of pressure sore, pain assessment, resident's mobility status, current treatments, and all active diagnoses. A record review of the Care Plan, Comprehensive Person-Centered Policy, dated 12/2016 reflected that the care plan would be formulated in conjunction with the resident and his or her legal representative and are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. A record review of the Care Plan, Comprehensive Person-Centered Policy, dated 12/2016, reflected that the comprehensive care planning process will include measurable objectives and timeframes, describe the services to be furnished to attain the highest practicable physical, mental, and psychosocial well-being, incorporate identified problem areas. The comprehensive person-centered care plan will be developed within seven days of the completion of the required comprehensive assessment (MDS; a Medicare required assessment for nursing facilities). The Policy also states that the Interdisciplinary Team must review and update the care plan when there is a significant change in the resident's condition and when the desired outcome is not met.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent avoidable accidents for 1 of 2 residents reviewed for accidents. (Resident #1) 1. The facility failed to develop and/or revise a plan to address Resident # 2's physical aggression which resulted in Resident #1 falling and sustaining a [MEDICAL CONDITION] after being pushed by Resident #2 on 6/27/19. 2. Social Worker failed to follow up on a psychiatric referral ordered on [DATE] for Resident #2 after increased episodes of aggression. Actual harm was determined to exist 06/03/2019 until 06/28/2019. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure affected one resident and could place other residents who are in close proximity to physically aggressive residents at risk of avoidable injuries. Findings include: Review of the Face Sheet for Resident #1 reflected a [AGE] year-old female who was originally admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #1 dated 2/08/19 reflected she was at risk for falls, issues with gait/balance and unawareness of safety needs. Further review of the Care Plan reflected interventions for [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of the Quarterly MDS for Resident #1 dated 4/22/19 reflected a BIMS score of 99 which indicated she was unable to complete the interview. Further review of the MDS reflected Resident #1 required supervision while walking. Review of the Face Sheet for Resident #2 reflected an [AGE] year-old female who was originally admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS for Resident #2 dated 2/01/19 reflected a BIMS score of 05 which indicated severe impairment. Further review of the MDS reflected Resident #2 exhibited physical behavioral symptoms directed towards others which puts her and others at significant risk for physical injury. Review of the Care Plan for Resident #2 dated 2/20/19 reflected she had a history of [REDACTED]. Care Plan interventions reflected staff were to intervene as necessary to protect the rights and safety of others. This plan was not revised after increased behaviors of aggression and agitation in (MONTH) 2019. The care plan was not revised until 06/28/19 after the incident of aggression that resulted in injury to Resident #1. Review of progress note dated 5/11/19 reflected Resident #2 was in the hallway hitting another resident with a shoe. She proceeded to walk alongside this resident and continued to hit her with a shoe. Review of the physician communication for Resident #2 dated 5/13/19 reflected Resident #2 was noted with increased behaviors, difficult to redirect and hitting others. Review of the physician communication for Resident #2 dated 5/23/19 reflected Resident #2 was noted with increased confusion, agitation and physical aggression. Further review reflected Resident #2 attempted to hit staff and sustained a small skin tear when she missed staff and hit the wall. Review of the physician's orders [REDACTED]. This referral was not acted on by the social worker until 6/28/19. Review of the Facility Incident Report dated 6/28/19 read in part, On 6/27/19 around 4:50 pm Resident #2 pushed Resident #1. Both of these residents live in our Dementia/Secure unit. Resident #1 was sent to the emergency room per orders of NP. On 6/28/19 we were informed that Resident #1 will need hip surgery. Resident # 2 has been on a 1:1 for other residents' safety. Review of the emergency department provider notes for Resident #1 dated 6/27/19 reflected Resident #1 was diagnosed with [REDACTED]. Review of the Care Plan for Resident #2 dated 6/28/19 reflected an increase in agitation in (MONTH) with interventions to continue 1:1 monitoring of resident to prevent agitation towards others. During an interview on 7/02/19 at 1:45 pm, LVN A stated Resident #2 gets confused and aggressive towards the evening hours. LVN A further stated Resident #2 does not like people getting too close and will push them away. During an interview on 7/02/19 at 5:13 pm, ADM stated there was an order in place for psychiatric services for Resident #2 prior to the incident. ADM stated expectations were for SW to obtain consents and fax orders to the psychiatric provider following psychiatric referrals from the doctor. ADM further stated SW overlooked the order and nothing had been done. During an interview on 7/03/19 at 1:40 pm, CMA B stated Resident #2 gets upset easily. CMA B stated Resident #2 prefers to be alone and does not like people getting too close. CMA B further stated Resident #1 will pat people on their bottoms when they are in her way. During an interview on 7/03/19 at 2:09 pm, CNA C stated Resident #2 can become verbally and physically aggressive towards staff and residents. CNA C stated she had witnessed Resident #2 hitting and pushing residents numerous times in the past. Resident #2 likes to be alone and does not like to be touched. CNA C further stated Resident #1 had a habit of patting people on the bottom when they are in her way. During an interview on 7/03/19 at 2:29 pm, CNA D stated she had witnessed Resident #2 being physically aggressive towards residents and staff. CNA D stated Resident #2 will push people out of her way. Resident #2 does not like being touched. CNA D stated Resident #1 had a habit of patting staff and residents on their bottoms when they are in her way. CNA D further stated the day of the incident Resident #2 was standing in the hallway in between the dining room and activity room. Resident #1 walked up behind Resident #2 and as she was attempting to walk by was pushed two times by Resident #2. Resident #1 fell to the floor and was sent to the hospital. CNA D stated Resident #1 could have patted Resident #2 on the bottom as she walked by but she was unsure. During an interview on 7/03/19 at 2:29 pm, SW stated she was responsible for handling all psychiatry and psychology referrals. SW stated she was expected to obtain consents and contact the psychiatric provider within a few days of the order. SW stated she missed Resident #2's order for psychiatric services and learned that she missed the order the day after the incident. It was determined the above failures caused actual harm past non-compliance to Resident #1 from 6/03/2019 until 6/28/2019. The facility took the following actions to correct the non-compliance on 6/28/2019. 1. On 6/28/2019 consents for psychiatric services were obtained and faxed to the provider. 2. On 6/28/2019 Resident #2 was placed on 1:1 supervision. 3. On 7/02/19 Resident #2 was seen by a psychiatric nurse practitioner and placed on psychiatric medication. 4. On 7/03/2019 all nursing staff were in-serviced on following up on doctor's orders. During an interview on 7/03/19 at 5:19 pm, DON stated there was no policy in place for following up on doctor's orders. DON stated this was the first time a doctor's order was overlooked. Nursing staff were being in-served on following up on doctor's orders. DON stated Resident #2 had not displayed any episodes of aggression since she was placed on 1:1. DON stated 1:1 had been removed per NP recommendations. DON stated Resident #2 had new medication orders to address behaviors. Observation conducted on 7/03/19 at 5:30 pm revealed Resident #2 calm and lying in bed. Further observation revealed Resident #2 was in her room without a 1:1. During a telephone interview on 7/03/19 at 5:45 pm, NP stated he evaluated Resident #2 and recommended that 1:1 be removed. NP stated he will continue to monitor Resident #2. Review of Resident #2's Medication Administration Record [REDACTED]. The investigator interviewed two CNAs, two CMAs, and two LVNs on 07/03/19 and all were knowledgeable of abuse/neglect policies/procedures and of reviewing resident's care plans for behavioral interventions. Review of facility in-service record dated 7/03/19 reflected an in-service on Checking Orders Daily.

Based on observation, interview, and record review, the facility failed to ensure each resident received assistance devices to prevent accidents for seven of seven residents reviewed for tab alarms (Residents #1, #2, #3, #4, #5, #6, #7, and #8). A). Resident #1 fell during an attempt to self-transfer from her wheelchair to her bed on [DATE] and sustained a right femoral fracture. RN A and Certified Nurse Aide (CNA) A found Resident #1 on the floor next to her bed with her right leg folded up under her with her Tab Alarm still intact. Resident #1's Tab Alarm did not alert staff that the resident had fallen because the cord was not properly adjusted to activate the alarm once she fell . The resident expired on [DATE] at the facility. B). Residents #2, #3, #4, #5, #6, #7, and #8 use an adjustable Tab Alarm to reduce the risk for falls; however, the cord was not adjusted properly to activate the alarm should a resident attempt to stand or fall. The cord is long enough, so that it can reach to the floor without separating properly to activate the alarm, and therefore staff would not be notified. This failure could place 7 residents, using the tab alarm at risk for a delay in staff notification and treatment should an alarm sound indicating a resident had fallen. Findings included: A). Review of the facesheet for Resident #1 reflected she was a [AGE] year old female, admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #1, dated [DATE] and [DATE] revealed she had experienced a decline in cognitive function. Behaviors had been identified including verbal and physical aggression. She requires extensive assistance including the need for a two person transfer. Review of the the Quarterly Fall Risk Assessments for Resident #1, reflected all overall scores were greater than (>) 10 (>/= 10 is indicative of the resident being at high risk for falls). Review of Care Plan Conference Signature Sheet revealed that the conference occurred on [DATE]. Neither the responsible party nor the resident was in attendance. The identified issues that were care planned, included refusal to participate in activities due to pain, Diabetes, being an amputee and requiring the use of a ? rail for bed mobility, self-care deficits, weight loss, bowel and bladder incontinence, being verbally and physically abusive to staff short and long term memory impairments due to cognitive impairments, depression, pain, use of antianxiety agents. The Care Plan Conference Signature Sheet did not reflect any issues regarding Resident #1 risk for falls. Review of Care Plans for Resident #1 reflected there was no care plan addressing any interventions for the prevention of falls and identifying the resident's risk for falls and need for interventions. During an interview on [DATE] at 7:20 p.m., Certified Nurse Aide (CNA) A stated she had worked the evening shift on [DATE] at 10:00 p.m. and she switched halls for a second shift. CNA A stated she did not check on the resident until 11:00 p.m., at which time she found her on the floor in front of her wheelchair. CNA A stated that when she found the resident, Resident #1's right leg was folded up under her. The resident was asked what happened, Resident #1 reported that she fell when attempting a transfer from the wheelchair to the bed. Once Resident #1 was returned to bed, CNA A observed the resident ' s leg was turned opposite from its normal position. CNA A stated the resident was returned to bed by her and another aide. The nurse (RN A) was present in the room during the transfer. Resident #1 did experience " lots of pain " during the transfer according to CNA A. Once Resident #1 was returned to bed, CNA A observed the resident ' s leg was turned opposite from its normal position. During an interview on [DATE] at 8:40 a.m., Registered Nurse (RN) A stated she and the aide (CNA A) were making rounds at 11:00 p.m. when they found Resident #1 on the floor in front of her wheelchair. The resident did have a Tab Alarm attached to her; however, the length of the cord was long enough to allow Resident #1 to sit on the floor and not activate the alarm. RN A stated that Resident #1 had no prior history of attempting a self-transfer. RN A stated Resident #1 was usually in bed and asleep at this time; however, on occasion she would still be awake and up. The resident was known to be strong willed and not follow instructions. RN A stated that she and two CNAs transferred the resident back to bed. RN A stated one of the staff held the leg during the transfer to immobilize the leg. The transfer was very painful for the resident per the RN. Review of Nurses Notes written by RN A, dated [DATE], revealed the Resident #1 had been found on the floor at 11:30 p.m. and was experiencing " extreme pain " of her right leg and hip. The notes reflect that the resident ' s leg was immobilized and the resident was transferred back to her bed. The on call physician was contacted at 11:45 p.m. and orders were received for an x-ray, pain medication, and transfer if a fracture. Further review of a Nurses Noted dated [DATE] at 1:10 a.m. reflected the x-ray was completed and Resident #1 had a femar fracture. The daughter was notified and the resident was sent to the emergency room (ER) at 2:25 a.m. Review of the Incident Report, dated [DATE] concerning Resident #1, revealed she experienced an unwitnessed fall on [DATE] at or about 11:30 p.m. The documentation revealed the resident attempted a self-transfer from her wheelchair to her bed. The fall caused the resident experience pain in her right leg. The leg was documented as being immobilized and the resident was transferred back into her bed. An X-ray of the resident ' s right leg revealed she had a fracture of the right femur with mild displacement. The incident report reflected the staff had asked the resident if she was ready to go to bed four times prior to her falling. The resident refused each request. Resident #1 was transferred to the hospital after the fracture was determined to have occurred. Review of physician orders, dated [DATE], revealed the resident was readmitted to the facility for palliative care after the family elected to not repair the fracture of the femur. The resident expired on [DATE]. During an interview on [DATE] at 9:30 a.m., Resident #1's Primary Care Physician (PCP) stated Resident #1 had a femoral fracture. The PCP stated the resident should not have been moved by the facility staff because of the possibility of converting the fracture to a comminuted or open fracture if the bones shifted. He would expect EMS to be called to transport the resident. The PCP stated it was his understanding that this is what occurred, not that staff moved the resident themselves. During an interview on [DATE] at 11:40 a.m. CNA B stated that Resident #1 had a tab alarm in use. The resident would frequently remove it. Resident #1 did not have a pressure alarm on her wheelchair or her bed. There was not mat on the floor beside the bed. During an interview on [DATE] at 10:15 a.m., the Director of Nursing (DON) stated when a resident falls the nurse should stop and assess the resident if pain occurs during an attempt to transfer. B). Observation on [DATE] at 10:45 - 11:00 a.m. revealed Residents #2, #3, #4, #5, #6, #7, and #8 revealed each resident had a Tab Alarm on. Each Tab Alarm cord between the clip and the alarm was not adjusted in a manner that would activate the alarm if the resident attempted to stand or if they slid out of the wheelchair. During an interview on [DATE] at 11:30 a.m. RN B stated she is not sure if there is a policy that addressed the use of the Tab Alarm. RN B stated staff does need to be sure the cord is of the proper length when the Tab Alarm is used on a resident. During an interview on [DATE] at 11:35 a.m. LVN C stated that when she uses a tab alarm on the resident she will make sure the alarm will activate if the resident moves to far away from the alarm. She was not aware if there was a policy addressing the use of Tab Alarms. During an interview on [DATE] at 11:40 a.m. CNA B stated staff can adjust the length of the cord that connects the clip and the alarm. During an interview on [DATE] at 11:45 a.m. CNA C stated that CNAs do not hear the alarms go off very often. During an interview on [DATE] at 2:05 p.m. CNA E stated the resident alarms are activated almost all of the time when a resident stands or falls. If an alarm fails to activate the alarm is replaced. During an interview on [DATE] at 3:05 p.m. the DON stated the facility does not have a policy that addresses the use of Tab Alarms. The DON also stated she was not aware of any issues with the length of the cord regarding Resident #1. Review of policy, Falls and Fall Risk, Managing, undated, revealed the facility staff were responsible to assess and identify fall risk. They were to identify which interventions to implement, to monitor the interventions and assess effectiveness. The facility staff were also responsible for adding or changing intervention if needed to minimize serious consequences. The facility daily census that was highlighted to reflect residents that have alarms in use, dated [DATE], indicated 28 residents were using alarms as an intervention to prevent falls.

Based on interview and record review, the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one of four residents reviewed for falls (Resident #1). Resident # 1 fell during an attempt to self-transfer from her wheelchair to her bed on [DATE] and sustained a right femoral fracture. RN A and Certified Nurse Aide (CNA) A found Resident #1 on the floor next to her bed with her right leg folded up under her. RN A, CNA A, and one unidentified CNA transferring the resident back to bed, while one CNA stabilized the resident's leg, even though Resident #1 reported extreme pain in her leg. The resident expired on [DATE] at the facility. This failure affected Resident #1, who are identified as a fall risk, at risk for additional injuries, pain and a delay for medical treatment due to insufficient nursing assessment. Findings included: Review of the facesheet for Resident #1 reflected she was a [AGE] year old female, admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #1, dated [DATE] and [DATE] revealed she had experienced a decline in cognitive function. Behaviors had been identified including verbal and physical aggression. She requires extensive assistance including the need for a two person transfer. Review of the the Quarterly Fall Risk Assessments for Resident #1, reflected all overall scores were greater than (>) 10 (>/= 10 is indicative of the resident being at high risk for falls). Review of Care Plan Conference Signature Sheet revealed that the conference occurred on [DATE]. Neither the responsible party nor the resident was in attendance. The identified issues that were care planned, included refusal to participate in activities due to pain, Diabetes, being an [MEDICAL CONDITION] and requiring the use of a ? rail for bed mobility, self-care deficits, weight loss, bowel and bladder incontinence, being verbally and physically abusive to staff short and long term memory impairments due to cognitive impairments, depression, pain, use of antianxiety agents. The Care Plan Conference Signature Sheet did not reflect any issues regarding Resident #1 risk for falls. Review of Care Plans for Resident #1 reflected there was no care plan addressing any interventions for the prevention of falls and identifying the resident's risk for falls and need for interventions. During an interview on [DATE] at 7:20 p.m., Certified Nurse Aide (CNA) A stated she had worked the evening shift on [DATE] at 10:00 p.m. and she switched halls for a second shift. CNA A stated she did not check on the resident until 11:00 p.m., at which time she found her on the floor in front of her wheelchair. CNA A stated that when she found the resident, Resident #1's right leg was folded up under her. The resident was asked what happened, Resident #1 reported that she fell when attempting a transfer from the wheelchair to the bed. Once Resident #1 was returned to bed, CNA A observed the resident ' s leg was turned opposite from its normal position. CNA A stated the resident was returned to bed by her and another aide. The nurse (RN A) was present in the room during the transfer. Resident #1 did experience " lots of pain " during the transfer according to CNA A. Once Resident #1 was returned to bed, CNA A observed the resident ' s leg was turned opposite from its normal position. During an interview on [DATE] at 8:40 a.m., Registered Nurse (RN) A stated she and the aide (CNA A) were making rounds at 11:00 p.m. when they found Resident #1 on the floor in front of her wheelchair. The resident did have a Tab Alarm attached to her; however, the length of the cord was long enough to allow Resident #1 to sit on the floor and not activate the alarm. RN A stated that Resident #1 had no prior history of attempting a self-transfer. RN A stated Resident #1 was usually in bed and asleep at this time; however, on occasion she would still be awake and up. The resident was known to be strong willed and not follow instructions. RN A stated that she and two CNAs transferred the resident back to bed. RN A stated one of the staff held the leg during the transfer to immobilize the leg. The transfer was very painful for the resident per the RN. Review of Nurses Notes written by RN A, dated [DATE], revealed the Resident #1 had been found on the floor at 11:30 p.m. and was experiencing " extreme pain " of her right leg and hip. The notes reflect that the resident ' s leg was immobilized and the resident was transferred back to her bed. The on call physician was contacted at 11:45 p.m. and orders were received for an x-ray, pain medication, and transfer if a fracture. Further review of a Nurses Noted dated [DATE] at 1:10 a.m. reflected the x-ray was completed and Resident #1 had a femar fracture. The daughter was notified and the resident was sent to the emergency room (ER) at 2:25 a.m. Review of the Incident Report, dated [DATE] concerning Resident #1, revealed she experienced an unwitnessed fall on [DATE] at or about 11:30 p.m. The documentation revealed the resident attempted a self-transfer from her wheelchair to her bed. The fall caused the resident experience pain in her right leg. The leg was documented as being immobilized and the resident was transferred back into her bed. An X-ray of the resident ' s right leg revealed she had a [MEDICAL CONDITION] femur with mild displacement. The incident report reflected the staff had asked the resident if she was ready to go to bed four times prior to her falling. The resident refused each request. Resident #1 was transferred to the hospital after the fracture was determined to have occurred. Review of physician orders, dated [DATE], revealed the resident was readmitted to the facility for palliative care after the family elected to not repair the [MEDICAL CONDITION]. The resident expired on [DATE]. During an interview on [DATE] at 9:30 a.m., Resident #1's Primary Care Physician (PCP) stated Resident #1 had a femoral fracture. The PCP stated the resident should not have been moved by the facility staff because of the possibility of converting the fracture to a comminuted or open fracture if the bones shifted. He would expect EMS to be called to transport the resident. The PCP stated it was his understanding that this is what occurred, not that staff moved the resident themselves. During an interview on [DATE] at 11:40 a.m. CNA B stated that Resident #1 had a tab alarm in use. The resident would frequently remove it. Resident #1 did not have a pressure alarm on her wheelchair or her bed. There was not mat on the floor beside the bed. During an interview on [DATE] at 10:15 a.m., the DON stated when a resident falls the nurse should stop and assess the resident if pain occurs during an attempt to transfer. Review of policy, Falls and Fall Risk, Managing, undated, revealed the facility staff were responsible to assess and identify fall risk. They were to identify which interventions to implement, to monitor the interventions and assess effectiveness. The facility staff were also responsible for adding or changing intervention if needed to minimize serious consequences. Review of First Aid information at the Mayo Clinic website reflected that basic first aid would be to call EMS if there is pain caused by movement or their is suspicion a bone was broken in the hip, pelvis or upper leg (for example, the leg and foot turn outward abnormally). <http://www.mayoclinic.com/health/first-aid-fractures>. The CMS 802, undated but presented to the surveyor on [DATE], indicated 13 residents were at risk for falls.