Every finding on record at Teague Nursing and Rehabilitation

Based on observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 6 residents (Resident #5) reviewed for resident rights. The facility failed to ensure Resident's #5's call light was within reach on 02/24/26. This failure could place residents at risk of their needs not being met.Findings included:Record review of Resident #5's face sheet, dated 02/24/26, reflected a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), dysphagia (difficulty in swallowing), cerebrovascular disease - a general term for conditions that affect the blood vessels in the brain and spinal cord, which can lead to serious complication, muscle wasting and atrophy (the loss of muscle tissue and strength, typically caused by inactivity, malnutrition, aging (sarcopenia), or diseases affecting nerves or muscles), and history of falling (indicates a patient is at high risk for future falls). Record review of Resident #5's Quarterly MDS assessment dated [DATE] reflected Resident #5 required partial/moderate assistance with showering, toileting, and personal hygiene and required supervision or touching assistance for eating. The MDS reflected Resident #5 had a BIMS score of 07 which indicated Resident #5 was severely cognitively impaired. Record review of Resident #5's care plan, dated 01/11/24 and revised on 01/24/24, reflected an ADL self-care performance deficit.Goal: Resident #49 would maintain current level of function in (Specify: Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review.Interventions included: The resident requires (1) staff participation to use toilet. The resident requires (1) staff participation with transfers. Duringn interview and observation on 02/24/26 at 10:28 a.m., Resident #5 stated she was ok. She stated things were going alright and the staff all treated her well. She stated she had a call light she used to call for help when needed. She stated she knew how to pull the cord to call for help and when she did the staff usually got to her in a timely manner. She stated she could not reach her call light where it was at that time. Observed residents call light on the top right side of the bed hanging from the wall, along the side and in front of resident's nightstand with a teddy bear tied to the end. Resident #5 stated she did not get out of bed by herself and it would not have been safe for her to try to get the call light where it was. During an interview on 02/24/2026 at 10:31 a.m., CNA B stated she was in-serviced on call light placement and keeping residents call light's within their reach. She stated Resident #5's call light was not in a place where she could have reached it and if a resident's call light was not within their reach it could have caused a resident to need something and not be able to tell staff or a resident could have fallen and not been able to call for help. During an interview on 12/11/26 at 9:17 a.m., the DON stated it was her expectation all residents call lights be within the residents reach at all times. She stated all staff were trained on residents call lights being within reach at all times. She stated if a residents call light was not within their reach, the residents could hurt themselves trying to get out of bed or could have a need that may not be met. During an interview on 02/26/26 at 9:22 a.m., the ADM stated it was her expectation all residents call lights be within the residents reach at all times. She stated all staff had been trained on residents' call lights being within reach at all times. She stated if a resident's call light was not within their reach, the resident would not be able to ask for assistance and that was the residents line of communication with staff. Record review of facility policy titled, Call System, Resident, dated September 2022 reflected, Policy Heading: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Policy Interpretation and Implementation: 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on interview and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 6 residents (Resident #2) reviewed for comprehensive assessments. The facility failed to complete an accurate comprehensive assessment for Resident #2 due to MDS assessment reflected resident did not receive anti-anxiety medication. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided.Findings included: Record review of Resident #2's face sheet, dated 02/25/26, reflected the resident was a [AGE] year-old male admitted on [DATE]. His diagnoses included generalized anxiety disorder (GAD) (chronic, uncontrollable, and excessive worry about everyday events lasting at least 6 months, often accompanied by physical symptoms like muscle tension, fatigue, and headaches), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), post-traumatic stress disorder (PTSD) (a mental health condition triggered by experiencing or witnessing terrifying, life-threatening events, such as abuse, accidents, or combat), and transient cerebral ischemic attack (a brief stroke like attack that, despite resolving within minutes to hours, still requires immediate medical attention to distinguish from an actual stroke). Record review of Resident 2's Quarterly MDS, dated [DATE], reflected Resident #2 was independent for eating, and required substantial/maximal assistance with toileting, showering, and personal hygiene. The MDS reflected Resident #2 had a BIMS score of 15 which indicated Resident #2 was cognitively intact. Resident #2's Quarterly MDS assessment reflected the resident was not receiving an anti-anxiety medication. Record review of Resident #2's care plan, dated 07/02/25, reflected, Resident used anti-anxiety medications (diazepam) r/t Anxiety disorder.Goal: Resident #2 would be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date.Interventions included: Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. Anti-anxiety side effects: drowsiness, lack of energy clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, Impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Paradoxical side effects: Mania, hostility and rage, aggressive or impulsive behavior, hallucinations. Record review of Resident #2's Physician's Orders, dated 02/04/26 with a start date of 02/05/26, reflected resident had an order for Diazepam Oral Tablet 5 MG (Diazepam) *Controlled Drug* (a drug or chemical whose manufacture, possession, and use are regulated by government, typically due to risks of abuse, addiction, or safety concerns) Give 1 tablet by mouth one time a day related to generalized anxiety disorder During an interview on 02/24/26 at 10:56 a.m., Resident #2 stated he was ok and things were going well. He stated the staff treated him well. He stated he got his medications correctly and he felt safe at the facility. He stated he used his call light a lot and staff got to him quickly when he called for them. He stated he had no concerns. During an interview on 02/24/26 at 1:13 p.m., LVN A stated she was responsible for completing the MDS assessments. She stated she was trained on completing MDS assessments accurately. She stated she was not sure if Resident #2 received an anti-anxiety medication or not and she would have to look, but she thought she remembered care planning Resident #2 for that medication recently. She stated she completed all of the MDS assessments for the facility. She stated if a resident was receiving an anti-anxiety medication it should have reflected that they did on the MDS. She stated if an MDS assessment was completed inaccurately, it would not affect the resident in any way that she could think of. During an interview on 02/26/26 at 9:17 a.m., the DON stated it was her expectation that MDS assessments were completed accurately and reflected the resident individually. She stated the MDS nurse was responsible for completing the MDS assessments and she was trained on completing the MDS assessments accurately. She stated if a resident received an anti-anxiety medication, the MDS assessment should have reflected that. She stated if a resident's MDS did not reflect that a resident received an anti-anxiety medication, it could have affected the MDS submission and reimbursement for the care that is provided to the resident but not caused any direct harm to the resident or affected the residents care in any way. During an interview on 02/26/26 at 9:22 a.m., the ADM stated it was her expectation that MDS assessments were completed accurately and reflected the resident individually. She stated the MDS nurse was responsible for completing the MDS assessments and she had been trained on completing the MDS assessments accurately. She stated if a resident received an anti-anxiety medication, the MDS assessment should have reflected that. She stated if a resident's MDS did not reflect that a resident received an anti-anxiety medication, it could possibly have some adverse effect but not cause any major harm to the resident. Record review of the facility's policy titled CMS's RAI Version 3.0 Manual and dated October 2025: High-Risk Drug Classes: Use and Indication - Steps for Assessment: 1. Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day lookback period (or since admission/entry or reentry if less than 7 days). 2. Review documentation from other health care settings where the resident may have received any of these medications while a resident of the nursing home (e.g., valium given in the emergency room). Coding Instructions: Code all high-risk drug class medications according to their pharmacological classification, not how they are being used. Column 1: Check if the resident is taking any medications by pharmacological classification during the 7-day observation period (or since admission/entry or reentry if less than 7 days). N0415: High-Risk Drug Classes: Use and Indication (continued). Antianxiety: Check if an anxiolytic medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).

Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Resident #1) reviewed for resident abuse and neglect. The facility failed to ensure Resident #1 was free from verbal sexual harassment by CNA A in November of 2025. This failure could place residents at risk of ongoing sexual harassment, psychosocial harm, fear, and decreased quality of life.Record review of Resident #1's face sheet, dated 01/20/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included unspecified injury at unspecified level of thoracic spinal cord- subsequent encounter, osteomyelitis (infection of the bone marrow), post-traumatic stress disorder (mental health condition that is caused by an extremely stressful or terrifying event), need for assistance with personal care, and muscle weakness. Record review of Resident #1's quarterly MDS assessment, dated 11/14/25, reflected a BIMS score of 15, which indicated the resident's cognition was intact. Section GG for functional abilities reflected Resident #1 was completely dependent on staff for rolling left and right, transfers, bathing/hygiene, and dressing. Record review of Resident #1's care plan, revised 01/09/26, reflected a focus on [Resident #1] has hemiplegia/ hemiparesis r/t trauma / spinal injury (chest down) with interventions that included range of motion (active or passive) with am/pm care and a focus for [Resident #1] has an ADL self-care performance deficit with interventions that included the resident requires (dependent on staff) to turn and reposition. A focus was also seen for [Resident #1] stated he is having some (minimal) emotional distress per social worker after completing an emotional distress assessment with interventions that included, [Resident #1] stated he feels safe to report any abuse to administrator or staff, counseling for social determinant of health risk, education about safety plan, and referral to social worker. Record review of Resident #1's emotional distress/ psychosocial monitoring post incident report, dated 01/08/26, reflected a positive assessment based on the following responses: If interviewable does the resident report feelings of nervousness or anxiousness related to the specific incident you are evaluating response was marked yes If the resident is interviewable do they verbalize fearfulness related to the specific incident you are evaluating response was marked yesComments based on yes responses reflected, resident would like to be informed of what is really going on. He verbalized worry that incident connected to him may sabotage his placement. Distress is minimal per resident.Document reflected it was signed 01/08/26 by the SW Record review of Resident #1's progress notes reflected a noted, dated 01/08/26, entered by the DON, Notified by social worker that resident reported some events that need to be addressed by the DON and a positive emotional distress assessment. DON speaks with resident who reports a CNA has made inappropriate remarks to him and these comments made him feel uncomfortable but scared to report them because of fear he would be removed from the facility. Resident denied any sexual contact between himself and the reported CNA and states his only emotional distress is related to fear of not having a place to go if kicked out of this facility. Assured resident that he is not being removed from the facility, he is not at fault, and he should always report any inappropriate comments or actions to myself or administrator. He verbalizes understanding and states he feels better about the situation following our discussion. Record review of Resident #1's progress notes reflected a note, dated 01/09/26, entered by the ADM, Notified by DON that resident had reported to her inappropriate comments were being made by a CNA. Administrator approachedresident in his room. Resident did confirm inappropriate comments were made by a CNA. Administrator asked when this incident took place and resident responded sometime in November 2025. Administrator asked why he did not report this event then, and he responded that he feared being kicked out of the facility. Administrator assured him that any concern should be brought to the attention of the administrative personnel at anytime without fear of retaliation. Resident assured the Administrator that he would do this moving forward. Administrator did ask resident if the comments upset him and he responded no and that he was only afraid of being kicked out of the facility. Resident did not appear to be in any emotion distress at the time of this conversation. Record review of Resident #1's progress notes reflected a note, dated 01/09/26, entered by the ADON, NP notified of sexual harassment allegations and investigation concerning resident and an employee. She is advised that the resident is not physically harmed in any way, declined any sexual contact between them, and that he is reporting only emotional concerns about the facility kicking him out. She is also informed that the state is being notified as a result of the founded allegation of sexual harassment via inappropriate comments. She advises that if anything changes or the resident needs to be seen or evaluated for any concerns related to this incident to let her know and she can get off cycle visit scheduled to address needs. Record review of the facility's self-reported 3613 and investigation packet, dated 01/13/26, reflected intake 1061475, Resident involved: Resident #1, alleged perpetrator: CNA A, how was the AP identified: by name, perpetrator: confirmed, witness name: CNA B, description of allegation: abuse- sexual harassment. Facility investigation findings: confirmed, signed by the ADM.Investigation packet included a signed statement from Resident #1, dated 01/09/26, When being questioned by social worker on 01/08/26, I expressed concerns about comments made to me by [CNA A]. She made comments about me 'having a nice ass' and going home with her, stating her home address, and telling me 'don't worry boo, I'll take care of you.' Another CNA, [CNA B] was present for these comments but CNA A stated [Resident #1] your only witness is [CNA B] and she gona deny it.' I did not report it at the time because I was scared of the report getting back to CNA A and it causing me to be kicked out of the facility.Investigation packet included a statement from the DON, During interview with Resident #1 regarding his alleged relationship with a CNA, he reports to DON and SW that [CNA A] made comments to him including telling him, 'you have a nice ass for a white boy' and 'you don't have to worry about leaving here, if you ever leave here you aren't going anywhere but to my house' in a flirting like manner and proceeded to give the resident her address. He also reports another CNA [CNA B] was present for these statements and can verify but that [CNA A] told him and [CNA B] not to say anything at the time. DON called facility 01/08/25 at 9PM and spoke to [CNA B] during her scheduled shift. [CNA B] confirms that all of these comments did take place by CNA A to Resident #1. She denied any further comments or any sexual contact to her knowledge. Record review of Associate Separation Record signed on 01/12/26 by CNA A, DON, and ADM reflected CNA A had a history of inappropriate behavior at the facility, the confirmed sexual harassment made Resident #1 feel awkward, humiliated, and embarrassed, and violated workplace rules. It reflected: Initial Conversations: August -October 2025 Multiple occasions on telephone and in person between employee, [CNA A], and DON, concerning threatening comments, bullying remarks toward coworkers, and complaints about CNA A's attitude and performance from other coworkers. Nursing wide inservice education provided: October 21, 2025, signed by [CNA A]. Second lnservice provided in person to all nursing staff and verbally over phone to [CNA A] from DON November 28, 2025. Ongoing phone calls and in person conversations between employee and DON with repeated complaints about coworkers, allegations against other associates, insubordination reports, and demands for disciplinary actions to be taken against various employees based on her unfounded allegations.January 8, 2025 [CNA A] adamantly directs DON to investigate, suspend, and write up an employee based on an alleged relationship between a resident and fellow CNA. She reports that everyone, including dietary, housekeeping, and all CNA's talk about this relationship, report to her about it, and all know that this is happening. Staff was interviewed and zero employees had any prior knowledge about any relationship or talk of any resident and staff relationship. The accused resident and staff member coincide that no relationship has ever occurred or even discussed to occur. However, during the investigation, the resident reports that [CNA A] has made multiple inappropriate comments to him about taking him home and his body parts. He also states that another CNA, [CNA B], was present for these remarks. [CNA B] confirmed these comments did occur. The resident reports that these comments made by [CNA A] caused him to feel awkward, humiliated, and embarrassed. The accused CNA reports feeling repeatedly targeted and bullied based on her current and previous actions/allegations.The bullying and intimidation by [CNA A] violates 500.4 Workplace Violence Prevention Policy for Health Care Facilities -Page 77,400.24 Performance Expectations numbers 4, 5, 14, 15, 17, 18, 21, 22, and 29. The inappropriate comments violates policies including 100.16 - Non-Discrimination & Antiharassment, Sexual Harassment section - Page 13, 400.24-Performance Expectations numbers 1, 12, 15, 17, 31. In an interview on 01/20/26 at 01:40 PM with the DON, revealed she first learned of the incident concerning Resident #1 on 01/08/26 after the SW completed an emotional distress evaluation for Resident #1 that was positive. She stated Resident #1 reported to the SW that CNA A made comments about his butt. Resident #1 stated this event occurred sometime approximately in November of 2025. The DON stated she became aware at this time also CNA B was a witness to the event and attempted to reach her but could not get ahold of her; she stated CNA B had a shift later that day and was interviewed. The DON stated on the evening of 01/08/26 during the interview with CNA B, she confirmed she was in the room present for the incident when CNA A made the comment to Resident #1 of having a cute ass for a white boy and making comments of taking him home to take care of him and giving him her address. The DON stated during the interview there was no confirmed sexual contact made between Resident #1 and CNA A. The DON stated the next day on 01/09/26, she also had a conversation with CNA B on needing to report things timely and asked her why this event was not reported. She stated CNA B told her during the incident CNA A made the comment to Resident #1 and CNA B [CNA B] is the only witness and she is going to deny it. The DON said CNA B stated she took this comment from CNA A telling her not to say anything. The DON stated there was no disciplinary action against CNA B for failing to report the incident but they did 1:1 in-servicing on the importance of reporting ANE in a timely manner. The DON stated upon learning of the incident on 01/08/26, CNA A was immediately suspended pending an investigation and not allowed to work with the residents, she stated CNA A remained out of the facility until 01/12/26 when she was called back in to the facility and terminated after the investigation revealed the allegations were founded and confirmed the sexual remarks were made. The DON stated it was her expectation if staff were a witness to any sexual harassment/ ANE or if they are aware of any allegations that it needs to be reported immediately. She stated a negative outcome of not reporting timely would be physical and emotional distress. The DON stated on the Friday after the suspension of CNA A [01/09/26] she had a phone call with CNA A to interview her over the phone about the allegations of sexual harassment of Resident #1. The DON stated during this phone call CNA A confirmed that she had in fact made those remarks to Resident #1 about having a nice ass for a white boy and she was asked if she gave her address and said she would take care of him and CNA A confirmed that had also occurred. In an interview on 01/20/26 at 02:05 PM with CNA B, she stated she was in the room when CNA A made the comments to Resident #1 that he had a cute butt and she said she wouldn't mind taking care of him if he got out. CNA B stated at the time the comments were made they were both in Resident #1's room assisting with repositioning. CNA B stated to her knowledge there was never any sexual contact made between Resident #1 and CNA A. CNA B stated when the comments were made Resident #1 did not seem uncomfortable. CNA B stated based on what she knew now, any sexual remarks made to residents should be reported immediately. She stated she believed at the time the comments were not inappropriate since Resident #1 did not seem bothered by it. CNA B stated she was not sure of what a negative outcome would be of not reporting verbal or physical sexual abuse or harassment of a resident. CNA B stated she learned there was an investigation into the incident recently, but the comments were made approximately November/ December. CNA B stated CNA A continued to work with Resident #1 after the comments were made. She stated she did not believe CNA A made similar comments to Resident #1 again or any other resident. CNA B stated she has known CNA A for a long time and were childhood friends and that was part of her personality she had a history of inappropriate comments and behavior. CNA B stated after the investigation began, she was in-serviced on the importance of reporting timely and the ANE policy. In an interview on 01/20/26 at 02:26 PM with Resident #1, he stated the inappropriate comments from CNA A about his butt were made in November of 2025, but he didn't tell anyone until recently when reporting it to the SW. Resident #1 stated there was another staff in the room at the time the comments were made, and identified CNA B as the witness to the event. Resident #1 stated he did not report the incident at the time due to feeling like he would have retaliation from CNA A. Resident #1 stated CNA A continued to work with him after the comments were made and continued to provide care such as ADL care. Resident #1 stated this was only verbal and there was no sexual contact made by CNA A. Resident #1 stated he felt uncomfortable by the comments made and uncomfortable with CNA A continuing to provide him care afterwards saying it brought him discomfort and embarrassment. In an interview on 01/20/26 at 03:36 PM with the ADM, she stated she became aware of the incident on 01/08/26 and she stated she immediately went to speak to Resident #1 to confirm the allegations and to get him to understand and feel comfortable coming to staff in situations such as this and she did not want him to fear being placed in another facility for something that was not his fault. She stated Resident #1 reported fear of being kicked out of the facility due to the event. The ADM stated the event with Resident #1 took place approximately in November of 2025. The ADM stated she did not speak to CNA A about the incident, as the DON was handling that. She stated to her knowledge in the conversation between the DON and CNA A, CNA A did say that she said those things confirming the incident. The ADM stated she did not ask CNA B why it was not reported earlier, she had also only been interviewed by the DON who managed the clinical staff and stated to her knowledge CNA B said she did not report this sooner out of fear of retaliation from CNA A. The ADM stated CNA A had a history of saying and spreading things that are not true. The ADM stated it was her expectation any verbal or physical sexual abuse or harassment of a resident should be reported immediately by staff to her or the DON. She stated it is important that the residents feel safe and that there is follow up. She stated a potential negative outcome of something like this going unreported would be that the harassment could continue to go on if unreported and fear from the resident. The ADM stated CNA A was suspended on 01/08/26 when they learned of the incident and then terminated on 01/12/26 after the event was confirmed. She stated the facility then in-serviced CNA B one on one in a lengthy discussion on the importance of reporting events timely. In an interview on 01/21/26 at 12:17 PM with the SW, she stated she first learned of the incident involving Resident #1 after the DON went to her and instructed her she needed to complete a mental distress assessment for Resident #1. The SW stated Resident #1 reported to her, CNA A made inappropriate comments to him and asked if he was in a relationship and then said to Resident #1 if you ever get out of here come see me and provided her address. The SW stated Resident #1 was a young man and nice and it is not appropriate for her to say those things to him. The SW stated Resident #1 did have mild distress during her assessment and he did have worry there were times she was coming on to him but nothing physical ever happened, so he laughed it off as a joke. The SW stated Resident #1 expressed he did not want what happened to disrupt his placement at the facility. The SW stated she advised Resident #1 he did not do anything wrong and provided reassurance. She stated at the time Resident #1 did not have any injuries, no behavior changes. She stated it was the expectation for all staff that if they witnessed or heard of alleged abuse, sexual harassment or physical abuse that it should be reported immediately and on that shift. She stated a potential negative outcome of it going unreported would be the abuse or harassment could continue and other residents would be at risk from that employee. She went on to say that for the witness the person that did not report becomes liable as well. The SW stated CNA B stated she did not report the incident due to being threatened by CNA A. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy last revised April 2021 reflected: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental or sexual, or physical abuse, and physical or chemical restraint not required to treat resident symptoms.The resident abuse, neglect and exploitation prevention program consist of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: facility staff. Record review of the facility's Resident Rights policy last revised February 2021 reflected: Employees shall treat all residents with kindness, respect, and dignity.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: be treated with respect, kindness, and dignity; be free from abuse, neglect, misappropriation of property and exploitation.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 facility reviewed for abuse and neglect. The facility failed to ensure CNA B reported verbal sexual abuse, of Resident #1 by CNA A, witnessed in November 2025, to the Administrator. This failure could place residents at risk for not having incidents reported as required.Record review of Resident #1's face sheet, dated 01/20/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included unspecified injury at unspecified level of thoracic spinal cord- subsequent encounter, osteomyelitis (infection of the bone marrow), post-traumatic stress disorder (mental health condition that is caused by an extremely stressful or terrifying event), need for assistance with personal care, and muscle weakness. Record review of Resident #1's quarterly MDS assessment, dated 11/14/25, reflected a BIMS score of 15, which indicated the resident's cognition was intact. Section GG for functional abilities reflected Resident #1 was completely dependent on staff for rolling left and right, transfers, bathing/hygiene, and dressing. Record review of Resident #1's care plan, revised 01/09/26, reflected a focus on [Resident #1] has hemiplegia/ hemiparesis r/t trauma / spinal injury (chest down) with interventions that included range of motion (active or passive) with am/pm care and a focus for [Resident #1] has an ADL self-care performance deficit with interventions that included the resident requires (dependent on staff) to turn and reposition. A focus was also seen for [Resident #1] stated he is having some (minimal) emotional distress per social worker after completing an emotional distress assessment with interventions that included, [Resident #1] stated he feels safe to report any abuse to administrator or staff, counseling for social determinant of health risk, education about safety plan, and referral to social worker. Record review of Resident #1's emotional distress/ psychosocial monitoring post incident report, dated 01/08/26, reflected a positive assessment based on the following responses: If interviewable does the resident report feelings of nervousness or anxiousness related to the specific incident you are evaluating response was marked yes If the resident is interviewable do they verbalize fearfulness related to the specific incident you are evaluating response was marked yesComments based on yes responses reflected, resident would like to be informed of what is really going on. He verbalized worry that incident connected to him may sabotage his placement. Distress is minimal per resident.Document reflected it was signed 01/08/26 by the SW Record review of Resident #1's progress notes reflected a noted, dated 01/08/26, entered by the DON, Notified by social worker that resident reported some events that need to be addressed by the DON and a positive emotional distress assessment. DON speaks with resident who reports a CNA has made inappropriate remarks to him and these comments made him feel uncomfortable but scared to report them because of fear he would be removed from the facility. Resident denied any sexual contact between himself and the reported CNA and states his only emotional distress is related to fear of not having a place to go if kicked out of this facility. Assured resident that he is not being removed from the facility, he is not at fault, and he should always report any inappropriate comments or actions to myself or administrator. He verbalizes understanding and states he feels better about the situation following our discussion. Record review of Resident #1's progress notes reflected a note, dated 01/09/26, entered by the ADM, Notified by DON that resident had reported to her inappropriate comments were being made by a CNA. Administrator approachedresident in his room. Resident did confirm inappropriate comments were made by a CNA. Administrator asked when this incident took place and resident responded sometime in November 2025. Administrator asked why he did not report this event then, and he responded that he feared being kicked out of the facility. Administrator assured him that any concern should be brought to the attention of the administrative personnel at anytime without fear of retaliation. Resident assured the Administrator that he would do this moving forward. Administrator did ask resident if the comments upset him and he responded no and that he was only afraid of being kicked out of the facility. Resident did not appear to be in any emotion distress at the time of this conversation. Record review of Resident #1's progress notes reflected a note, dated 01/09/26, entered by the ADON, NP notified of sexual harassment allegations and investigation concerning resident and an employee. She is advised that the resident is not physically harmed in any way, declined any sexual contact between them, and that he is reporting only emotional concerns about the facility kicking him out. She is also informed that the state is being notified as a result of the founded allegation of sexual harassment via inappropriate comments. She advises that if anything changes or the resident needs to be seen or evaluated for any concerns related to this incident to let her know and she can get off cycle visit scheduled to address needs. Record review of the facility's self-reported 3613 and investigation packet, dated 01/13/26, reflected intake 1061475, Resident involved: Resident #1, alleged perpetrator: CNA A, how was the AP identified: by name, perpetrator: confirmed, witness name: CNA B, description of allegation: abuse- sexual harassment. Facility investigation findings: confirmed, signed by the ADM.Investigation packet included a signed statement from Resident #1, dated 01/09/26, When being questioned by social worker on 01/08/26, I expressed concerns about comments made to me by [CNA A]. She made comments about me 'having a nice ass' and going home with her, stating her home address, and telling me 'don't worry boo, I'll take care of you.' Another CNA, [CNA B] was present for these comments but CNA A stated [Resident #1] your only witness is [CNA B] and she gona deny it.' I did not report it at the time because I was scared of the report getting back to CNA A and it causing me to be kicked out of the facility.Investigation packet included a statement from the DON, During interview with Resident #1 regarding his alleged relationship with a CNA, he reports to DON and SW that [CNA A] made comments to him including telling him, 'you have a nice ass for a white boy' and 'you don't have to worry about leaving here, if you ever leave here you aren't going anywhere but to my house' in a flirting like manner and proceeded to give the resident her address. He also reports another CNA [CNA B] was present for these statements and can verify but that [CNA A] told him and [CNA B] not to say anything at the time. DON called facility 01/08/25 at 9PM and spoke to [CNA B] during her scheduled shift. [CNA B] confirms that all of these comments did take place by CNA A to Resident #1. She denied any further comments or any sexual contact to her knowledge. Record review of Associate Separation Record signed on 01/12/26 by CNA A, DON, and ADM reflected CNA A had a history of inappropriate behavior at the facility, the confirmed sexual harassment made Resident #1 feel awkward, humiliated, and embarrassed, and violated workplace rules. It reflected: Initial Conversations: August -October 2025 Multiple occasions on telephone and in person between employee, [CNA A], and DON, concerning threatening comments, bullying remarks toward coworkers, and complaints about CNA A's attitude and performance from other coworkers. Nursing wide inservice education provided: October 21, 2025, signed by [CNA A]. Second lnservice provided in person to all nursing staff and verbally over phone to [CNA A] from DON November 28, 2025. Ongoing phone calls and in person conversations between employee and DON with repeated complaints about coworkers, allegations against other associates, insubordination reports, and demands for disciplinary actions to be taken against various employees based on her unfounded allegations.January 8, 2025 [CNA A] adamantly directs DON to investigate, suspend, and write up an employee based on an alleged relationship between a resident and fellow CNA. She reports that everyone, including dietary, housekeeping, and all CNA's talk about this relationship, report to her about it, and all know that this is happening. Staff was interviewed and zero employees had any prior knowledge about any relationship or talk of any resident and staff relationship. The accused resident and staff member coincide that no relationship has ever occurred or even discussed to occur. However, during the investigation, the resident reports that [CNA A] has made multiple inappropriate comments to him about taking him home and his body parts. He also states that another CNA, [CNA B], was present for these remarks. [CNA B] confirmed these comments did occur. The resident reports that these comments made by [CNA A] caused him to feel awkward, humiliated, and embarrassed. The accused CNA reports feeling repeatedly targeted and bullied based on her current and previous actions/allegations.The bullying and intimidation by [CNA A] violates 500.4 Workplace Violence Prevention Policy for Health Care Facilities -Page 77,400.24 Performance Expectations numbers 4, 5, 14, 15, 17, 18, 21, 22, and 29. The inappropriate comments violates policies including 100.16 - Non-Discrimination & Antiharassment, Sexual Harassment section - Page 13, 400.24-Performance Expectations numbers 1, 12, 15, 17, 31. In an interview on 01/20/26 at 01:40 PM with the DON, revealed she first learned of the incident concerning Resident #1 on 01/08/26 after the SW completed an emotional distress evaluation for Resident #1 that was positive. She stated Resident #1 reported to the SW that CNA A made comments about his butt. Resident #1 stated this event occurred sometime approximately in November of 2025. The DON stated she became aware at this time also CNA B was a witness to the event and attempted to reach her but could not get ahold of her; she stated CNA B had a shift later that day and was interviewed. The DON stated on the evening of 01/08/26 during the interview with CNA B, she confirmed she was in the room present for the incident when CNA A made the comment to Resident #1 of having a cute ass for a white boy and making comments of taking him home to take care of him and giving him her address. The DON stated during the interview there was no confirmed sexual contact made between Resident #1 and CNA A. The DON stated the next day on 01/09/26, she also had a conversation with CNA B on needing to report things timely and asked her why this event was not reported. She stated CNA B told her during the incident CNA A made the comment to Resident #1 and CNA B [CNA B] is the only witness and she is going to deny it. The DON said CNA B stated she took this comment from CNA A telling her not to say anything. The DON stated there was no disciplinary action against CNA B for failing to report the incident but they did 1:1 in-servicing on the importance of reporting ANE in a timely manner. The DON stated upon learning of the incident on 01/08/26, CNA A was immediately suspended pending an investigation and not allowed to work with the residents, she stated CNA A remained out of the facility until 01/12/26 when she was called back in to the facility and terminated after the investigation revealed the allegations were founded and confirmed the sexual remarks were made. The DON stated it was her expectation if staff were a witness to any sexual harassment/ ANE or if they are aware of any allegations that it needs to be reported immediately. She stated a negative outcome of not reporting timely would be physical and emotional distress. The DON stated on the Friday after the suspension of CNA A [01/09/26] she had a phone call with CNA A to interview her over the phone about the allegations of sexual harassment of Resident #1. The DON stated during this phone call CNA A confirmed that she had in fact made those remarks to Resident #1 about having a nice ass for a white boy and she was asked if she gave her address and said she would take care of him and CNA A confirmed that had also occurred. In an interview on 01/20/26 at 02:05 PM with CNA B, she stated she was in the room when CNA A made the comments to Resident #1 that he had a cute butt and she said she wouldn't mind taking care of him if he got out. CNA B stated at the time the comments were made they were both in Resident #1's room assisting with repositioning. CNA B stated to her knowledge there was never any sexual contact made between Resident #1 and CNA A. CNA B stated when the comments were made Resident #1 did not seem uncomfortable. CNA B stated based on what she knew now, any sexual remarks made to residents should be reported immediately. She stated she believed at the time the comments were not inappropriate since Resident #1 did not seem bothered by it. CNA B stated she was not sure of what a negative outcome would be of not reporting verbal or physical sexual abuse or harassment of a resident. CNA B stated she learned there was an investigation into the incident recently, but the comments were made approximately November/ December. CNA B stated CNA A continued to work with Resident #1 after the comments were made. She stated she did not believe CNA A made similar comments to Resident #1 again or any other resident. CNA B stated she has known CNA A for a long time and were childhood friends and that was part of her personality she had a history of inappropriate comments and behavior. CNA B stated after the investigation began, she was in-serviced on the importance of reporting timely and the ANE policy. In an interview on 01/20/26 at 02:26 PM with Resident #1, he stated the inappropriate comments from CNA A about his butt were made in November of 2025, but he didn't tell anyone until recently when reporting it to the SW. Resident #1 stated there was another staff in the room at the time the comments were made, and identified CNA B as the witness to the event. Resident #1 stated he did not report the incident at the time due to feeling like he would have retaliation from CNA A. Resident #1 stated CNA A continued to work with him after the comments were made and continued to provide care such as ADL care. Resident #1 stated this was only verbal and there was no sexual contact made by CNA A. Resident #1 stated he felt uncomfortable by the comments made and uncomfortable with CNA A continuing to provide him care afterwards saying it brought him discomfort and embarrassment. In an interview on 01/20/26 at 03:36 PM with the ADM, she stated she became aware of the incident on 01/08/26 and she stated she immediately went to speak to Resident #1 to confirm the allegations and to get him to understand and feel comfortable coming to staff in situations such as this and she did not want him to fear being placed in another facility for something that was not his fault. She stated Resident #1 reported fear of being kicked out of the facility due to the event. The ADM stated the event with Resident #1 took place approximately in November of 2025. The ADM stated she did not speak to CNA A about the incident, as the DON was handling that. She stated to her knowledge in the conversation between the DON and CNA A, CNA A did say that she said those things confirming the incident. The ADM stated she did not ask CNA B why it was not reported earlier, she had also only been interviewed by the DON who managed the clinical staff and stated to her knowledge CNA B said she did not report this sooner out of fear of retaliation from CNA A. The ADM stated CNA A had a history of saying and spreading things that are not true. The ADM stated it was her expectation any verbal or physical sexual abuse or harassment of a resident should be reported immediately by staff to her or the DON. She stated it is important that the residents feel safe and that there is follow up. She stated a potential negative outcome of something like this going unreported would be that the harassment could continue to go on if unreported and fear from the resident. The ADM stated CNA A was suspended on 01/08/26 when they learned of the incident and then terminated on 01/12/26 after the event was confirmed. She stated the facility then in-serviced CNA B one on one in a lengthy discussion on the importance of reporting events timely. In an interview on 01/21/26 at 12:17 PM with the SW, she stated she first learned of the incident involving Resident #1 after the DON went to her and instructed her she needed to complete a mental distress assessment for Resident #1. The SW stated Resident #1 reported to her, CNA A made inappropriate comments to him and asked if he was in a relationship and then said to Resident #1 if you ever get out of here come see me and provided her address. The SW stated Resident #1 was a young man and nice and it is not appropriate for her to say those things to him. The SW stated Resident #1 did have mild distress during her assessment and he did have worry there were times she was coming on to him but nothing physical ever happened, so he laughed it off as a joke. The SW stated Resident #1 expressed he did not want what happened to disrupt his placement at the facility. The SW stated she advised Resident #1 he did not do anything wrong and provided reassurance. She stated at the time Resident #1 did not have any injuries, no behavior changes. She stated it was the expectation for all staff that if they witnessed or heard of alleged abuse, sexual harassment or physical abuse that it should be reported immediately and on that shift. She stated a potential negative outcome of it going unreported would be the abuse or harassment could continue and other residents would be at risk from that employee. She went on to say that for the witness the person that did not report becomes liable as well. The SW stated CNA B stated she did not report the incident due to being threatened by CNA A. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy last revised April 2021 reflected: Investigate and report any allegations within timeframes required by federal requirements.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 4 (Resident #24, Resident #14, Resident #11, and Resident #86) of 8 residents reviewed for infection control. CNA C and CNA D failed to wash their hands and change their gloves when removing a soiled brief and placing a clean brief during peri care observation for Resident #11. LVN A placed soiled linens and dressing on the Resident #86's floor during wound care. CNA B and LVN A failed to change their gloves or cleanse their hands when removing a dirty brief and placing a clean brief on Resident #86. MA E failed to sanitize blood pressure monitor before, in between and after use on Resident #24 and Resident #14. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Resident #11 Record review of Resident #11's undated face sheet reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (Stroke a disruption of the blood flow to the brain causing part of the brain to die), dementia (a chronic condition causing a decline in cognitive functioning such as thinking, remembering, and reasoning), and anxiety disorder. Record review of Resident #11's care plan dated 11/02/2022 reflected she had an ADL Self Care Performance (Bed Mobility, Transfers, Eating, Bathing, Dressing, and Personal Hygiene) Deficit. Her goals included: Resident #11 will maintain current level of function in ADL's, through the next review date. Interventions included The resident requires assistance (wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet) to use toilet. Record review of Resident #11's Quarterly MDS assessment, dated 09/12/2024, reflected she had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #11 was coded always incontinent of bowel and bladder and as dependent for toileting and toileting hygiene indication the helper or CNA does all the effort to complete the activity. In a peri care observation on 11/25/24 at 2:30 PM CNA C and CNA D did not change their gloves or wash their hands when removing a dirty brief and applying a clean brief. In an interview on 11/25/24 at 2:58 PM CNA C and CNA D stated they had been trained on infection control and peri care. They stated the nurses visually check CNA's off on peri care annually with skills training. They just stated they forgot to wash their hands. They stated not changing gloves or washing hands when working from a dirty to clean surface or area could spread germs and bacteria. Resident #86 Record review of Resident #86's undated face sheet reflected she was a [AGE] year-old female, originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Pneumonia, Respiratory Failure, Acute Kidney Failure, and Gastro-esophageal reflux (indigestion). Record review of Resident #86's care plan dated 10/19/2023 and revised on 03/07/24 reflected she had a history of urinary tract infections. Interventions included Resident/family/caregiver teaching should include good hygiene practices: Females to wipe and cleanse from front to back, clean peri area well after bowel movement in order to help prevent bacteria in urinary tract. Record review of Resident #86's Admission MDS assessment, dated 11/17/2024, reflected staff assessment of her mental status indicated short term and long-term memory problems. The MDS indicated Resident #86 was able to recall her own room and names of staff. Resident #86 was Substantial/maximal assistance staff assistance with eating, personal hygiene, toileting, and showering. Section H of the MDS Bowel and Bladder indicated resident #86 was always incontinent of bowel and bladder. Record review of Resident #86's Physician Orders Summary Report dated 11/26/24 reflected an order for care to surgical incision to left gluteal fold (left buttocks) that read cleans with wound cleanser and gauze, pat dry with gauze, pack wound with iodoform packing strip (a gauze strip soaked in iodine) and apply dry dressing to wound daily. In a wound care and peri care observation on 11/25/24 at 11:38 AM for Resident #86 LVN A and CNA B removed the soiled brief and linens and place them unbagged on the floor in the room. CNA B cleansed Resident #86 from front to back and placed a new clean brief under resident without washing her hands or changing her gloves. LVN A then removed a soiled dressing from Resident #86's left buttocks and placed the soiled dressing in the pile with the soiled linens and soiled brief on the resident's floor. LVN A then changed her gloves and applied a clean pair. LVN A did not wash her hands or use alcohol-based hand sanitizer between glove changes. LVN A packed wound to left buttocks and applied a clean dressing. In an interview on 11/25/24 at 12:00 PM CNA B stated staff do normally use alcohol-based hand sanitizer in between glove changes. She stated they were trained on infection control often. CNA B stated the risk for the resident for not cleansing hands and using clean gloves would be passing germs from one to the other. She stated normally staff keep trash bags available at bedside and put soiled linens in the trash bag. Soiled briefs were placed in the trash can and staff change the liner out when removed. CNA B stated it was not practice putting soiled linens or briefs on the floor. She stated the risk for residents for not cleansing hands and placing soiled linens on the floor wound be spreading germs. In an interview on 11/25/24 at 12:10 PM LVN A stated she does not normally perform peri care on residents. I'm not aware of what the policy says about glove changes between dirty and clean surfaces. LVN A stated yes she normally throws soiled linens on the floor if the dirty has been folded up inside. She stated the housekeepers come in and mops the floor. LVN A stated she had thrown soiled wound dressings on the floor if the dirt is on the inside. She stated risk to the residents for not cleaning hands and placing soiled linens on the floor would be spreading germs. Resident #24 Record review of Resident #24's face sheet dated 11/26/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were, Type 2 diabetes, Edema (swelling), Adjustment disorder with mixed anxiety and depressed, Pain in right hip, Chronic obstructive pulmonary disease ( difficulty to breath) , Muscle weakness and Lack of coordination, Record review of Resident #24's care plan dated 10/11/24 reflected Resident #24 had hypertension and relevant intervention was giving anti-hypertensive medications as ordered and monitoring side effects such as orthostatic hypotension and increased heart rate. Record review of Resident #24's quarterly MDS assessment, dated 09/17/24 revealed a BIMS score of 14 indicating her cognition was intact. Resident #14 Record review of Resident #14's face sheet dated 11/26/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were Cognitive communication deficit, Anemia, Unsteadiness on feet, Difficulty in walking, Lack of coordination, Type 2 diabetes, Hypertension and Muscle weakness. Record review of Resident #14's care plan dated 09/11/24 reflected, she had hypertension and relevant intervention was giving anti-hypertensive medications as ordered and monitoring side effects such as orthostatic hypotension and increased heart rate and effectiveness. Record review of Resident #14's quarterly MDS assessment, dated 09/06/24 revealed a BIMS score of 01 indicating her cognition was severely impaired. An observation on 11/26/24 at 8:25AM , revealed MA E failed to sanitize the blood pressure monitor before using it on Resident #24, in between Resident #24 and Resident #14 and after Resident #14. MA E took the blood pressure monitor from the top of the med cart and without sanitizing it she took the blood pressure of Resident #24. MA E then moved on to Resident #14 and took her blood pressure with the same blood pressure monitor without sanitizing it. After completing the measurement on Resident #14, without cleaning the blood pressure monitor ,she kept it on the top of the med cart. During an interview on 11/26/24 at 9:05AM , MA E stated she was working at the facility for about [AGE] years. MA E said she was concentrating on administering medications for the residents and forgot to sanitize blood pressure cuff before and after using it on Resident #24 and Resident #14. She stated it was important to follow infection control protocol and sanitize the blood pressure cuffs before using it on the residents. She added, this was essential to minimize the risk of spreading contagious diseases. MA E stated she was aware of the importance of sanitizing medical equipment and received training in the past however did not remember exactly when it was. In an interview on 11/26/24 at 11:48 AM the DON stated it was her expectation that all staff followed the policy for infection control. She stated when staff cross from a dirty to a clean area, they should disinfect their equipment, change their gloves and use alcohol-based hand sanitizer gel in between dirty and clean surfaces. She stated linens were to be bagged and disposed of properly. She stated she was responsible for training the staff on infection control. She stated the risk for residents for not cleaning hands, equipment items like blood pressure monitor , and maintaining a clean environment would be cross contamination and spreading of infections. In an interview on 11/26/24 at 12:00 PM the ADM stated it was his expectation staff to follow policy and procedures for infection control. He stated that the DON had in serviced the staff on peri care, handwashing we and infection control practices. The ADM stated The DON was responsible for providing education on infection control. He stated she completed the Inservice quarterly and as needed. The ADM stated the risk to the resident for not following infection control practices would be the spread of infections. Record review of the facility's policy titled Dressings, Soiled/Contaminated dated 2001 Revised 2009 reflected: Disposable items such as bandages, applicators, gauze pads, that are soiled or contaminated with infective material, blood, or body fluids must be place in a plastic bag and removed from the residents' room upon completion of any procedure. Record review of the facility policy titled Laundry and Bedding, Soiled dated 2001 Revised 2018 reflected: Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. Record review of the facility policy titled Handwashing / Hand Hygiene dated 2001 Revised 2023 reflected: Hand Hygiene is indicated: after contact with blood, body fluids or contaminated surfaces, after touching a resident, after touching a resident's environment, before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. Review of the facility's policy titled Cleaning and disinfection of Resident care Items and Equipment revised in October 2018 reflected: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. The purpose of this procedure is to provide guidelines for disinfection of non-critical resident care items. . 1.The following categories are used to distinguish the levels of sterilization/ disinfection necessary for items used in resident care d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment)

Based on observatations, interviews, and record review, the facility failed to ensure the medical record contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatments and/or services, and changes in his/her condition for 1of 7 residents (Resident #1) review for resident assessments. The facility failed to ensure Resident #1's Weekly Nursing Summary dated 08/14/24, 08/21/24 & 08/28/2024 reflected that Resident #1 had an indwelling catheter. This deficient practice could place residents at-risk for inadequate care due to an inaccurate assessment. Findings included: A record review of Resident #1's face sheet dated 08/29/24 reflected a [AGE] year-old male who was readmitted to the facility on [DATE]. Resident #1's diagnoses included retention of urine (a condition that make it difficult or impossible to empty the bladder), muscle wasting and atrophy (loss of muscle tissue), chronic kidney disease stage 4 (when the kidneys are severely damaged and can't filter waste from the blood as well as they should), and muscle weakness (loss of muscle strength). A record review of Resident #1's Quarterly MDS assessment, dated 07/31/24, reflected Resident #1 had a BIMS score of 14, which indicated cognitively intact. Resident #1's Quarterly MDS Section H Bladder and Bowel reflected that Resident #1 had an indwelling catheter. A record review of Resident #1's care plan, dated 06/11/24, reflected Resident #1 was care planned for history of urinary tract infection, chronic kidney disease, and an indwelling catheter. A record review of Resident #1's Weekly Nursing Summary , dated 08/14/24, 08/21/24 & 08/28/2024 reflected Resident #1 did not have a catheter. During an observation and interview on 08/29/24 at 10:15 a.m., Resident #1 appeared to have a catheter with a navy-blue privacy bag cover. Resident #1 stated he has had a catheter since he was admitted to the facility. In an interview on 08/29/24 at 1:15pm, LVN A stated that Resident #1 has had a catheter since his admission. LVN A stated if a resident had a catheter, but an assessment did not reflect the catheter the resident would not receive proper care. In an interview on 08/29/24 at 3:45 p.m., the DON stated that Resident #1 was admitted to the facility with a catheter. The DON stated that the Weekly Nursing Summary should have reflected Resident #1's catheter. The DON stated that if the Weekly Nursing Summary was inaccurate that could cause the resident to receive inadequate care. In an interview on 08/29/24 at 3:55 p.m., the ADM stated Resident #1 had catheter. The ADM stated Resident #1's Weekly Nursing Summary should have reflected Resident #1's catheter. The ADM stated it was the nurse's responsibility to ensure the Weekly Nursing Summary was completed accurately. The ADM stated if resident's assessment was inaccurate that could cause the resident to receive improper care. A record review of the facility's Charting and Documentation policy, dated July 2017, reflected, 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. Medication administered; c. Treatment 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; 3. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate .

Based on interviews and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 7 residents (Resident #1) reviewed for assessments. The facility failed to ensure Resident #1's weekly skin assessments were performed timely, accurately, and appropriately. This failure could place residents at risk of missing treatment needs. Findings included: Record review or Resident #1's AR, dated 4/2/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with a urinary tract infection (which was the result of bacteria, that caused an infection of the urinary system,) chronic kidney disease, stage 3 (which was a disease of the kidney that disrupted the body's ability to filter impurities,) and diabetes mellitus type 2 (which was a condition of the body that disrupted how the body used sugar for fuel.) Record review of Resident #1's Admission MDS, dated [DATE], reflected Section C., Cognitive Patterns; Resident #1 had a BIMS Score of 15. (A BIMS Score of 15 indicated no cognitive impairment). Section M., Skin Conditions reflected Resident #1 he was not a risk for pressure ulcers; had no unhealed pressure ulcers; had no venous or arterial ulcers; had no infections of the feet; had no diabetic foot ulcers; had no open lesions of the feet; and he had no moisture associated skin damage. The resident did not reflect any skin/ulcer or injury treatments. Section GG., Functional Abilities and (Range of Motion;) Resident #1 had no impairment on either side of his upper extremities (shoulder, elbow, wrist, and hand) and no impairment in either lower extremities (hip, knee, ankle, and foot.) Resident #1 utilized a wheelchair for mobility. Resident #1 was dependent upon staff for toileting hygiene, shower/bathe self, lower body dressing, and putting on/talking off shoes, sitting to standing, chair/bed to chair transfer, and tub/shower transfer. Being dependent upon staff meant the helper did all of the effort, or the assistance of 2 or more helpers was required for the resident, to complete the activity. Record review of discharge paperwork for hospitalization from a 1/28/2024 to 2/2/2024. On 2/2/2024, the resident returned to the nursing facility. Record review of a complaint, made on 2/2/2024, reflected Resident #1 was hospitalized on [DATE] through 2/2/2024 for low blood pressure and low urine output. He released from the local hospital on 2/2/2024 to return to the nursing facility. The complainant made allegations that Resident #1 was not receiving appropriate skin care. Record review of Resident #1's CP, initiated on 2/2/2024, reflected a focus area for skin conditions, evidenced by Resident #1 having returned from the hospital on 2/2/2024 with a stage II pressure injury to his coccyx, tailbone, and a scabbed area on top of his bi-lateral feet. The goal, initiated on 2/5/2024, reflected Resident #1 would have intact skin, free from redness, blisters, or discoloration. Resident #1's pressure injury would show signs of healing and remain free from infection. The intervention, initiated 2/2/2024, reflected nursing staff would administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing at least weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report declines to the MD. Avoid positioning the resident on (coccyx). Do not massage over bony prominences and use mild cleansers for peri care/washing. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. Record review of Resident #1's WSA performed on WSA 2/15/2024 reflected other skin finding reflected redness r/t friction on inner thigh area- barrier cream applied. Signed 2/28/2024 by the DON. (The WSA was not completed timely as the document was dated to have occurred on 2/15/2024 but was not signed until 13 days later on 2/28/2024.) Record review of discharge paperwork for hospitalization from a 2/18/2024 to 3/3/2024. On 3/3/2024, the resident returned to the nursing facility Record review of Resident #1's WSA performed on 2/22/2024 reflected other skin finding reflected redness r/t friction on inner thigh area-barrier cream applied. Signed 3/04/2024 by the DON. (The WSA was not accurate because Resident #1 was not at the facility on 2/22/2024.) Record review of Resident #1's WSA performed on 2/29/2024 reflected other skin finding reflected redness r/t friction on inner thigh area-barrier cream applied. Signed 3/04/2024 by the DON. (This WSA was not accurate because Resident #1 was not at the facility on 2/29/2024.) Record review of a WSA performed on 3/14/2024 reflected other skin finding reflected redness r/t friction on inner thigh area-barrier cream applied. Signed 3/20/2024 by the DON. (The WSA was not completed timely as the document was dated to have occurred on 3/14/2024 but was not signed until 6 days later on 3/20/2024.) A telephone interview on 4/01/2024 at 12:57 PM with the complainant revealed Resident #1 admitted to the local hospital for low urine output and low blood pressure on 1/28/2024. While in the care of the facility, the complainant learned that Resident #1 had skin integrity issues and thought the facility could do more to protect his skin. The hospital treated Resident #1's skin concerns and he discharged back to the nursing facility on 2/2/2024. Interview and observation on 4/02/2024 at 9:40 AM with Resident #1 revealed he had been at the facility since the end of November 2023. He was observed was lying on his back. His feet and ankles were in PU relieving boots with a pillow in between; There was a visible bandage on the resident's right foot/ankle dated 4/01/2024. The visible portions of his feet were observed clean with recently trimmed nails. He denied pain with his wounds. Resident #1 revealed he did not have any pressure ulcers on his body when he came to the facility, but he had developed pressure ulcers and sores on his feet, ankles, and back side since his arrival. Since his return to the facility on [DATE], Resident #1 was receiving skin assessments, ulcer assessments, and VOHRA. He has been provided with pressure relieving boots and staff have been placing a pillow between his legs to provide comfort. He denied physical pain associated with his wounds. Interview on 4/04/2024 at 2:15 PM with LVN B revealed she had been an LVN for [AGE] years and had been working at the facility for the last 3.5 years. She stated that she had been trained to complete accurately and to sign the treatment note once completed. She described timely documentation to be done as soon as possible. She remembered a time when she was 2 days late with accurate and timely documentation and she received a one-on-one counseling. She stated that staff was not allowed to enter documentation for other staff members. She stated late and inaccurate documentation placed residents at [NAME] of meeting treatments, the need for follow up assessments, and worsening health condition. Interview on 4/04/2024 at 2:25 PM with LVN D revealed she had been an LVN for the last 8 years and had been working at the facility for the last 10 months. She stated she had been trained to perform accurate assessments and to make sure they were completed at the time. She explained she had been late one time with an assessment and was counseled by the DON the next day. Timely and accurate documentation helps the team provide care to the resident and inaccurate, or missing information, placed the resident at risk of missing important aspects of care. Interview and record review on 4/4/2024 at 4:40 PM with the DON revealed WSA were supposed to be performed weekly. The WSAs were supposed to be filled out by the nursing staff and the assessments were supposed to be passed along to the DON and the ADON with any issues or concerns. The DON stated WSA performed on 2/15/2024 was completed by her but was not signed until 2/28/2024, 13 days later. She stated she did not perform the WSA but got the assessment on a piece of paper from a nurse and entered the information for a nurse after the fact. The WSA performed on 2/22/24 was completed by the DON on 2/22/24 but was not signed until 3/04/2024, 13 days later. The DON stated that she had been having trouble with staff not completing their notes on time. She knew she was not supposed to be entering other staff's documentation, but she did it anyway to help them out. If the resident's skin condition did not get identified through assessments, the failure was the first line of defense, who were the CNAs, who did not report skin conditions to the charge nurse. The second line of defense, who were the charge nurses, were supposed to document skin conditions and refer those issues with the ADON and the DON. The third line of defense, who were the ADON and the DON, were at fault for inaccurate assessments because they were not checking behind the nursing staff. There were no safeguards in place to identify documentation errors. If there were, she stated we would have caught them. The DON stated that untimely and inaccurate documentation placed residents at risk of missing treatments, worsening of wounds, missing follow up care, and having their needs go unmet. The DON was the facility's Assessment Coordinator. Interview on 4/4/2024 at 4:40 PM with the ADM revealed he expected his staff to follow facility policy and make sure assessments were accurate, appropriate, and timely. He stated a daily assessment should be completed that day and a weekly assessment should be completed that week. Late documentation, inaccurate, or inappropriate documentation placed the residents at risk of facing barriers to receiving good care. A fail safe in place to catch errors in documentation was the standard of care meeting held each week. Also, the DON and the ADON were supposed to be following up on staff to make sure documentation was being completed correctly. If there were documentation errors committed by the DON, the ADM felt the regional nurse was at fault for not checking up and making sure the DONs documentation was being done correctly. The DON was the facility's assessment coordinator. Record review of the facility's Resident Assessment Policy, dated October 2023, reflected the assessment coordinator was responsible for ensuring timely and appropriate resident assessments. Assessments were completed by staff members who had skills and qualifications to assess relevant care areas and who were knowledgeable about the resident's strengths and areas of decline.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development of transmission of communicable diseases and infections for 1 ( Resident # 26) of 2 residents reviewed for infection control. LVN B failed to perform hand hygiene while performing wound and incontient care for Resident #26. This failure could place residents at risk for cross contamination and infection. Findings include: Record review of Resident #26's face sheet, dated 10/11/2023, reflected a [AGE] year-old female who was admitted to the facility on ,d+[DATE]. Resident #26 had diagnoses which included Atrial Fibrillation (irregular heart rate), Hypertension (elevated blood pressure), Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves), Pressure ulcer of sacral region (an injury to skin and underlying tissue resulting from prolonged pressure on the skin) and Non Pressure Chronic Ulcer ( a wound caused by poor circulation to the lower extremities). Record review of Resident #26's significant change MDS , dated 7/25/2023, reflected a BIMS score of 13, which indicated the resident was cognitively intact. Record review of Resident #26 physician orders, dated 9/27/2023, reflected clean wound to right anterior ankle with wound cleanser, apply alginate pad and cover with dressing. Clean wound to left lateral foot with wound cleanser, apply alginate pad and cover with dressing. Clean wound to coccyx with wound cleanser, pack with alginate pad, cover with dressing. Clean blister to right lateral foot, cleanse with wound cleanser and cover with dressing. Observation on 10/11/2023 at 1:30 PM revealed LVN B preformed wound care on Resident #26. LVN cleaned and placed ordered wound care and dressing on right anterior ankle without changing gloves or preforming hand hygiene. LVN B then cleaned and placed ordered wound care on the left lateral foot without changing gloves or preforming hand hygiene. LVN B then removed gloves, preformed hand hygiene, and left the room to gather supplies. LVN B performed hand hygiene upon return to room. LVN B preformed incontinent care and changed gloves without preforming hand hygiene. LVN B removed soiled dressing to coccyx, cleaned the wound, applied ordered treatment and applied dressing without changing gloves or preforming hand hygiene. LVN B then changed gloves and preformed wound care to the right foot, removing the dressing, cleaning the wound and applying a clean dressing without changing gloves or preforming hand hygiene. Interview on 10/11/2023 at 1:45 PM with LVN B, she stated she thought as long as she did care on the same resident it was not necessary to change gloves. LVN B stated she thought the policy might say to change gloves between dirty and clean. She stated she could imagine cross contamination could occur if gloves were not changed and proper hand hygiene was not preformed. Interview on 10/12/2023 at 1:00 PM with the DON, she stated her expectations was infection control and proper hand hygiene be used by staff when providing any resident care. When preforming wound care the gloves should be changed and hand hygiene done between removing the dirty dressing and wound cleaning and applying wound treatments and a clean dressing . Potential risk to resident is infection of the wound. Interview on 10/12/2023 at 1:30 PM with the ADM, he stated his expectation was all staff followed the infection control and hand hygiene policies when interacting with residents. He stated he expected the policy and procedures for resident care be followed. He stated failure to follow these policies could place the residents at risk of infection. Record review of the policy titled Dressing Dry/clean, dated September 2013, revealed .6. Put on clean gloves, loosen tape and remove soiled dressing, 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly. 13. Put on clean gloves, 15. Cleanse the wound as ordered.

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 reviewed for dietary services. 1. The facility failed to ensure food items in the refrigerator were dated and labeled appropriately. 2. The facility failed to ensure expired items were discarded. These failures could place residents in the facility at risk for food-borne illness, and food contamination. Findings included: Observations of the walk in Refrigerator in the kitchen on [DATE] at 9:15 AM revealed the following items were either expired and/or not dated and labelled appropriately: Three packets of honey ham with 'used by [DATE]' written on the box. 3 packets of honey ham in a box with [DATE] written on it. There was no used by date. ,d+[DATE] unsealed packet of sausage with no date on it. Observation and interview on [DATE] at 9:30 am with the DS revealed the above-mentioned items and deficiencies. He immediately removed those items from the shelves of the refrigerator. He said he never knew that the used by date was a mandatory requirement. He also stated that the expired items should not be there. He took full responsibility of the mistakes and stated he was determined to eliminate these issues in the future. During the interview with the Diet over the phone on [DATE] at 1:00 PM, she stated the 'used by date' should be written on opened packets, leftovers and items removed from freezer to the refrigerator. She stated the shelf life of ham is five days when it is in the refrigerator. She would be providing a list of items and their allowed shelf lives to the kitchen at the facility for future reference. During an interview with the ADM on [DATE] at 10:00 AM, he stated that labelling (that includes 'used by date') on every product that are stored was mandatory and expired items should be discarded immediately. He said a deficiency in food handling was evident in the kitchen and he would be organizing an in-service with the support of the Diet to address this issue. Record review of the Dietary Services- Departmental Operations policy revised on August, 2010, revealed . 6. Dry foods that are stored in bins will be removed from original packaging, labelled and dated ('used by' date). Such food will be rotated using a 'first in- first out system'. 7. All foods stored in the refrigerator or freezer will be covered, labeled, dated ('use by' date) .

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 1 residents reviewed for medication administration (Residents #23). Licensed Vocational Nurse (LVN) failed to properly wash or sanitize her hands when moving from Resident to Resident when administering medications to resident # 23. This deficient practice placed all residents identified at risk for cross contamination and the spread of infection. Findings include: Review of Resident #23's face sheet reflected Resident #23 was a [AGE] year-old female with an admitted [DATE]. Resident #23's diagnoses included anemia (blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells), diabetes type 2 (high blood sugar, insulin resistance, and relative lack of insulin), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), muscle wasting and atrophy (when muscles waste away), and hypokalemia (a low level of potassium in the blood serum). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #23 was cognitively intact and able to complete an interview. During an observation on 08/15/2022 at 11:37 AM, LVN was observed passing medication to Residents #10 and #23 without sanitizing hands in between. LVN prepared and administered medications to Resident #10 and then without washing or sanitizing hands, prepared and administered Resident #23's medications. During an interview on 08/15/2022 at 11:41 AM, LVN stated no, she did not sanitize her hands in between passing medication to the 2 residents. She stated she just forgot to sanitize her hands in between the 2 residents. She stated she normally sanitized her hands in between residents, and it was their policy to do so. She stated she was in-serviced regularly on handwashing and sanitizing hands when passing medication or doing anything in between residents. She stated she was aware that not sanitizing her hands in between residents could spread germs and increase the risk of infection which could possibly cause harm to residents. During an interview on 08/16/2022 at 11:22 AM, MA stated she either washed or sanitized her hands in between every resident when passing medications. She stated she was in-serviced regularly on handwashing and sanitizing hands when passing medication or doing anything in between residents. She stated she believed that not sanitizing hands in between residents could spread germs and increase the risk of infection which could possibly cause harm to residents. She stated no matter what department or title someone was, whether they are in management or working on the floor, everyone should wash or at least sanitize their hands when going from one resident to the next. During an interview on 08/16/2022 at 12:52 PM, ADON stated she washed or sanitized her hands in between every resident no matter what task she was performing and always in between administering medications. She stated she had been in-serviced on handwashing/sanitizing hands when going from one resident to another and performing any task. She stated she believed that not sanitizing or not washing hands in between residents could cause an increased risk of spreading infection and could potentially cause harm to a resident. During an interview on 08/16/2022 at 1:00 PM, the DON stated it was her expectation that all staff washed or sanitized their hands when going from resident to resident when passing medications or performing any task. She stated she in-serviced staff on handwashing or sanitizing hands when going from resident to resident when performing any task including administering medications. She stated she believed that not sanitizing or not washing hands in between residents could cause an increased risk of spreading infection and could potentially cause harm to a resident. During an interview on 08/16/2022 at 1:12 PM, the ADM stated it was his expectation that all staff washed or sanitized their hands in between every resident when passing medication or performing any task. He stated he is in-serviced staff regularly on handwashing or sanitizing hands when going from resident to resident during any task including medication administration. He stated he believed that not sanitizing or not washing hands in between residents could cause an increased risk of spreading infection and could potentially cause harm to a resident. Review of the Handwashing/Hand Hygiene policy (revised August 2019), provided by the ADM, titled revealed the following: policy statement: This facility considers hand hygiene the primary means to prevent the spread of infections; # 2. stated all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. #7 stated use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: c. Before preparing or handling medications. Review of the Administering Medications policy (revised April 2006) provided by the DON revealed the following: Policy Interpretation and Implementation; # 2. Established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) must be followed during the administration of medications. Review of the Policies and Practices - Infection Control policy (revised September 2005) provided by the DON, revealed the following: Policy Statement: The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation; # 4. All personnel will be informed of our infection control policies and practices, including where and how to find and use pertinent procedures. Review of documents dated 07/11/2022, 07/20/2022, and 08/03/2022 revealed staff was in-serviced frequently on handwashing and policies and practices of infection control. Review of documents 07/11/2022 on handwashing and policies and procedures - infection control, revealed LVN attended these in-services.

Based on observation and interview, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff and resident for one (Hall 4 medicating cart) of 1 medication carts reviewed for medication storage. The medication cart on Hall 4, outside the medication room, was observed to be unlocked and left unattended by LVN A. These failures could place residents at risk of drug diversion and access to medications. Findings included: Observation on 10/12/2021 at 1:43 PM revealed the medication cart located on Hall 4, next to the medication room, was unattended and unlocked until 1:51 PM. Observation of all drawers revealed the drawers were unlocked and contained over-the-counter and prescription medications . Interview on 10/12/2021 at 1:51 PM LVN A stated she had been in the medication room collecting refilled medications for the medication cart and she was working as a medication aide today. She stated it was not the normal procedure to walk away from the medication cart while it was unlocked. She stated, as soon as she walked out of the medication room and saw she had left the cart unlocked, it was not the correct procedure. She stated she should have made sure the drawers were closed and the cart was locked, and that she had the keys with her . In an interview on 10/12/2021 at 3:07 PM DON stated it was her expectation that all medication carts are to be locked if the staff must be more than an arms-length from the cart. She stated she has already put out an in-service for the nursing staff about that issue. She stated LVN A told her what had happened and admitted that she knew she should not have left the cart unlocked . During the exit conference on 10/12/2021 at 3:49 PM RVPO stated he was sorry to hear the medication cart had been left unlocked, and it should have been locked . Policy for Medication Storage was requested on 10/12/2021 but not provided prior to exit.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food under sanitary conditions in the kitchen. A clear plastic bag of chicken was not dated or labeled A clear plastic bag of hamburger patties was not dated or labeled. This failure could place the residents who ate meals prepared in the kitchen at risk for food borne illness. Findings included: During an observation of the freezer on 06/14/21 at 8:29 a.m., there was an unlabeled clear bag of raw chicken and an unlabeled clear bag of raw hamburger patties with no date. During an interview on 06/14/21 at 9:36 a.m., Cook A said the weekend cook didn't label or date the chicken and hamburger patties before putting it back in the freezer. During an interview on 06/16/18 at 9:25 a.m., the DM said he expects all staff to follow the rules by labeling and dating all foods. During an interview on 06/16/21 a.m., 9:45 a.m., the Administrator said he expects the staff to follow the policies and procedures and to label and date the plastic bangs out of the boxes. A policy on Food Receiving and Storage, revised December 2008 read in part: .all food stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

Based on record review and interview, the facility failed to ensure residents have the right to formulate an advance directive, for 1 of 6 residents (Resident #13) reviewed for advanced directives in that: 1. Resident #13 did not have a signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice could put residents at risk of not having their wishes known, which could delay emergency treatment or incur unwanted treatment. Findings: 1. Review of Resident #13's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #13's Electronic Medical Record (EMR) Point Click Care (PCC) indicated the Code Status was Full Code, order for full code dated 02/01/21 and an executed, signed by resident representative (Out-Of-Hospital Do-Not Resuscitate (OOH-DNR) dated 4/19/21. Review of Resident #13's consolidated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's care plan for code status indicated: Goal: Resident is a FULL CODE status. Interventions: Review medical record to ensure that proper documentation is signed date initiated 1/27/21 and revision date 02/03/21. Interview on 06/20/21 at 3:30 p.m. the DON said I personally am responsible for the documentation of that OOH-DNR being implemented and will have the proper documentation obtained and filed in the medical record. She said this error could results in resident harm by unwanted interventions. Review of facility policy, dated April 2006, titled Do Not Resuscitate Order: Policy statement: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. An Out of Hospital DNR form must be completed and signed by the attending physician and the resident (or resident's responsible party) and placed in the front of the Resident's medical record. legal surrogate, as permitted by the state law.

Based on observation, interview, and record review the facility failed to ensure the policy regarding safe and sanitary storage of food items was implemented for 1 of 6 resident's personal refrigerators reviewed for food safety (Resident #20). The facility did not remove expired food from Resident #20's personal refrigerator. The deficient practice could place the resident at risk for food borne illnesses. The findings were: Record review of a facility policy for Refrigerators and Freezers with a revision date of [DATE] indicated, . Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates . An Admission Record dated [DATE] for Resident #20 indicated she is a [AGE] year old female that was admitted to the facility on [DATE] with diagnoses of generalized anxiety disorder (severe anxiety that affects daily activities), major depressive disorder (persistent feeling of sadness and loss of interest), adjustment disorder with mixed anxiety (symptoms include a mix of depression and anxiety as well as behavioral problems), heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood) and [CONDITION(S)] and [CONDITION(S)] affecting the left side (Muscle weakness or [CONDITION(S)] on one side of the body that can affect the arms, legs, and facial muscles). During an observation on [DATE] at 9:13 a.m., Resident #20's personal refrigerator had a 2 pack of Jell-O with an expiration date of [DATE], 5 chocolate vanilla pudding snacks with an expiration date of [DATE], an opened can of Vienna sausages in barbecue sauce that were dried out and a ,d+[DATE] frozen sandwich. During an interview on [DATE] at 11:16 a.m., the housekeeping supervisor said he checks the personal refrigerators weekly usually on Mondays and records the temperatures and keeps the log in his office. During an interview on [DATE] at 11:50 a.m., CNA E said she thinks the Administrator is responsible for checking the temperatures of personal refrigerators and for expired food items inside the refrigerators. During an observation and interview on [DATE] at 11:56 a.m., LVN D said she is not sure who is responsible for checking expired food items in personal refrigerators, but the housekeeping supervisor checks the temperatures. LVN D removed all expired food items from the personal refrigerator of Resident #20 and said she would let housekeeping know to come and clean the refrigerator. She said she didn't know Resident #20 had expired food items in her refrigerator. During an interview on [DATE] at 12:02 p.m., LVN C said the CNA's and housekeeping were responsible for keeping up with the personal refrigerators and removing expired food items. During an interview on [DATE] at 12:03 p.m., Administrator said the housekeeping supervisor is responsible for keeping up with expired food items and it has been a constant battle with family bringing in foods for residents. He said Resident #20 has behaviors and sometimes doesn't want staff to mess with her personal foods. A policy for refrigerators and freezers was provided. Record review of a facility policy for Refrigerators and Freezers with a revision date of [DATE] indicated, . Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates .

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs for 3 of 8 residents observed during medication pass. (Resident #'s 9, 14 and 26) Medication Aide (MA) A administered Resident #9, Resident #14 and Resident # 26's routine medications outside of the facility-scheduled time frame. This deficient practice placed 8 residents reviewed for medication administration at risk for receiving less than therapeutic benefits from medications. Findings include: A. Review of the Face Sheet dated 02/28/18, revealed Resident #9 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's Physician order [REDACTED]. * [MEDICATION NAME] 300 milligrams (mg) by mouth daily for Gout * [MEDICATION NAME] 60 mg by mouth daily for [MEDICAL CONDITION] * Aspirin 81 mg by mouth daily for Hypertension * [MEDICATION NAME] 40 mg by mouth daily for Hypertension * [MEDICATION NAME] 800 mg by mouth three times a day for Type 2 Diabetes Mellitus * [MEDICATION NAME] 10-325 mg by mouth two times a day for pain. Review of Resident #9's Medication Administration Record [REDACTED]. During an observation on 02/27/18 at 9:47 AM, MA A administered medications, including [MEDICATION NAME], Aspirin, [MEDICATION NAME] and [MEDICATION NAME], to Resident #9. B. Review of the Face Sheet dated 02/28/18, revealed Resident #14 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14's Physician order [REDACTED]. * [MEDICATION NAME] 24 mg by mouth daily for Hypertension * [MEDICATION NAME] 30 mg by mouth two times a day for [MEDICAL CONDITION] * [MEDICATION NAME] 5 mg by mouth daily for Hypertension * [MEDICATION NAME] 400 mg by mouth three times a day for Nerve Pain and Discomfort * [MEDICATION NAME] 20 mg by mouth daily for Hypertension. Review of Resident #14's MAR indicated [REDACTED]. During an observation on 02/27/18 at 9:28 AM, MA A administered medications, including [MEDICATION NAME] and [MEDICATION NAME], to Resident #14. C. Review of the Face Sheet dated 02/28/18, revealed Resident #26 was a [AGE] year old male re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #26's Physician order [REDACTED]. * [MEDICATION NAME] 100 mg by mouth two times a day for Secondary Parkinsonism * [MEDICATION NAME] 25 mg by mouth daily for Hypertension * [MEDICATION NAME] 7.5 mg by mouth daily for Arthritis * [MEDICATION NAME] 28 mg by mouth daily for Dementia without Behavioral Disturbance * [MEDICATION NAME] 75 mg by mouth daily for Preventative * [MEDICATION NAME] 75 mg by mouth two times a day for [MEDICAL CONDITION]. Review of Resident #26's MAR indicated [REDACTED]. During an observation on 02/27/18 at 10:04 AM, MA A administered medications, including [MEDICATION NAME] , [MEDICATION NAME] and [MEDICATION NAME], to Resident #26. During observations of medication pass on 02/27/18 from 9:25 AM through 10:04 AM, MA A was required to stop medication administration once to locate a CNA to assist a Resident. MA A was required to stop medication administration two additional times to locate medication refilled, but not placed on the medication cart. During an interview on 02/27/18 at 9:25 AM, MA A said medications administered to Resident #9, Resident #14, and Resident #26 were late. MA A stated medications were sometimes late because she was the only Medication Aide for 44 residents. MA A said she often needed to assist other Certified Nurse Aides (CNAs) with residents, which took away from time required for medication administration. During an interview on 02/28/18 at 10:14 AM, the Director of Nurses (DON) stated if a medication was scheduled to be administered at 8:00 AM, she expected the medication to be given either an hour before (7:00 AM) or an hour after (9:00 AM). The DON said Medication Aides were only supposed to pause medication administration to assist residents or CNAs with care during an emergency. Review of a current facility policy titled Administering Medications revised 01/2001 revealed the following elements: Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medication director. Policy Interpretation and Implementation . 2. The Director of Nursing Service is responsible for the supervision and direction of all personnel with medication administration duties and functions. 3. Medications must be administered in a timely manner (1 hour before or 1 hour after) and in accordance with the attending physician's written/verbal orders . 8. The individual administering the medication must ensure that the right medication, the right dosage, the right time and the right method of administration are verified before the medication is administered . Eight residents were observed during medication pass.

Based on observation, interview and record review, the facility failed to ensure 1 of 1 dishwashing machines sanitized properly in accordance with professional standards for food service safety. The facility's dishwashing machine did not have sanitizer going into it to fully sterilize the dishes. This deficient practice placed 54 residents who receive their meals from the facility's only kitchen at risk for food-borne illness. Findings Include: On 1/09/17 at 9:45 AM, the dish machine was observed in use by Dietary Assistant B. At the conclusion of the rinse cycle the Dietary Supervisor (DS) used a chlorine test strip and tested the concentration of the sanitizer. The test strip did not register a significant color change. Another strip was used and still no response/color change was observed indicating the dish machine was not sanitizing. An empty container of sanitizer was observed under the machine, with the wand and tubing in place. The DS replaced the container with a full one and placed the wand in position. Another dishwashing cycle was run, and the test strip still did not show the appropriate 50 ppm reading. During an interview on 1/09/17 at 11:45 AM, the DS stated, I called the dishwasher vendor and they will be coming out. We will use disposable dishes and utensils for lunch since the sanitizer is not working properly. During an interview on 1/09/17 at 12:40 PM, the DS stated that the dishwasher was fixed and ran a load of dishes through a cycle for the surveyor. The test strip revealed a response/color between 50 to 100 ppm. When asked what the dishwashing representative stated was wrong with the machine, the DS stated the tubing needed priming (which indicates there was no solution in the line) and showed him and his staff where and how to prime it. The surveyor asked the DS whose responsibility is it to make sure the dishwasher has sanitizer and he stated, It's the Dish Aide's (Dietary Assistant) responsibility. Review of a current facility policy dated revised August 2010 titled, Dishwashing Machine Use revealed the following elements: Policy Statement: Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. Policy Interpretation and Implementation 4. Dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Type of Solution Chlorine Minimum Concentration 50 - 100 ppm 8. A supervisor will check the dishwashing machine for proper concentration of sanitizer solution after filling the dishwashing machine and once a week thereafter. On 1/09/17 at 10:45 AM, the DS supplied a dish machine log and it reflected the sanitizer concentration had been checked at 100 ppm for breakfast, dinner and supper the previous day, 1/08/17. The facility competed CMS 672 form reflected a census of 54, all who receive their meals from the kitchen.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs for 1 of 10 residents reviewed for medication administration. (Resident #15) Licensed Vocational Nurse (LVN) A failed to ensure Resident #15 received his meal within 30 minutes of a scheduled injection of Humulin R (a fast acting insulin), which could result in [DIAGNOSES REDACTED] (Low Blood Sugar) This deficient practice could place 2 residents who receive Humulin R routinely at risk for [DIAGNOSES REDACTED]. (Low blood sugar) Findings include: Review of Resident #15's Admission Record revealed a [AGE] year old male resident with an original admission date of [DATE]. Resident #15's [DIAGNOSES REDACTED]. Review of Resident #15's current physician orders [REDACTED]. The other order was for Regular insulin to be given per sliding scale (amount determined by the result of a finger stick blood sugar) The sliding scale insulin was to be initiated when the blood sugar results were 201 and up to 450. Observation on 1/9/17 at 11:35 AM revealed LVN A correctly obtained Resident #15's blood sugar as 181. She did not give sliding scale insulin but gave Humulin R 5 units as ordered. The resident wheeled himself to the dining room to wait for lunch to be served. Observation of Resident #15 revealed he did not receive his lunch tray until 12:35 PM, an hour after the insulin injection had been administered by LVN A. The resident had a glass of water and a glass of cranberry juice while waiting for his meal. On 1/9/17 at 2:45 PM when advised of the observation, the ADON stated, That's an hour, that is not good. We need to make sure residents who get insulin get food sooner. Review of documents provided by the ADON on 1/10/17 reflected the following information regarding Humulin R (generic name: insulin regular): Humulin R is a fast-acting form of the hormone insulin. It works by lowering the amount of glucose (sugar) in the blood to treat diabetes. Under subtitle, Insulin Administration: Regular insulin is administered 30 minutes before meals. Under subtitle, How to use Humulin R: Use Humulin R within 30 minutes before a meal and; Humulin R begins lowering blood sugar within 30 minutes after an injection. The ADON identified 6 insulin dependent diabetics in the facility with 2 residents identified who received Humulin R insulin.

Based on observation, interview and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for one (1) of thirteen (13) residents reviewed for accuracy of physician orders. (Resident #10) Resident #10's November 2015 Consolidated Physician Orders did not reflect an order for [REDACTED]. Findings Include: Review of Resident #10's Face Sheet dated 10/12/2014 reflected [DIAGNOSES REDACTED]. Review of Resident #10's Physician Order Summary Sheet dated for the month of November, 2015 revealed the following orders: Check [MEDICAL TREATMENT] Shunt Access Right Arm for Thrill/Bruitt (Listening for blood rushing though Graph site and pulse sounds), Post [MEDICAL TREATMENT] (when returned from [MEDICAL TREATMENT]), Check Graph Site for Thrill/Bruitt per Shift, Check Post [MEDICAL TREATMENT] for Mental Status Change, Change in Skin Condition/Color Neck/Vein Distention, Increased [MEDICAL CONDITION] of Face or Extremities, Change in Color of Nailbeds, or Muscle Twitching, May Check Blood Pressure in Left Wrist, Check Blood Pressure Post [MEDICAL TREATMENT] and Prior to Blood Pressure Medications. Remove Pressure Dressing to [MEDICAL TREATMENT] Shunt the Morning After [MEDICAL TREATMENT]. May Reinforce Dressing as Needed every day shift Sunday, Wednesday, Friday, Vital Signs ( Temperature, Blood Pressure and Pulse Rate) after [MEDICAL TREATMENT]. In an interview on 12/9/15 at 3:00 PM, Licensed Vocational Nurse (LVN) A stated she didn't know why there was no order regardng [MEDICAL TREATMENT] on Resident #10's consolidated orders. She stated that Resident #10 had gone to [MEDICAL TREATMENT] 3 times a week as long as she had been in the facility In an interview with LVN B on 12/9/15 at 3:15 PM, after looking for the order on the computer and in paper records, she stated she didn't realize that the physician order for [REDACTED].>An interview with the Director of Nurses (DON) on 12/9/15 at 3:30 PM, after searching in archived records, revealed a document dated October 12, 2014 from an emergency room visit that stated OP HD which means Out Patient Hemo [MEDICAL TREATMENT] signed by an out of town physician. The DON stated that the order did not get transcribed to Resident #10's Order Summary. An interview with Resident #10 on 12/9/2015 at 1:35 PM, revealed she had gone to [MEDICAL TREATMENT] 3 times a week since entering the facility. Review of a current facility Policy titled Policy Interpretation and Implementation dated June, 2004 revealed: 4. A physician's order is needed for diets, therapies, and other treatments. The DON identified Resident #10 as the only resident receiving [MEDICAL TREATMENT].

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. Two (2) of 2 treatment carts were left unlocked and unattended on 4 occasions on Hall 5 during medication pass by 1 of 1 Licensed Vocational Nurse (LVN) A and on 1 occasion at the nurses station. This deficient practice placed 59 residents at risk of drug diversion. Findings include: A. During observation of a medication pass on 11/18/14 at 11:35 AM, LVN A left the treatment cart unlocked and unattended in the hallway to perform an accucheck for Resident #16. LVN A was observed in Resident #16's room with her back to the door and the cart was facing out to the hallway during this time. B. During observation of a medication pass on 11/18/14 at 11:40 AM, LVN A left the treatment cart unlocked and unattended facing out to the hallway while in Resident #17's room to administer an Atrovent inhaler, perform an accucheck and administer his insulin injection. Two housekeepers were cleaning the floor and the room across the hall at the time. C. During observation of a medication pass on 11/18/14 at 11:49 AM, LVN A left the treatment cart unlocked and unattended facing out to the hallway. LVN A closed the door to administer Resident #18's insulin, rendering the unlocked cart completely out of sight. D. During observation of a medication pass on 11/18/14 at 12:05 PM, LVN A left the treatment cart unlocked and unattended out in the hallway to administer medication to Resident #11 in the dining room. Several staff and residents were coming in and out of the dining room at the time for lunch. LVN A was observed to be completely out of sight of the unlocked treatment cart. E. Observation at the nurses station on 11/18/14 between 2:00 PM and 2:15 PM revealed a treatment cart unlocked and unattended against the wall. The surveyor pulled open a drawer on the cart without drawing anyone's attention. At one point a visitor was standing next to the cart. The Minimum Data Set (MDS) Coordinator came up to the desk and was asked by the surveyor, "Should that cart be unlocked and unattended?" She stated, "No, it should be locked." Observation of the treatment cart during medication pass revealed insulin, inhalers, eye drops, liquids, and blister packs of pills. During an interview on 11/19/14 at 2:25 PM, the Director of Nurses (DON) stated that the carts should be locked, but that she felt none of the residents would try to open the drawers. Review of a current facility policy dated April 2007 titled, "Security of Medication Cart" revealed the following elements: Policy Statement - The medication cart shall be secured during medication passes. Policy Interpretation and implementation 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room 3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when out the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room. The facility Room Roster dated 11/17/14 reflected a census of 59.

Based on interview and record review, the facility failed to conduct annual screenings of the Employee Misconduct Registry (EMR) for two (2) of sixteen (16) employee files reviewed for screening (Housekeeper) and the Assistant Activity Director. The facility failed to provide evidence of EMR screening for 2014. This deficient practice placed 59 residents at risk of abuse, neglect and/or misappropriation. Findings include: Review of personnel records reflected the following: The Housekeeper's personnel record reflected a hire date of 09/08/14. No EMR screening was conducted prior to hire for 2014. The Assistant Activity Director's personnel record reflected a hire date of 10/22/14. No EMR screening was conducted prior to hire for 2014. During interview on 11/20/14 at 10:30 AM, the Business Office/Human Resource staff person stated that she did not conduct the EMR screenings. She stated, "I thought the Director of Nurses (DON) ran the misconducts." During interview 11/20/14 at 10:40 AM, the DON stated," I only run the Certified Nurse Aides (CNA's), Medication Aides (MA's) and nurses. The Business Office/Human Resource person should run other misconducts." The facility completed CMS 672 form reflected a census of 59.

Based on observation, interview and record review, the facility failed to provide adequate supervision in use of a Hoyer Lift (mechanical lifting device) to prevent an accident during transfer for 1 of 2 sampled residents reviewed for reported incident/accidents involving staff assisted transfers. (Resident #5) Certified Nurse Aide (CNA A) transferred Resident #5 without assistance of another staff member using the Hoyer lift on 2/1/2011. The Hoyer lift tipped over with Resident #5 in the sling. Resident #5 was hospitalized for [REDACTED]. This deficient practice placed 8 residents identified as requiring assistance of two staff members for transfers at risk of injury when staff fails to provide care and services specific to resident care plans. Findings include: Review of Resident #5's Face Sheet dated 6/29/10 reflected admission to the facility on [DATE]. Resident #5 is a [AGE] year old male with [DIAGNOSES REDACTED]. Review of Resident #5's Care Plan updated on 1/26/11 revealed the following: Problem: Had gotten weaker with transfers and was a potential for falls. Goals: Will have no falls until next review. Approach: Transfers with 2 aides. Review of Resident #5's Minimum Data Set (MDS) Assessment by the facility prior to the fracture, dated 19/1/10 revealed he required extensive assistance of two + person physical assist with bed mobility and transfers. During interview with the Director of Nurses (DON) on 2/16/11 at 3:00 PM, she stated that when using a Hoyer lift, the transfer should be done by 2 staff members. Review of a staff inservice dated 2/01/11 (following Resident #5's incident) revealed the following: If a Certified Nurse Aide or Nurse is using the lift you must have 2 people to do this. Review of a facility Investigation Report dated 2/1/11 revealed the following: On 2/1/11 at approximately 5:30 AM, CNA A was transferring Resident #5 from the bed to a wheelchair. Resident #5 was care planned to be a two person transfer. CNA A was transferring Resident #5 using a Hoyer lift. As she attempted to put him in the wheelchair, his weight went forward and the lift went in the opposite direction and fell over with Resident #5 hitting his legs on the back of the roommate's chair. CNA A immediately notified the charge nurse, who assessed Resident #5 and found no obvious injury. Resident #5 was placed back in bed. The physician was notified and ordered an x-ray of the left femur (right leg just above knee). The x-ray results revealed a comminuted diaphyseal fracture (a fracture in which the bone has broken into a number of pieces) of the left femur. Resident #5 was transferred to a local hospital on [DATE] where he had surgical repair of the fractured femur. Resident #5 was transferred from the hospital back to the nursing facility on 2/5/11. Review of a hospital radiologist's impression of the X-ray of Resident #5's left femur dated 2/1/11 revealed a comminuted diaphyseal fracture of the left femur. During interview on 2/16/11 at 4:30 PM, the administrator stated, "The CNA's have a book at the nurse's station with a flow sheet that explains the care needs of the residents. They should not deviate from that plan. CNA A did not follow the plan. She transferred Resident #5 using the Hoyer lift without assistance. Before the fracture Resident #5 was in a high back wheelchair that could recline and was wheeled by the staff. We are using a Geri-chair at this time because it is wider and more comfortable for positioning. He will return to the wheelchair when he's healed." Observation of Resident #5 on 2/17/11 at 8:20 AM revealed a staff member feeding him breakfast. Resident #5 was non-interviewable. During interview on 2/16/11 at approximately 2:00 PM, CNA A stated she did not know at the time that Resident #5 required two staff members during transfer. She stated she did not have orientation on using the Hoyer lift until after the incident. She stated, "They just assumed since I worked here before that I knew how to work the lift. I was never told to use two staff members when using the Hoyer lift. Another CNA assisted me in getting the Hoyer lift sling under Resident #5, but was called away to answer a call light and assist another resident. I tried to transfer him by myself and as I turned the lift to put him in his wheelchair, his weight shifted and the lift turned over. He hit his legs on his roommate's wheelchair. I notified the nurse and she did an assessment. There appeared to be no injury and he did not complain of pain. We put him back to bed." Review of CNA A's personnel file on 2/16/11 revealed no evidence she received training regarding the Hoyer lift transfers. Review of a Resident care flow sheet in the book at the nurses station revealed Resident #5 was a total two person transfer. CNA A's signature was on Resident #5's flow sheet. During interview on 2/16/11 at approximately 11:00 AM, the DON (Director of Nurses) stated she did not know if CNA A received training regarding the new lift. She stated she was not DON at that time and that she could not find any paper work regarding the training. During a telephone interview on 2/25/11 at 10:00 AM, Resident #5's primary care physician stated that Resident #5 had multiple medical problems and that he required total care before the recent fracture. He stated I have "pulled him out of the woods multiple times." He stated Resident #5 was in a Geri-chair for comfort at this time. The Director of Nurses stated the facility has 8 residents who require assistance of two staff members for transfers.