Every finding on record at Texoma Healthcare Center

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 6 residents observed for infection control. The facility failed on 08/18/2026 when CNA A failed to perform hand hygiene between gloves changes during incontinence care for Resident #1. Record review of Resident #1's annual MDS assessment, dated 08/10/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE], and readmitted on [DATE]. She had a BIMS score of 11/15, which indicated her cognition was moderately impaired. Resident #1 had diagnoses which included Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks), hereditary spastic paraplegia (a group of rare, inherited genetic disorders causing progressive weakness and severe stiffness (spasticity) in the lower limbs due to nerve damage in the spinal cord), muscle weakness, and hypertension (elevated blood pressure). Further review revealed toileting hygiene: Substantial/maximal assistance; urinary continence: always continent; bowel continence: always continent. Record review of Resident #1's care plan, with a revised date of 08/05/26 reflected, focus: the resident has an ADL Self Care. Goal-The resident will maintain or improve current level of function through the review date. Interventions- Bed Mobility: requires staff x1 (one staff) for assistance. In an observation on 08/18/26 at 09:58 AM revealed CNA A entered Resident #1's room and told the resident she was here to change the resident brief. CNA A washed her hands, pulled gloves from her uniform pocket, and put them on. CNA A unfasten Resident#1's brief, cleaned Resident#1's front area using one wipe per stroke, tacked the brief between Resident#1's legs. CNA A helped Resident#1 turn to her left side, cleaned the buttocks area using one wipe per stroke. CNA A Pushed the brief underneath Resident#1. CNA A changed gloves without performing any form of hands hygiene (washing or sanitizing with hands sanitizer), she pulled the clean brief put it underneath the resident. CNA A turned Resident#1 to her back, removed the dirty brief put it in trash. She changed her gloves without any form of hands hygiene and finished putting the clean brief on Resident#1, fastening it in the front. CNA A covered Resident#1 and adjusted her bed. CNA A removed gloves and washed hands before exiting the room. Interview with CNA A on 08 /18/26 at 10:45 AM revealed she was supposed to perform hand hygiene every time she removed her dirty gloves before putting on clean gloves. She stated she was not supposed to carry gloves in her uniform pocket. She stated she had training on hand hygiene, and that she was supposed to wash hands for 20 seconds, and in between changing glove sanitized hands. CNA A stated not washing her hands or using hand sanitizer between glove changes could cause an infection control problem for the residents. In an interview with DON on 08/19/26 at 10:01 AM she stated infection control was important during care. DON stated during care the staff were to use the hand sanitizer or wash hands if they were physically soiled. DON stated the staff were expected to complete hand hygiene before care and after care, she also stated during incontinent care the staff were supposed to change gloves and use hand sanitizer. DON stated staff were not supposed to carry gloves in their uniform pockets, and they were supposed to put gloves in a clean plastic bag to take to resident's room. DON stated hand hygiene was to be completed for infection control. DON said she was the infection preventionist and in-service on infection control were done on hire and monthly. Review of the facility's undated policy, titled Fundamentals of Infection Control Precautions reflected, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions.1. Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene:. After removing gloves or aprons.Gloves are worn for three important reasons1 To provide protective barrier and prevent gross contamination of the hands whentouching blood, body fluids, secretions, excretions, mucous membranes, and nonintactskin. The wearing of gloves. is mandatory for all employees.2 To reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to residents during invasive or other resident-care procedures that involve touching a resident's mucous membranes and nonintact skin.3 To reduce the likelihood that hands of personnel contaminated with microorganismsfrom a resident or a fomite can transmit these microorganisms to another resident; inthis situation, gloves must be changed between resident contacts, and hands washedafter gloves are removed. Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves

Based on observation, interview and record review the facility failed to ensure that a resident with urinary incontinence, based on the resident's comprehensive assessment, received the appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #1) of 6 residents reviewed for incontinent care. The facility failed to ensure Resident #1 was assisted with incontinence care and toileting in a timely manner on 08/18/2026 when CNA A did not round on Resident#1 for four hours. This failure could place residents at risk of skin breakdown, infection and a diminished quality of life by not receiving care and services to meet their toileting needs. Record review of Resident #1's annual MDS assessment, dated 08/10/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE], and readmitted on [DATE]. She had a BIMS score of 11/15, which indicated her cognition was moderately impaired. Resident #1 had diagnoses which included Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks), hereditary spastic paraplegia (a group of rare, inherited genetic disorders causing progressive weakness and severe stiffness (spasticity) in the lower limbs due to nerve damage in the spinal cord), muscle weakness, and hypertension (elevated blood pressure). Further review revealed toileting hygiene: Substantial/maximal assistance; urinary continence: always continent; bowel continence: always continent. Record review of Resident #1's care plan, with a revised date of 08/05/26 reflected, focus: The resident has bladder incontinence Disease Process. Goal- The resident risk for septicemia will be minimized/prevented via (by way of) prompt recognition and treatment of symptoms of UTI (urinary tract infection) through the review date. Interventions- INCONTINENT care at least q2h (every 2 hours) and apply moisture barrier after each episode. Observation and interview on 08/18/26 at 09:58 AM, Resident #1 was lying in bed wearing only a T-shirt and pants, Resident#1 stated she needed to be changed because her brief was wet with urine. Resident#1 stated the last time she had her brief changed was at 4:00 AM, and she asked to be change around 7:30 AM and the staff told her it will be done after they pick up the morning breakfast trays. Resident #1 removed her blanket to the side, and her brief was swollen large with liquid. CNA A came into Resident #1's room to answer her call light. When asked if Resident #1 had been checked and changed, CNA A stated she had not changed Resident#1 brief this morning. CNA A shift started at 6:00 AM. CNA A stated she could not get to Resident#1 until this time 10:00 AM because she was doing other Residents during her morning round. During the process of providing incontinent care to Resident #1 by CNA A this state surveyor observed Resident#1's skin, and there was redness noted on her sacral area. CNA A applied barrier cream on the area after incontinent care. CNA A stated the risk to Resident left wet for long period was skin breakdown, and loss of dignity. Interview on 08/19/26 at 10:01 AM DON stated the charge nurses and CNAs supposed to do rounds room to room at least every 2 hours to check residents and change them if they were wet. DON stated the risk of incontinent care not being provided on time would be skin breakdown, infection, and resident dignity. A record review of the facility's policy titled Perineal care, dated 04/27/2022, reflected . It is essential that residents using various devices, absorbent products, external collection devices, etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice, and the manufacturer's recommendations.Skin problems associated with incontinence and moisture can range from irritation to increased risk of skin breakdown. Moisture may make the skin more susceptible to damage from friction and shear during repositioning. This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition

Based on observation, record review, and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 4 residents (Resident #1 and Resident #2) reviewed for ADLs. The facility failed to provide Resident #1 with showers or baths on 7/22/26, 7/27/26 and 08/05/26. The facility failed to provide Resident #2 with showers or baths on 7/25/26, 7/30/26, 8/1/26, 8/4/26 and 8/8/26. This failure could place residents at risk of exposure to infectious diseases, decline in ADLs, and decreased dignity.Findings included: 1. Record review of Resident #1's face sheet, dated 8/11/26, reflected a [AGE] year-old male resident who was admitted to the facility on [DATE]. Resident #1 was discharged from the facility to the hospital on 8/8/26. Resident #1's pertinent diagnoses were hemiplegia (total or near total paralysis on one side of the body) and hemiparesis (partial weakness or reduced muscle strength on one side) following cerebral infarction (a stroke), aphasia (difficulty talking, listening, reading or writing), dysphagia (impairment in the production of speech), vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow and oxygen to the brain) and muscle weakness. Record review of Resident #1's care plan, revised 7/1/26, reflected, .The resident has an ADL Self Care Performance Deficit d/t weakness/debility and cognitive decline r/t Intraventricular Hemorrhage (bleeding inside the brain) and CVA (stroke) w/Right Sided Hemiparesis (partial weakness or reduced muscle strength on one side) Date Initiated: 02/28/2024 Revision on: 02/28/2024 The resident will maintain or improve current level of function through the review date. Date Initiated: 02/28/2024 Revision on: 10/14/2025 Target Date: 08/26/2026 Bathing: requires staff x1 for assistance Date Initiated: 02/28/2024 Bed Mobility: requires staff x1 for assistance Date Initiated: 02/28/2024 Provide supervision with dressing as needed Date Initiated: 02/28/2024 PT/OT evaluation and treatment as per MD orders. Date Initiated: 02/28/2024 The resident is NPO Date Initiated: 02/28/2024 The resident uses a wheelchair Date Initiated: 02/28/2024 Toilet use: requires staff x1 for assistance Date Initiated: 02/28/2024 Transferring: requires staff x2 for assistance Date Initiated: 02/28/2024 Encourage the resident to participate to the fullest extent possible with each interaction. Date Initiated: 02/28/2024 Encourage the resident to use bell to call for assistance. Date Initiated: 02/28/2024 Monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Date Initiated: 02/28/2024 BATHING: Avoid scrubbing & pat dry sensitive skin. Date Initiated: 02/28/2024 BATHING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care Date Initiated: 02/28/2024 BATHING: Provide the resident with a sponge bath when a full bath or shower cannot be tolerated. Date Initiated: 02/28/2024 PERSONAL HYGIENE/ORAL CARE: the resident requires (X1) staff participation with personal hygiene and oral care. Date Initiated: 02/28/2024 Revision on: 02/28/2024 DRESSING: Assist the resident to choose simple comfortable clothing that CNA. Record review of Resident #1's Quarterly MDS Assessment, completed on 7/5/26, reflected Resident #1 had severe cognitive impairment with a BIMS score of 2. Resident #1 required the assistance of 2 or more helpers with all ADLs. Record review of Resident #1's Bathing Bath Sheet Task, dated 7/21/26 to 8/8/26, reflected Resident #1's bath days were Monday, Wednesday, and Friday and the following bath days were not completed 7/22/26, 7/27/26, and 08/05/26. An interview with CNA C on 8/11/26 at 12:42 p.m. stated she was the CNA who was assigned to Resident #1 during 07/21/26-08/08/26 CNA C stated she last worked with Resident #1 last Thursday (8/6/26). CNA C stated she had worked with Resident #1 for 3 weeks. CNA C stated she had never provided Resident #1 a bath or shower because she was unsure of his shower days (Monday, Wednesday,Friday)aff and he only liked to be bathed by certain staff. CNA C stated she had never tried to bathe or shower Resident #1. CNA C stated the only thing she had done for Resident #1 regarding hygiene was incontinent care and cleaning his nails because the nails would get bad. CNA C stated she was not aware of the process when a resident refused a bath/shower and was not trained on how to document showers. CNA C stated the risk to the residents of not having regular showers were fungal infections and increased dry skin. An interview with LVN D on 8/11/26 at 1:18 p.m. revealed he worked with Resident #1 for 2 months. LVN D stated he had never seen Resident #1 receive a shower because he was never out of his bed. LVN D stated he believed Resident #1 would get bed baths but was unsure of the last time he had gotten one. LVN D stated he had never signed a refusal form for baths or showers for Resident #1. LVN D stated he assumed Resident #1 had gotten showers at some point because Resident #1 had oily skin and there were days his skin was not as oily. LVN D stated the risk to the residents of not having regular showers was transfer of germs and skin breakdowns. An interview with LVN E on 8/11/26 at 3:36pm revealed he worked with Resident #1 on the date he was discharged (8/8/26) and he was unsure whether the resident had gotten a shower or bath that day. LVN E stated Resident #1 refused a couple of showers a few months ago but none that he was aware of in the last month. LVN E stated he had not signed a shower refusal sheet for Resident #1 in July or August of 2026. LVN E stated the risk to the residents of not receiving showers or baths regularly were skin breakdown and infection. 2. Record review of Resident #2's face sheet, dated 8/11/26, reflected a [AGE] year-old male resident who was admitted to the facility on [DATE]. Resident #2 had the following pertinent diagnoses: anxiety disorder (a mental health condition involving excessive, ongoing fear or worry that is hard to control and interferes with daily life), pain in unspecified joint, muscle spasm of calf, effusion on left knee (buildup of excess fluid inside or around the left knee joint capsule), acute kidney failure (a sudden loss of kidney function), Alzheimer's disease (a progressive irreversible brain disorder that slowly destroys memory, thinking skills and ability to carry out simple daily tasks), unsteadiness on feet, cognitive communication deficit (trouble with communication), and unspecified abnormalities of gait and mobility. Record review of Resident #2's care plan, revised on 2/23/26, reflected, .The resident has an ADL Self Care Performance Deficit Date Initiated: 02/23/2026 The resident will maintain or improve current level of functionin (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date. Date Initiated: 02/23/2026 Target Date: 08/03/2026 Bathing: requires staff x1 for assistance Date Initiated: 02/23/2026 Bed Mobility: requires staff x1 for assistance Date Initiated: 02/23/2026 Discuss with resident/family/POA care any concerns related to loss of independence, decline in function. Date Initiated: 02/23/2026 Dressing: requires staff x1 for assistance Date Initiated: 02/23/2026 Praise all efforts at self care. Date Initiated: 02/23/2026 PT/OT evaluation and treatment as per MD orders. Date Initiated: 02/23/2026 The resident uses a wheelchair Date Initiated: 02/23/2026 Toilet use: requires staff x1 for assistance Date Initiated: 02/23/2026 Encourage the resident to discuss feelings about self-care deficit. Date Initiated: 02/23/2026 Encourage the resident to participate to the fullest extent possible with each interaction. Date Initiated: 02/23/2026 Encourage the resident to use bell to call for assistance. Date Initiated: 02/23/2026 Monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Date Initiated: 02/23/2026 BATHING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care Date Initiated: 02/23/2026 DRESSING: Assist the resident to choose simple comfortable clothing that maximizes the resident's ability to dress self. Date Initiated: 02/23/2026. Record review of Resident #2's Quarterly MDS Assessment, completed on 7/2/26, reflected Resident #2 was moderately impaired cognitively with a BIMS score of 9. Resident #2 required moderate to substantial assistance on most ADLs. Record review of Resident #2's Bathing Bath Sheet Task, dated 7/21/26 to 8/11/26, reflected Resident #2 had no bath or shower on 7/25/26, 7/30/26, 8/1/26, 8/4/26 and 8/8/26. An interview with Resident #2 on 8/11/26 at 11:37 a.m. revealed he did not always get showers and baths. Resident #2 stated he believed he did not get showers on his scheduled shower days because the staff was too busy. Resident #2 stated the last shower he had was the previous week (08/04/26-08/11/26) because he had a doctor's appointment. Resident #2 was unable to state the exact date he last had a shower or bath. Resident #2 stated he was due for a shower today (8/11/26) but had not had one yet. Resident #2 stated his shower days were Tuesdays, Thursdays and Saturdays. An interview with CNA A on 8/11/26 at 12:11 p.m. revealed she was the CNA assigned to Resident #2 on 08/11/26. CNA A stated residents were scheduled to shower 3 times per week and if a resident refused the resident would sign a paper of refusal. CNA A stated she had given Resident #2 a bed bath about 30 minutes ago and stated his shower days were Tuesday, Thursday and Saturdays. CNA A stated bed baths and showers were documented in the medical record in residents' point of care. CNA A stated she typically alternated between shower and baths due to Resident #2's wound vac (A special type of sealed dressing to provide suction and remove pressure over the area of the wound and to promote healing of wounds). CNA A stated she had not worked the dates there was not documentations for Resident #2's showers (7/25/26, 7/30/26, 8/1/26, 8/4/26 and 8/8/26) and was unable to state who worked those dates and whether the showers/baths were completed. CNA A stated residents not having regular showers could have affected their skin integrity and health. During an interview with RN B on 8/11/26 at 12:26 p.m. revealed she was the nurse assigned to Resident #2. RN B stated Resident #2 loved his showers and baths and she had never been informed he refused a shower or bath. RN B stated she was unsure if Resident #2 had a shower on Saturday (08/08/26) because she had not worked Saturday (8/8/26). RN B stated if a resident refused a shower, the CNAs were required to let the nurse know and the nurse would have had to talk to the resident and would have the resident sign the refusal sheet. RN B stated the risk to the residents of not having regular showers was infection and an overall feeling of being unwell. An interview with the DON on 8/11/26 12:56 p.m. revealed the expectation for residents' showers were that they were provided 3 days per week and upon request. The DON stated if a resident refused a shower the CNAs would have had to fill out a shower refusal sheet and document the refusal. The DON was unable to provide shower refusals for Resident #1 and Resident #2. The DON stated she typically got flagged when residents missed showers but was unsure if she had gotten flagged for Resident #1 and Resident #2. The DON stated she was not aware Resident #1 and Resident #2 had not gotten their showers consistently and was unable to provide reasons why the residents would not have gotten showers on the dates in question. The DON stated the risk to the residents of not having regular showers were issues with infection control and dignity. An interview with the Substitute Administrator on 8/11/26 at 4:15pm revealed the expectation for resident showers was that every resident deserved to have scheduled showers. The Substitute Administrator stated he was not the Administrator for the building but his expectation at his building was if a resident refused a shower, then it should have been documented in their file. The Substitute Administrator stated the risk to the residents of not receiving regular showers was uncleanliness, dignity, increased body odors, and development of sores and infections. Record review facility policy, Bath, Tub/Shower, undated, reflected, Bathing by tub bath or shower is done to remove soil, dead epithelial( skin sic) cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation. A medicated tub bath can also be provided to treat skin conditions. The aging skin becomes dry, wrinkled, thinner and blemished with various aging spots over time and is easily affected by environmental temperature and humidity, sun exposure, soaps, and clothing fabrics. The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed. Goals 1. The resident will experience improved comfort and cleanliness by bathing. 2. The resident will maintain intact skin integrity.3. The resident will be free from soil, odor, dryness, and pruritus following bathing. Procedure 1. The resident will receive assistance with bathing according to their resident centered plan of care. 2. Become familiar with type and pattern of bathing, assistance or aids needed, skin condition, presence of dressing or casts.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 (Resident #2) reviewed for infection control. The facility failed to implement Enhanced Barrier Precautions for Resident # 2, who had a wound infection of the left toe. This failure could place residents at risk for infection and cross contamination. Findings included: Record review of Resident #2's face sheet dated 8/11/26 reflected a [AGE] year-old male resident who was admitted to the facility on [DATE]. Resident #2 had the following pertinent diagnoses: anxiety disorder (a mental health condition involving excessive, ongoing fear or worry that is hard to control and interferes with daily life), pain in unspecified joint, Osteomyelitis (an infection and inflammation to the bone and bone marrow) to left ankle and foot, effusion on left knee (buildup of excess fluid inside or around the left knee joint capsule), acute kidney failure (a sudden loss of kidney function), severe sepsis without sepsis shock (where an infection causes extreme bodily inflammation that leads to vital organ dysfunction), and completed traumatic amputation of left foot (a severe injury where ethe foot is totally cut or torn off from the body). Record review of Resident #2's care plan revised on 4/29/26 reflected .Resident is on enhanced barrier precautions R/T WOUND Date Initiated: 02/23/2026 Revision on: 04/29/2026 There will not be any transmission of infection from or to the resident. Date Initiated: 02/23/2026 Revision on: 04/29/2026 Target Date: 08/03/2026 Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach (trachea sic)care, bathing, or other high-contact activity Date Initiated: 02/23/2026 Revision on: 04/29/2026 Perform hand sanitation before entering the room and prior to leaving the room Date Initiated: 02/23/2026 Revision on: 04/29/2026 Posting at the residents room entrance indicating the resident is on enhanced barrier precautions. Date Initiated: 02/23/2026 Revision on: 04/29/2026 Therapy should use gown and gloves, when transfer training, mobility training, or other high-contact activity. Date Initiated: 02/23/2026 Revision on: 04/29/2026. Record review of Resident #2's Quarterly MDS Assessment, completed on 7/2/26, reflected Resident #2 was moderately impaired cognitively with a BIMS score of 9. Record review of Resident #2's Order Summary Report, dated 8/11/26, reflected the following active orders as of 7/13/26, WOUND CARE: OPEN SURGICAL: LEFT TOE AMPUTATION: Cleanse with wound cleanser, pat dry, apply black foam, transparent film and negative pressure wound vac (A special type of sealed dressing to provide suction and remove pressure over the area of the wound and to promote healing of wounds)) @125mmhg intermittent suction as needed for wound treatment and WOUND CARE: OPEN SURGICAL: LEFT TOE AMPUTATION: Cleanse with wound cleanser, pat dry, apply black foam, transparent film and negative pressure wound vac @125mmhg intermittent suction every day shift every Tue, Thu, Sat (Tuesday, Thursday, Saturday sic) for Wound Treatment. There was no order for Enhanced Barrier Precaution. An interview and observation of Resident #2 on 8/11/26 at 11:37 a.m. revealed the resident had dressing on his left heel and dressing with wound vacuum on his foot. Resident #2 stated the wound doctor and nurse had come in earlier on 08/11/26 and cleaned his wounds. Resident #2 stated they were not wearing any gowns or protective gear. Observation of Resident #2's room did not reveal any containers with PPE or signage on the door or wall indicating EBP. An interview with CNA A on 8/11/26 at 12:11pm revealed she believed Resident #2 should have been on EBP but stated there was no PPE in his room. CNA A stated she had not seen any signage and was following EBP when providing care to Resident #2 because she was not notified he was on EBP. CNA A stated she believed Resident #2 should have been on EBP because he had a wound vac on his foot. CNA A stated she had not asked the nurse or DON whether Resident #2 should have been on EBP. CNA A stated the risk to the resident of not having EBP was infection. An interview with RN B on 8/11/26 at 12:26pm revealed EBP was for residents who had an indwelling urinary catheter, wound vac or contagious illness. RN B stated Resident #2 had wounds and a wound vac and therefore he should have been on EBP but was not. RN B stated there should have been EBP signage on his door and PPE supplies in his room. RN B stated Resident #2 did not have signage for EBP and no PPE supplies in his room. RN B stated she did not know the reason Resident #2 was not on EBP and stated it had never come up in the morning meetings. RN B stated it was everyone's responsibility to ensure residents with EBP received the proper precautions. RN B stated when a resident was on EBP it would have been on the residents MAR as well and it was not. RN B stated Resident #2 really should have had EBP and without it, he was at risk of infection and germs spreading into his room. An interview with the DON on 8/11/26 at 12:56pm revealed EBP was necessary when the residents had something going that caused them to be more susceptible to infection, for example when they had a foley catheter or wound. The DON stated if a resident had a wound vac, they would definitely need to have been on EBP. The DON stated she was not aware Resident #2 was not on EBP and stated she needed to verify the policy for EBP and wound vacs. The DON stated it was the responsibility of the nurses to ensure their residents with EBP had the appropriate signage and supplies in their room. The DON stated that when a resident was on EBP there should have been a sign on the door or near the door and supplies by the door. The DON stated the risk to the resident of not having EBP if required was an increased risk of infections. An interview and observation with the Treatment Nurse on an undisclosed date and time revealed she was wearing a gown, gloves and mask while performing wound care for a confidential resident. The Confidential resident had PPE cart in their room and a sign on the wall outside the door that indicated the confidential resident was on EBP. The Treatment Nurse stated residents who were on EBP had a sign on their door and a PPE cart inside their room. The Treatment Nurse stated she had already provided wound care to Resident #2 and stated she always wore PPE when providing Resident #2 wound care because he had a wound vac. The Treatment Nurse stated she believed Resident #2's sign for EBP had fallen but he always had the cart in his room for PPE. The Treatment Nurse stated she had to re-tape the EBP sign to Resident #2's door. The Treatment Nurse stated the risk to the resident of not having EBP when they required EBP was cross-contamination. An interview and observation with Resident #2 on 8/11/26 at 3:38pm revealed he had an EBP sign posted outside his room and a PPE cart inside his room directly across from the resident. Resident #2 stated the Treatment Nurse had just brought in the PPE cart today. Resident #2 stated he had never observed the Treatment Nurse, Nurses or the doctor wearing any of the stuff in the cart or any gowns when they provided him treatment. Resident #2 stated no staff had used the things in the cart since they brought it to his room a few hours ago and insisted the cart was not in his room prior to today. An interview with the Substitute Administrator on 8/11/26 at 4:15pm revealed if a resident required EBP during care, there should have been a sign on the door describing the EBP and there should have been PPE somewhere in the resident's room. The Substitute Administrator stated the risk to the residents of staff not using EBP when necessary was there would be a break in infection control and cross contamination could happen. Record review of the facility's, Enhanced Barrier Precaution policy, revised 11/28/23, reflected, .EBP are used in conjunction with standard precautions and expand the use of PPE to donning (put on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A single set of PPE cannot be used for more than 1 patient. EBP are indicated for residents with any of the following: Colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply (see MDRO list on page 3); or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized( the presence of germs but does not have symptoms of infection with a MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage . or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers (wound caused by poor blood flow). Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies (surgical openings made through the front of the neck into the windpipe). A peripheral intravenous (small flexible tube placed in a surface vein) line is not considered an indwelling medical device for the purpose of EBP. The facility will utilize postings outside the room and Point Click Care to communicate to staff if a resident requires EBP.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for four of nine residents (Resident #3, #5, #6, and #8) reviewed for accident prevention. The facility failed to ensure Resident #6 did not have scissors and odor ban disinfectant spray in his room on 07/27/26. The facility failed to ensure Resident #5 did not have a container of Tide Pods laundry soap in her room on 07/27/26. The facility failed to ensure Resident #8 did not have Nystatin cream, scissors and safety pin in his room on 07/27/26. The facility failed to ensure that Resident #3 did not have scissors and 2 nail clippers in his room on 07/27/26. This failure could place residents at risk of injuries or accidents.Findings included: Record review of Resident #6's Face Sheet, dated 07/27/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with bipolar disorder (A condition where depressive episodes alternate with periods of abnormally high energy or mania). Record review of Resident #6's Quarterly MDS Assessment, dated 06/04/26, revealed a BIMS of 9 (moderate cognitive impairment). The MDS Assessment revealed the Resident needed Supervision with shower, upper body dressing, lower body dressing and putting on of footwear. It revealed he had a diagnosis of bipolar disorder. Record review of Resident #6's care plan revision dated 06/08/26 revealed, the resident has mood problem r/t bipolar with intervention to 1) Monitor/record/report to MD prn risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. 2) Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. During an observation and interview on 07/27/26 at 9:30 a.m. with Resident #6, it was observed that an odor ban disinfectant spray was hanging on his bed rails and a pair of scissors on his nightstand. He stated he got the odor ban from Walmart; he uses it because it stinks in his room and the scissors are used to trim his beard; he stated that he is not supervised when he uses it and does not need supervision. Record review of Resident #5's face sheet dated 07/27/26 revealed a [AGE] year-old female admitted to the facility on [DATE], she had a diagnosis of bipolar disorder (A condition where depressive episodes alternate with periods of abnormally high energy or mania) Record review of Resident #5's change in condition MDS Assessment, dated 04/22/26, revealed a BIMS of 11 (mild cognitive impairment). The MDS Assessment revealed the Resident needed substantial / Maximal assistance to Supervision with shower, upper body dressing, lower body dressing and putting on footwear. It revealed she had a diagnosis of bipolar disorder. Record review of Resident #5's care plan dated 03/11/26 revealed the resident had an ADL Self Care Performance Deficit with intervention for Resident will ask for assistance as needed with ADLS and toileting, bathing. During an interview and observation on 07/27/26 at 9:40 a.m. with Resident #5 revealed Tide Pods container with Pods observed on her nightstand. She stated that she has had them there since she moved in, she stated that the staff moved her things in and kept the container of Tide Pods on her nightstand and it has been there ever since. She stated that she knew it should not be stored in the open because it could pose a danger to residents who are confused, she stated they can eat it if they get a hold of it. Record review of Resident #8's face sheet dated 07/27/26 revealed a [AGE] year-old male admitted to the facility on [DATE], he had a diagnosis of Lack of coordination, Need for assistance with personal care. Record review of Resident #8's Quarterly MDS Assessment, dated 06/10/26, revealed a BIMS of 14 (no cognitive impairment). The MDS Assessment revealed the Resident has medically complex conditions. Record review of Resident #8's care plan dated 03/11/26 revealed the resident has an ADL Self Care Performance Deficit with intervention to requiring 1 staff for ADL's and Encourage the resident to participate to the fullest extent possible with eachinteraction. During an observation and interview on 07/27/26 at 10:10 a.m. with Resident #8, it was revealed that a safety pin, pair of scissors and Nystatin cream was observed on his nightstand. He stated that they were given to him by the facility. He stated that he was not given any instructions on how to use them, but he is safe with them. He stated that he had a lock box that he locked them in that was stolen in September 2025 and was not found, a police report was filled. He stated that the facility had put a lock on his nightstand, but he has not had a key to it in the last 2 months and has complained to maintenance about it 2 months ago and it is still locked. Record review of Resident #3's Face Sheet, dated 07/27/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The Resident was diagnosed with Dementia (A progressive loss of memory, reasoning and communication skills) and Intermittent explosive disorder (sudden, intense fits of anger or physical aggression that are completely out of proportion to what caused them). Record review of Resident #3's Annual MDS Assessment, dated 05/22/26, revealed a BIMS of 6 (severe cognitive impairment). The MDS Assessment revealed the Resident had Medically Complex Conditions. Record review of Resident #3's care plan dated 06/27/25 revealed the resident has impaired cognitive function/dementia or impaired thought processes r/t intermittent explosive disorder, psychotic disorder with delusions due to now physiological condition andDementia with intervention to Provide a program of activities that accommodates the resident's abilities. During an interview and observation on 07/27/26 at 10:45 am with Resident #3, it was observed that Resident #3 had scissors, 2 pairs of nail clippers and bleed stop in a clear plastic drawer in his room. He stated that he was not sure how they got in his room. He did not answer any other questions asked. During an interview on 07/27/26 at 3:23 p.m. with CNA F, she stated that these items should not be in the resident room. She stated that chemical sprays, tide pods, scissors and nail cutters are a hazard, the nystatin cream is a treatment and should be locked up in the treatment cart. She stated that residents could drink these items, she stated they can cut themselves with the scissors and get hurt bad. She stated that all nursing staff are responsible for making sure no hazards are left in any resident rooms. She stated that she has been in serviced about what items are not allowed in the residents' rooms. During an interview on 07/27/26 at 3:45 p.m. with CNA L, she stated that Resident #3 has had the Tide Pods in her room for a while even when she was in a different hall. She stated that the resident should not have the Tide Pods in her room. She stated that anyone can get a hold of it and eat it and get very sick. She stated that she takes out aerosol sprays if she sees them. She stated that these items can potentially hurt any resident. She stated that all staff that work in the halls are responsible for making sure no hazardous items are in the resident's room. During an interview on 07/27/26 at 4:31 p.m. with LVN C, he stated that the facility policy is that any chemicals, scissors and sharp objects should be locked up in a secure compartment and room checks should be done during rounds for these items. He stated that all chemicals should comply with the MSDS standard for the facility. He stated that all staff in the hall should be doing rounds to make sure that there are no safety hazards in any resident rooms. He stated that if any chemicals or sharp objects are in the room, the residents could cut themselves, and the chemicals could burn them or could be a fire hazard. During an interview on 07/27/26 at 5:07 p.m. with the DON, she stated that she has started a list of items that should not be in resident rooms and will pass it on to all staff when they do rounds and will also make sure families who bring in any prohibited items are educated. She stated that hazards could affect the residents, they can interact with their meds, they could be fire hazards, and someone who does not have the capability of using the items correctly can hurt themselves or others. During an interview on 07/27/26 at 5:47 p.m. with the Administrator, he stated that hazardous items should not be in residents' rooms, he stated that the challenge is that some residents order things online and due to resident rights, they cannot open the boxes for inspection. He stated that they make rounds to ensure that any hazardous items or sharp objects are not stored in the residents' rooms. He stated that every staff member is responsible for making sure no hazardous chemicals or sharp objects are in the resident's room. He stated that they do room rounds to check for items that are not allowed but they will have to do so more intently to remove the items. He stated that they educate the residents when any items that are not allowed in the facility are found in the rooms. Record review of the facilities undated list of Items not allowed in rooms (these items may be kept in the med rooms, labeled with the resident's name and room number) The med room next to B hall has many cubbies available to be labeled. Revealed the following items:Triple antibiotic ointment (Neosporin)ScissorsWound care productsTylenol (acetaminophen)Advil (ibuprofen)Aleve (naproxen)Pain creamPain patchesAir freshenerAerosol Cans (ie. Hairspray, deodorant)Deodorant of any kindRazors (electric razors are ok)Tide pods (laundry detergent of any kind)Vape pensCigarettesLightersCleaning productsDish soapSharp objects (knives)Chemicals of any kindElectric Tea kettlesMicrowave ovensToastersHeating padsPersonal heatersLarge amounts of moneyUnsecured credit cardsCurling ironsBlow dryer

Based on observations, interviews, and record reviews the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 9 residents (Residents #5, #7 and #1) reviewed for respiratory care. The facility failed to ensure Resident #5's Oxygen Nasal Canula and breathing treatment masks storage bags were changed every 7 days on 07/27/26. The facility failed to ensure Resident #7's breathing treatment masks storage bag was changed every 7 days on 07/27/26. The facility failed to ensure Resident #1's CPAP storage bag was changed every 7 days on 07/27/26. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #5's face sheet dated 07/27/26 revealed a [AGE] year-old female admitted to the facility on [DATE], she had a diagnosis of bipolar disorder (A condition where depressive episodes alternate with periods of abnormally high energy or mania) and COPD. Record review of Resident #5's change in condition MDS Assessment, dated 04/22/26, revealed a BIMS of 11 (mild cognitive impairment). The MDS Assessment revealed the resident needed substantial / maximal assistance to supervision with shower, upper body dressing, lower body dressing and putting on footwear. The MDS revealed she was on oxygen therapy. Record review of Resident #5's care plan dated 03/11/26 revealed the resident had oxygen therapy with intervention to administer oxygen at 2-4 liters per nasal canula. Record review of Resident #5's physician order dated 07/22/26 revealed an order for Oxygen LPM: 2-4 Via: nasal canula every shift related to COPD. During an observation and interview on 07/27/26 at 9:40 a.m. with Resident #5, it was observed that a breathing treatment mask storage bag dated 07/17/26 was hanging on the wall and a nasal canula storage bag on the oxygen machine was dated 07/02/26. She stated that she is not sure how often it should be changed but that they needed to be changed. She stated that she does not want to get sick from any contamination. Record review of Resident #7's face sheet dated 07/27/26 revealed a [AGE] year-old female admitted to the facility on [DATE], she had a diagnosis of Acute Respiratory Failure (sudden, life-threatening condition where your lungs can no longer get enough oxygen into your blood or get rid of enough waste carbon dioxide). Record review of Resident #7's Quarterly MDS Assessment, dated 06/12/26, revealed a BIMS of 11 (mild cognitive impairment). The MDS Assessment revealed the resident was coded for Acute Respiratory Failure. Record review of Resident #7's care plan dated 11/07/25 revealed the resident had altered respiratory status/Difficulty Breathing / Shortness of Breath and hx of ACUTE RESPIRATORY FAILURE with intervention to Administer medication/puffers as ordered. Monitor for effectiveness and side. Record review of Resident #5's physician order date 06/09/26 revealed an order for Budesonide Inhalation Suspension 0.25 MG/2ML (Budesonide (Inhalation)) 1 vial inhale orally via nebulizer two times a day related to RESPIRATORY DISORDERS. During an observation and interview on 07/27/26 at 10:25 a.m. with Resident #7, breathing mask storage bag dated 07/02/26 and 2 undated bags were observed. She stated she is not sure what the schedule was for changing the bag, she stated that they should be thrown away at this time since they may be contaminated. Record review of Resident #1's face sheet dated 07/27/26 revealed a [AGE] year-old male admitted to the facility on [DATE], he had a diagnosis of COPD and sleep apnea (sleep disorder where a person's breathing repeatedly stops and starts throughout the night). Record review of Resident #1's MDS Assessment, dated 07/17/26, revealed a BIMS of 14 (no cognitive impairment). The MDS Assessment revealed the Resident was coded for COPD and sleep apnea. Record review of Resident #1's physician order dated 07/10/26 revealed an order for BIPAP - Settings IPAP 10.0 cm H2O EPAP 4.0 cm H2O every night shift related to SLEEP APNEA. During an observation and interview on 07/27/26 at 10:35 a.m., Resident #1 stated that all he has to say is that some staff members should leave their problems at home. BIPAP mask storage bag was dated 7/10/26 on the nightstand. He stated he did not want to answer any questions at this time. During an interview on 07/27/26 at 4:31 p.m., LVN C stated that the nebulizer and oxygen bags should be changed weekly and as needed if soiled. He stated that the charge nurse, ADON, and DON are responsible for making sure that they are changed as ordered. He stated that an in-service was conducted on 07/14/26 on changing the oxygen tube and nebulizer mask bag. He stated that if the bags are not changed, it could get molded, the plastic of the nebulizer could get stiff and irritate the residents' nose and ear. During an interview on 07/27/26 at 5:07 p.m., the DON stated that the expectation is that the nasal canula bags and nebulizer mask bags should be changed every 7 days and dated, she stated that this applied to all respiratory apparatus including CPAP and BIPAP masks. She stated that the nurses are responsible for making sure that the bags are changed and dated. She stated that it is an infection control issue. She stated that for residents with respiratory issues, it can cause an infection for them and worsen their condition. Record review of the Facility's undated Policy for Oxygen Administration revealed: The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. Theadministration, monitoring of responses, and safety precautions associated with it are performed by the nurse.The resident will be free from infection. Record review of the facility's undated policy for Aerosolized Hand-Held Nebulizer revealed: A compressor-driven nebulizer will be used (unless piped-in oxygen is available), to administeraerosolized medication as ordered by a physician.Change nebulizer set-up every 7 days and more often if necessary.

Based on observations, interviews and record reviews, the facility failed to ensure parental fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive care plan and the resident's goals and preferences for 1 of 9 residents (Resident #4) reviewed for PICC lines (Peripherally Inserted Central Catheter). The facility failed to change the PICC line (an intravenous catheter that is suitable for long term infusion therapy) dressing on Resident #4 for more than 7 days on 07/27/26. These failures placed the residents at risk of infection or dislodgement.Findings included: Record review of Resident # 4's face sheet dated 07/27/26 revealed he was a [AGE] year-old-male admitted on [DATE] he was diagnosed with Severe Sepsis without septic shock (blood pressure remains stable enough to avoid a critical drop). Record review of Resident #4's Quarterly MDS assessment date 07/02/26 revealed a BIMS score of 9 (moderate cognitive impairment), it revealed active diagnosis of septicemia (blood poisoning, which occurs when bacteria or other germs from an infection elsewhere in the body enter and multiply in the bloodstream), it revealed the resident is on antibiotics due to infection. Record review of Resident #4's physician order dated 06/30/26 revealed an order for Vancomycin HCl in NaCl Intravenous Solution 1.5-0.9 GM/500ML-% (Vancomycin HCl-Sodium Chloride) Use 500 cc intravenously at bedtime for foot until 8-6-26. During an interview and observation on 07/27/26 at 10:57 a.m., with Resident #4, he was observed sitting in his wheelchair, clean, well-groomed and free of odors, his PICC line dressing located on the residents right arm was dated 07/16/26. The dressing was intact and no redness was noted on insertion site. He stated that he is not sure if it should be dated and how often it should be changed. During an interview on 07/27/26 at 4:31 p.m., LVN C stated that the expectation is that the PICC line dressing should be changed every 7 days, it is a standard order for the facility or follow the current order from the physician. He stated that the nurse is responsible for making sure that the orders are followed by changing the dressings. He stated that if the PICC line dressing is not done as ordered, it could lead to infection and deterioration of the skin under it. During an interview on 07/27/26 at 5:07 p.m. with the DON, she stated that the expectation is that PICC line dressings should be changed every 7 days and as needed if soiled. She stated that this is to prevent infection to the PICC line insertion site. She stated the nurses are responsible for making sure the PICC line dressing is changed as ordered. She stated if the PICC line dressing is not changed as ordered and infection can occur and this could be detrimental to the resident.

Based on observation, interview and record review the facility failed to ensure prescribed medications were stored in a locked compartment for 1 of 9 residents (Resident #6) reviewed for medication storage. The facility failed to ensure Resident #1's prescribed medications were not left on top of the resident's bed side table by MA D on 07/27/26 These failures could place residents at risk of wrong medication administration, not getting the getting the full benefit of the medication, accidental overdose, misuse of medications, diversion and possible adverse reactions.Findings include: Record review of Resident #1's face sheet dated 07/27/26 revealed a [AGE] year-old male admitted to the facility on [DATE], he had a diagnosis of COPD and sleep apnea (sleep disorder where a person's breathing repeatedly stops and starts throughout the night). Record review of Resident #1's MDS Assessment, dated 07/17/26, revealed a BIMS of 14 (no cognitive impairment). The MDS Assessment revealed the resident had medically complex conditions. Record review of Resident #1's care plan dated 01/07/26 revealed, Adverse medication effect and behavior Monitoring with intervention to Monitoring and accurate documentation of the resident's response to any treatment (such as, lab results, vital signs, progress notes, behavior flow sheets, medication administration records and the consultant pharmacist's drug regimen review) isessential to evaluate the ongoing effectiveness, benefits as well as risks of nonpharmacological approaches and medications. During an observation and interview on 07/27/26 at 10:35 a.m., with Resident #1, a medication cup with medication in it was observed on the resident's bedside table while he was asleep. He was easily aroused. He stated he was asleep when the nurse came and she left the medication on the table for him to take after breakfast. He stated that he gets his medication after breakfast and dinner. During an interview on 07/27/26 at 4:19 p.m. with MA D, she stated that she should observe the following protocol for medication pass right resident, right dose, right time, right route, right medication and to make sure the resident took the medication before she moved on to the next resident. She stated that she had given Resident #1 his medication but was distracted by the roommate and assumed the resident took his medication. She stated that if the resident does not take his medication as scheduled, he will not get the full therapeutic effects of the medication prescribed for him. She stated that if the medications are not taken it could lead to a worsening of his health conditions or an overdose if he takes it close to the next dose. She stated that she has been in serviced on medication pass. She stated that she reports any medication errors to the DON or the charge nurse During an interview on 07/27/26 at 4:31 p.m. with LVN C, he stated that the expectation is that medication administration should be observed and not left at the bedside for the resident to take. He stated that the resident could take it close to the next dose or the roommate can take it when it's not meant for them and this could be life threatening. He stated that the medication aide and the charge nurse are responsible for making sure that all medications should be administered by facility protocol for the resident's safety. During an interview on 07/27/26 at 5:07 p.m. with the DON, she stated that the medications should never be left with the resident, she stated that it is expected that the MA /Nurse should observe the resident take the medication and take the medication cup with her as she leaves the room. She stated that the resident will not get as much medication as they should, to make sure they are not chocking on the meds, to make sure they are fully swallowing the medication and not pocketing it in their mouths and to prevent other residents from getting a hold of the medication which is not meant for them and have an allergic reaction. She stated that whoever is giving the medication is responsible for making sure they are taken as ordered by the resident. Record review of the facility's V3 2025 Medication Storage in the Facility revealed Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations orthose of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staffmembers lawfully authorized to administer medications. Record review of the facility's V3 2025 Medication Administration and General Guidelines revealed Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or otherpersonnel authorized by state laws and regulations to administer medications.Medications are administered at the time they are prepared. Medications are not pre-poured.Medications supplied for one resident are never administered to another residentAdheres to the 6 Rights of Medication Administration:1) Right Dose2) Right Route3) Right Resident4) Right Medication5) Right Time6) Right Documentation Observes the resident take the medications

Based on observation, interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary care team to reflect a residents changed in condition following a fall for one of nine residents (Resident #9) reviewed for care plan implementation. The facility failed to ensure Resident #9's comprehensive care plan was updated following a fall resulting in a left ankle fracture on 07/02/26. These failures could place the residents at risk of not having their needs meet and receiving the necessary care and services.Findings included: Record review of Resident #9's Face Sheet, dated 07/27/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20 had a diagnosis Age related osteoporosis (Thinning bones) and muscle weakness. Record review of Resident #9's Quarterly MDS Assessment, dated 07/27/26, revealed a BIMS of 7, indicative of severe cognitive impairment. The Quarterly MDS Assessment did not reveal a history of falls. Record review of Resident #9's care plan dated 12/22/26 revealed the resident was at a risk for falls, goal that the resident will be free of falls and will not sustain serious injury through the review period, interventions included to anticipate and meet Resident's needs, be sure the Resident's call light is within reach and encourage the Resident to use it and review information on past falls and attempt to determine cause of falls, record possible root cause, alter any potential causes if possible. Educate resident/family/caregivers and IDT as to causes. During an interview on 07/27/26 at 10:15 a.m., Resident #9 stated that transferred herself to the bathroom and she fell when she was coming out of the bathroom and hurt her leg, she stated that she tried to land on her bed but missed and landed on the floor. She stated that she was lucky to be alive. She was observed with a boot on her left leg. She stated that she is unable to recall the details of the events that led to the fall. During an interview on 07/27/26 at 3:23 p.m., CNA F stated that she looks as the Kardex to know the type of care each resident needs. She stated that the Kardex is usually updated and if she notices any changes she reports to the nurse to update the Kardex. She stated that if the Kardex is not updated and level of care changes for a transfer can cause injury for the residents and staff involved in the care. During an interview on 07/27/26 at 3:45 p.m., CNA L stated that she cares for the residents based on the direction on their Kardex. She stated that the Kardex is always updated and she tries to keep up. She stated that the MDS and therapy keep the Kardex updated. She stated that if the Kardex is not updated she reports to the charge nurse. She stated that if the Kardex is not updated the right care that is needed would not be provided. During an interview on 07/27/26 at 4:31 p.m., LVN C stated that the MDS coordinator updates the care plan, he stated that there should be communication for any change in condition. He stated that rounds should be made by the MDS coordinator daily to find out any changes in resident conditions. He stated that due to the facility being short staffed a lot of times it is hard for the MDS coordinator to keep up, he stated that he has not noticed any management nursing staff do rounds to check on any changes with the residents. He stated that he reports changes in resident conditions to the ADON and the DON. He stated that the care plan needs to be updated so that PRN Staff who don't work regularly will know what is going on with each resident so they can provide the proper care and the expectation of the care for each resident. He stated that if the care plan is not updated the resident care would not be provided and the resident condition could deteriorate. He stated that the care plan should be updated after any significant change in condition or fall in the case of Resident #9. During an interview on 07/27/26 at 5:07 p.m., the DON stated that the expectation is that the nurses, MDS or the DON should update the care plan when a resident is readmitted into the facility. She stated that updating the care plan is to make sure that everyone knows and is updated on how to care for the residents. She stated that if the care plan is not updated it will affect their safety during care. She stated that the CNAs have an update on the Kardex and plan of care whenever the care plans are updated. The DON stated that they should have updated the fall care plan for Resident #9 after the fall and that it was an oversite on their part. Record review of the facility's policy, undated Fall Policy revealed: Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correctingintrinsic factors, and educating the resident and family. A Fall Risk Assessment will be completed onadmission and after each fall. The MDS 3.0 will also assist in determining a resident who is a fall risk.Fall Risk Assessment The Fall Risk Assessment Tool will be completed at admission and after each fall occurrence.The assessment should be completed by reviewing the resident's medical history, social history, andcurrent functional status. Information may be obtained by reviewing current medical records,interview with resident/family, or conference with the interdisciplinary team members. Theassessment tool should be scored and interventions implemented as indicated. The MDS completed on admission quarterly and upon significant change will also assess for fallRiskAppropriate interventions will be addressed immediately on the interdisciplinary plan of care.Reassessment will occur after each fall.The DON or designee will be responsible for investigating all resident falls to attempt to determine thecause and need for new interventions as required.

Based on observations, interviews, and record review, the facility failed to ensure the resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life by recognizing the resident's individuality for one of nine residents (Residents #2) reviewed for residents' rights and dignity. The facility failed to ensure that Resident #2's Foley bag was in a privacy bag while in his wheelchair on 07/27/26. This failure could place the residents at risk of not having their right to a dignified existence maintained.Findings included: 1.Record review of Resident #2's Face Sheet, dated 07/27/26, revealed a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate causing trouble with peeing). Record review of Resident #2's Quarterly MDS dated [DATE], revealed that the resident had a BIMS of 10 which is indicative of moderate cognitive impairment. The MDS assessment revealed that the Resident had an indwelling catheter. The MDS assessment revealed Resident #2 required supervision or touch assistance for personal hygiene and toileting. Record review of Resident #2's Physician Order, dated 06/05/26, revealed an order to Ensure foley bag is in privacy bag while in bed or w/c every shift related to BENIGN PROSTATIC HYPERPLASIA WITH LOWER URINARY TRACT SYMPTOMS; OBSTRUCTIVE AND REFLUX UROPATHY, UNSPECIFIED (enlarged prostate causing trouble with peeing). Record review of Resident #2'ss care plan dated 06/05/26 revealed that The resident has (Indwelling) Catheter: r/t obstructive uropathy with intervention to Check tubing for kinks and maintain the drainage bag off the floor; Ensure tubing is anchored to the residents leg or linens so that tubing is not pulling on the urethra (pipe that carries urine from bladder out of the body), Monitor and document intake and output as per facility policy, and Perform Catheter care at least every shift and at each incontinent episode. The care plan revealed the resident has an ADL self-care performance deficit with intervention requiring staff x 1 assistance for bathing, bed mobility, dressing and toilet use and the residents require a lift for all transfers. During an interview and observation on 07/27/26 at 10:45 a.m., Resident #2 was in his power chair in hallway C, his Foley bag was not covered in a privacy bag, he stated that it is usually covered but could not find the privacy bag. He found the bag under his food tray and placed the foley bag in a privacy bag when he got into his room. He stated that he usually does his own foley care and does not ask for help. During an interview on 07/27/26 at 3:23 p.m. with CNA C, she stated that the expectation is to have a privacy bag over the foley bag to maintain the residents' privacy and dignity. She stated that Resident #2 is very particular about how he wanted things done. She stated that she checks on the resident to see if the bag is full and needs to be emptied, she stated that the resident insists on emptying the bag himself. She stated that the privacy bag needs to be in place to prevent others from seeing that he has a foley catheter. She stated that the resident can get upset and angry if the bag is not covered with a privacy bag. During an interview on 07/27/26 at 3:45 p.m. with CNA L, she stated that privacy bags are supposed to always be in place, he stated that Resident #2 always takes his privacy bag off. She stated that the privacy bag should be in place to maintain the residents' dignity. She stated that if his dignity is not maintained it could make him feel depressed and uncomfortable know that others can see what is going on with him. She stated that she tries to encourage him to have the privacy bag on, but the resident is alert and oriented and does not always follow the direction and does things his way. During an interview on 07/27/26 at 4:31 p.m. with LVN C, he stated that the privacy cover should always be on. He stated that Resident #2 is forgetful and leaves the privacy cover off sometimes. He stated that he is not sure of any challenges with him keeping the privacy bag on. He stated that the privacy cover should be on to maintain the resident's dignity and not everyone should know if he has a foley catheter. He stated that he could have depression and not see himself as a normal person and a constant reminder of his condition if the privacy bag is not in place. He stated that all nursing staff and other employees are responsible for making sure that the privacy bag is always in place. During an interview on 07/27/26 at 5:07 p.m., the DON, she stated that it is expected that every foley should always have a privacy cover. She stated that it's a dignity and privacy issue and his care and condition should be between him and his nurse and doctor. She stated it could affect him emotionally and take away his dignity. She stated that nursing and CNAs are responsible for making sure that the privacy bag is always on.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of ten residents (Resident #1 and Resident #14) reviewed for respiratory care. 1.The facility failed to ensure Resident #4's oxygen nasal canula and Nebulizer mask were properly stored when not in use on 07/11/26. 2.The facility failed to ensure Resident #1's nebulizer mask was properly stored when not in use on 07/11/26. 3.The facility failed to ensure Resident #3's nebulizer mask was properly stored when not in use on 07/11/26. These failures could place residents at risk of respiratory infection, respiratory complications, and not having their respiratory needs met.Findings Include 1. Record review of Resident #4's face sheet, dated 06/11/26, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with the following: Chronic Obstructive Pulmonary Disease - COPD (a progressive, long-term lung disease that makes it hard to breathe), Respiratory Failure (your lungs or breathing system have long-term damage, making it hard to get enough oxygen into your blood or push out waste gases), Heart Failure (chronic, progressive condition in which the heart cannot pump blood efficiently enough to meet the body's needs). Record review of Resident #4's significant change in status MDS Assessment, dated 05/05/26, revealed a BIMS of 12 (moderate memory and thinking problems). The Quarterly MDS Assessment indicated the resident was on oxygen therapy. Record review of Resident #4's Comprehensive Care Plan, dated 11/25/25, revealed the resident had Emphysema (Air sacs in the lungs are damaged making it difficult to breathe) / COPD and oxygen therapy and one of the interventions was to give oxygen therapy as ordered by the physician. Record review of Resident #4's Physician's Order, dated 03/31/26, revealed Oxygen LPM: 2-4 Via: nc every shift related toCHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION and Levalbuterol HCL Inhalation Nebulization Solution 0.63 MG/3ML (Levalbuterol HCL) 1 inhalation inhale orally via nebulizer every 8 hours as needed for Wheezing. During an interview and observation on 07/11/26 at 9:50 a.m. with Resident #4 revealed the oxygen tube connected to the oxygen tank was hanging on the wheelchair and her nebulizer mask was lying on the bedside table and not bagged while not in use. Resident #4 stated that no staff had told her it needed to be in a bag. She stated that she thought it should be bagged for health reasons to prevent germs from getting in them. She stated that if germs got into it she could catch something because she had COPD and her lungs were very bad. During an interview on 07/11/26 at 10:19 a.m. with CNA L, she stated that it was the facility policy for oxygen cannulas and nebulizer masks to be bagged. She stated that the CNAs and the nurses were responsible for making sure they were bagged when not in use. She stated that the canula and nebulizer mask should be bagged because of cross contamination. She stated that it could make the resident sick. She stated that she told h nurse when she found the canula and nebulizer mask as not properly bagged, for them to change it. She stated she had been in-serviced on what to do when she finds a respiratory device not properly stored. 2. Record review of Resident #1's face sheet, dated 06/11/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with the following: COPD, Acute Respiratory Failure (lungs suddenly cannot put enough oxygen into your blood or take enough carbon dioxide out), Pulmonary Hypertension (high blood pressure in arteries of the lungs) Record review of Resident #1's Physician Order dated 07/09/26 revealed an order for Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation)) 1 vial inhale orally via nebulizer every 12 hours for ARF with hypoxemia (abnormally low level of oxygen in the blood) related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED; SHORTNESS OF BREATH;ACUTE RESPIRATORY FAILURE WITH HYPOXIA; OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC) Assess before & after a treatment During an interview and observation on 07/11/26 at 11:30 a.m. with Resident #1, revealed his nebulizer mask was sitting on his nightstand and not bagged. Resident #1 stated he did not know much about the machine, but that the nurses came and put the medicine in it and put the mask on. He stated that he was not sure if it should be bagged or not. Record review of Resident #'3s face sheet, dated 07/11/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with Unspecified Foreign Body in Bronchus Causing Asphyxiation, Initial Encounter (object blocking the main lung tube). Record review of Resident #3's Quarterly MDS Assessment, dated 07/02/2026, revealed the resident had moderate impairment with a BIMS score of 09. The Comprehensive MDS Assessment indicated the residents had heart failure, pneumonia and pulmonary hypertension. Record review of Resident #3's Physician's Order date 07/01/26 revealed and order for Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 1 vial inhale orally via nebulizer every 6 hours related to UNSPECIFIED FOREIGN BODY IN BRONCHUS CAUSING ASPHYXIATION, INITIAL ENCOUNTER Assess before & after a treatment During an observation and interview on 07/11/26 at 11:37 a.m. with Resident # 3, it was observed that his nebulizer mask was on his nightstand and not bagged while not in use. The available bag in the room was dated 07/03/26. He stated that he thought it should be bagged to keep germs out, but was not sure why the nurses did not bag it and he never asked. During an interview on 07/11/26 at 11:55 a.m. with LVN B, she stated that the nebulizer mask was supposed to be stored in a bag and dated. She stated that the mask and bag were changed weekly. She stated that if nebulizer mask was dirty or soiled, they changed them in less than a week. She stated that bagging and changing the mask weekly helped to keep respiratory infections down and prevented it from happening. She stated the charged nurse were responsible for making sure the mask and bag were both changed weekly. She stated that the night shift is usually responsible for changing the mask and bag, she stated that any nurse giving the breathing treatment should also note if the mask was changed or not. During an interview on 07/11/26 at 12:05 p.m. with LVN K, she stated that the facility policy states that oxygen tubing and the nebulizer mask should be dated and be in a dated bag when not in use. She stated that it was to prevent bacteria from growing in them especially since it went into the resident's mouth and nose. She stated that since they inhale both the treatment from the nebulizer and the oxygen, any bacteria that could get in their lungs can make them sick. She stated that they had educated on making sure she bags her oxygen tube when not in use since she transfers herself. She stated that that the nurses on the floor were responsible and the nurse giving the nebulizer should make sure the nebulizer mask was bagged after treatment is completed. She stated that every employee, both CNs and admin staff also made rounds and let the nurse know to fix any issues found. She stated that they would continue to educate and reinforce with Resident #3 to make sure she kept her oxygen tube and in the designated bag, and that the nurse giving the nebulizer treatment will be more proactive to make sure she gets to the resident before the treatment is completed. During an interview on 07/11/26 at 12:23 p.m. with CNA S, she stated that the facility policy was that the oxygen tube and nebulizer mask should be bagged when not in use. She stated that they should be bagged for infection control. She stated that if the oxygen tube and the nebulizer mask were not bagged, it could cause a respiratory infection for the resident. She stated that she checks on and other residents often to care for their needs and make sure that they are met. She stated that the CNAs and nurses are responsible for making sure the oxygen tube and nebulizer mask are both bagged. During an interview on 07/11/26 at 12:32 p.m. with the DON, she stated that oxygen tubes and nebulizer mask should be bagged when not in use. She stated that the bags, oxygen tube and nebulizer mask should be changed weekly and dated. She stated that she will do a walk through and conduct in services to make sure every staff member is on board with the policy. She stated that will be completed in the next 3 days. She stated that the rationale for the policy is for infection control since most of the residents who use oxygen and nebulizer have respiratory issues and we don't want it to get worse. She stated that the nurses are primarily responsible since they give the treatments and the CNAs are trained to alert the nurse if they are not bagged. Record review of the facility's Nursing Policy and Procedure Manual 2003 Oxygen Administration revealed: Goals1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen.2. The resident will maintain an effective breathing pattern with administration of oxygen.3. The resident will be free from infection.10. Change the tubing (including any nasal prongs or mask) that is in use on one patient when itmalfunctions or becomes visibly contaminated. Record review of the facility's Nursing Policy and Procedure Manual Aerosolized Hand-Held Nebulizer revealed: 13. Rinse the nebulizer and mouthpiece shake and store in a plastic bag the is labeled withthe patient's name and room number.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for one of seven residents (Resident #2) reviewed for quality of care. The facility failed to ensure that Resident #2's wound dressing on pressure ulcer on left plantar foot (bottom sole of left foot) was dated and signed on 07/11/26 The failure could place residents at risk for worsening pressure injuries and could result in a decline in health.Findings included: Record review of Resident #2's face sheet dated 07/11/26 revealed an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Sepsis (the body's extreme, dangerous response to an infection), Dementia (A progressive loss of memory, reasoning and communication skills). Record review of Resident #2's MDS dated [DATE] revealed that the resident had a BIMS score of 05 (severe cognitive impairment) and was at risk of pressure-ulcers. The MDS revealed that Resident #2 was admitted to the facility with one stage III pressure ulcer (ulcer exposing all the outer skin layers and exposes the layer of fat underneath), one unstageable pressure ulcer (also called a bed sore that is a deep wound covered by thick, dead tissue. The dead tissue hides the bottom of the wound. Doctors cannot see how deep the wound goes). Record review of Resident #2's current physician's order revealed an order dated 07/07/26 for WOUND CARE: UNSTAGEABLE: LEFT PLANTAR FOOT: Cleanse with wound cleanser, pat dry, apply medical grade honey and cover with silicone borderedsuperabsorbent dressing every day shift every Tuesday, Thursday, Saturday for Wound Treatment and PRN. Record review of Resident #2's care plan dated 06/26/26 revealed the resident had a pressure ulcer to: COCCYX (tail bone) UNSTAGEABLE LEFT PLANTAR FOOT STAGE III with intervention to follow facility policies/protocols for the prevention/treatment of skin breakdown. Wound care observation and interview on 07/11/26 at 11:15 a.m. to 10:50 a.m., with RN K revealed Resident #2's wound dressing on the left planter foot was not dated and initialed. RN K stated that the facility policy was that all wound dressings needed to be dated and initialed by the treating nurse. She stated that dating the wound dressing was to make sure of the time it was last completed and that it was done in a timely manner. She stated that the nurses were responsible for making sure that the wound dressing was dated and initialed. She stated that if it was not dated and initialed, no one would know when it was completed and that the dressing could be on past when it needed to be changed. She stated this could result in infections or sepsis. She stated that not dating the dressing and initialing could interrupt continuity of care. She stated that the undated dressing must have been a PRN dressing after she completed the last dressing on Thursday 07/09/26 for Resident #2 During an interview on 07/11/26 at 12:32 p.m. with the DON, she stated that the policy was that the wound dressings should be dated and signed and that she planned to in-service the nurses on how important it was to make sure they were dating and initialing the wound dressing when it was done. She stated that they had a wound doctor and nurse practitioner that rounded every Tuesday. She stated the undated dressing on Resident #2's right plantar foot must have been a PRN dressing that was done and the nurse forgot to date it. She stated that all the nurses who did wound care should make sure that the wound dressing was intact and dated as per policy. She stated that not dating the wound dressing could delay the wound healing and the wound could get worse and delay any kind of treatment they need. Record review of the facility's policy Pressure Injury: Prevention, Assessment and Treatment Wound Care Policy & Procedure Manual Revised 5/5/25 revealed: Procedure:1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulationto prevent breakdown, injury and infection.3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatmentnurse/designee. The treatment nurse/designee will:1. Notify the physician of pressure sore and obtain and follow any orders as directed by thephysician.2. Notify family and dietary department. Document Notification

Based on interview and record review, the facility failed to make prompt efforts to resolve grievances of resident rights and failed to follow their grievance policy for one of seven residents (Resident #1) reviewed for grievances, in that, The facility failed to document, resolve and follow-up with grievances on 06/09/26 and 06/12/26 for Resident #1 brought up by Resident #1's guardian concerns about Resident #1's dietary tray and milk being left longer than 1.5 hours. This failure could affect residents by placing residents at risk of a decline in quality of life and a delay in resolving grievances.Findings included:Review of Resident #1's face sheet undated reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of multiple sclerosis (autoimmune disease that affects your brain and spinal cord), paraplegia (partial or complete paralysis of the lower half of the body, including both legs), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and dysphagia (difficulty swallowing). Resident #1 had a guardian listed on his face sheet as the responsible party for Resident #1.Review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 4 indicating he was severely cognitively impaired. Resident #1 was substantial/maximal assistance to total dependent for ADLs of dressing, personal hygiene, bathing and mobility.Review of Resident #1's comprehensive care plan last reviewed 04/13/26 reflected The resident has impaired cognitive function/impaired thought processes r/t (related to) Dementia. It reflected The resident refuses to eat/resists feeding. Resident refuses to allow staff to remove his tray at times. Intervention included Staff will remove tray after 1.5 hours and offer snack if resident wants to continue eating.Record Review of Grievances for April 2026 to June 2026 reflected a grievance dated 06/03/26 was reported to DON about [Family member] is upset that his tray is still in his room, 1.5 hr after the meal. Findings include Spoke with staff and staff reports that resident refuses to allow staff to remove his tray, stating he is sill eating. Corrective Action included Staff will continue to try to remove tray after meals. Care plan updated to reflect resident's desire to keep tray in room. It reflected grievance resolved.There were no grievances documented about the meal trays or milk being left in Resident #1's room from Resident #1's Guardian since 06/03/26. Record Review of Email reflected Resident #1's Guardian emailed the DON and Administrator on 06/09/26 at 1:07 AM the following: Please talk to [CNA B] about leaving milk for [Resident #1}. Tonight dinner was served at 4:54. He picked the tray up at 6:23 but left the milk and did not pick up the milk until 7:26. In the past, I have reached out to a couple of nurses asking them to remind [CNA B] not to leave milk. I can't verify if they did speak with him. This is nothing personal and he seems like a very nice person, but I think he hates to take the milk from [Resident #1] if [Resident #1] says he wants to keep it. I speculate that he feels compassion for him. However I do not want [Resident #1] getting sick because of dairy setting out too long. I do not want him to get into trouble, but I do request that you speak with him about the importance of removing the milk in a timely manner. I have been speaking with the state and they are telling me that it is on the nurse treatment plan and the nurses are ultimately responsible. This has been an ongoing discussion. Whatever the case , I just want the meals and the milk removed in a timely manner. Review of email response from DON dated 06/09/26 at 11:01 AM reflected Thank you. Record Review of Email reflected Resident #1's Guardian emailed the DON on 06/12/26 at 7:11 PM the following [CNA B] left [Resident #1's] milk again when he picked up his tray. After months of complaining about this, he had milk left too long every. Single. Meal. Today. Interview on 06/16/26 at 9:50 AM with Resident #1's Guardian revealed she was still having issues with facility staff removing the dietary meal trays after 1.5 hours of being given to Resident #1 and would leave his milk and shake in his room. She stated each time she had to call facility staff to get the staff to remove it. She stated she had reached out to the DON and Administrator about her concerns and she was still having issues with staff not picking up the meal tray or leaving his milk past the 1.5 hours. She stated she was not certain if the DON even read her emails and did not follow up with her grievance. Interview on 06/16/26 at 4:00 PM with CNA B revealed last Sunday (06/14/26) when he was working Resident #1 wanted to keep his health shake when he picked up the meal tray he stated he would be back to pick it up within 20 minutes but he got busy with other residents so there was a delay. He could not recall if it was on Friday (06/12/26) he had left the milk in his room. He stated he did his best to pick up the meal tray in the evenings for Resident #1 within the1.5 hours but Resident #1 did not want him to take the health shake so he left it in his room. He stated it was not communicated to him when the meal tray was placed for Resident #1 for supper. He stated he was aware the meal tray for Resident #1 needed to be picked up in 1.5 hours. He stated the charge nurse would alert him if meal tray or shake was left in room too long. He stated no one from administration had specifically spoke to him about being late picking up Resident #1's meal tray and shake. He stated if resident wanted him to leave the shake in his room he did and did not understand why the meal tray including shake had to be removed. Interview on 06/16/26 at 5:06 PM with RN A revealed Resident #1's guardian did text her at 7:08 PM on Friday (06/12/26) she looked at her phone to know the time she received the text and stated the text revealed CNA B had left the milk/shake in Resident #1's room. She stated Resident #1 would reach out to her if the meal tray or shake was left past the 1.5 hours in his room since there was an electronic monitoring device in Resident #1's room. She stated she did not understand why the health shake needed to be picked up. She stated when the staff start their shift at 6 pm they try to pick up meal trays first. She stated prior shift did not communicate to them when Resident #1 received his meal tray so they would know when to pick it up by to meet the 1.5 hour timeframe. Interview on 06/16/26 at 4:45 PM with DON revealed at the care plan conference it was agreed upon for meal trays including the shake/milk to be picked up within 1.5 hours. She stated she started a monitoring tool to check 1 of the meals each day where it was written down when meal received and if tray was picked up within the 1.5 hours. The DON stated there should be a grace period of 15 to 30 minutes from that 1.5 hour period. She stated the weekend shifts were more difficult for staff to adhere to the 1.5 hours. She stated nurses would receive a phone call from Resident #1's guardian since he has an electronic device in room if meal tray or shake was left in resident room past the 1.5 hours. She stated after the care plan conference on 06/03/26 the nurses and CNAs were in-serviced to ensure meal trays including dairy shake was removed within the 1.5 hours of receiving the tray. She stated she had received an email on Friday (06/12/26) and had not had an opportunity to follow up with Resident #1's guardian yet. She stated she was not sure if she followed up with Resident #1's guardian about her email on 06/09/26. She stated it was difficult for staff to understand that Resident #1's meal tray including dairy shake needed to be removed within 1.5 hours since resident wanted it kept in his room. Interview on 06/16/26 at 5:15 PM with Administrator revealed Resident #1's guardian did voice continued concerns about Resident #1's meal trays including shake/milk not being picked up within the 1.5 hours of receiving the tray. He stated DON participated in the care plan conference with Resident #1's guardian and he was not in the care plan conference. He stated he thought the DON had responded to Resident #1's guardian's emails saying they would address it. He stated it was important to document grievances, follow-up with grievances to ensure concerns were being met for residents. The Administrator stated he was responsible for overseeing the grievance process. Review of facility's policy Grievances last revised 11/02/16 reflected The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. Procedure.2. The grievance official of this facility is the administrator or their designee. 3. The grievance official will Oversee the grievance process Receive and track grievances to their conclusion Lead any necessary investigations by the facility.Issue written grievance decisions to the resident.6. All written grievances decisions will include: The date the grievance was received A summary statement of the residents grievances The steps taken to investigate the grievance A summary of the pertinent findings or conclusions regarding the resident's concern(s) A statement as to whether the grievance was confirmed or not confirmed Any corrective action taken or to be taken by the facility as a result of the grievance The date the written decision was issued.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six of eight (Resident #96, Resident #9, Resident # 69, Resident # 70, Resident #46 and Resident #8) observed for infection control. 1.The facility failed to ensure LVN E sanitized the glucometer with a recommended germicidal wipe between resident use when she obtained a fingerstick blood sugar on Resident #9 and then proceeded to obtain a fingerstick blood sugar on Resident #96 with the contaminated glucometer and then placed the un-sanitized glucometer back into the medication cart on 03/17/26. 2. The facility failed to ensure LVN D prevented cross-contamination of the bottle of test strips when she carried the bottle of strips into Resident #69's room, placed them on the resident's bedside table and then returned them to medication cart without sanitizing the bottle. 3. The facility failed to ensure RN C utilized Enhanced Barrier Precautions while performing G tube medication administration for Resident # 70 on 03/18/26. 4. The facility failed to ensure CNA F and CNA H utilized Enhanced Barrier Precautions during incontinence care and a mechanical lift transfer for Resident # 46 on 03/17/26. 5. The facility failed to ensure CNA G and CNA M utilized Enhanced Barrier Precautions during incontinence care and a mechanical lift transfer for Resident # 46 and failed to ensure CNA G disposed of a soiled brief and wipes in a plastic bag instead of on the floor on 03/18/26. 6. The facility failed to ensure CNA J performed hand hygiene and glove changes during incontinence care of Resident #8, and before leaving the resident's room on 03/17/26. These failures could place residents at risk for infection and cross contamination.Findings included:1. Record review of Resident #9's face sheet, dated 03/19/26, reflected a [AGE] year-old female admitted [DATE], diagnosis included type 2 diabetes mellitus (chronic condition where high blood sugar results from insufficient insulin production). Record review of Resident #96's face sheet, dated 03/19/26, reflected a [AGE] year-old female, admitted [DATE]. Diagnosis included type 2 diabetes mellitus (chronic condition where high blood sugar results from insufficient insulin production). During an observation on 03/17/26 at 10:56 a.m. revealed LVN E was at the medication cart preparing to perform Resident #9's fingers stick blood sugar. LVN E removed the glucometer from the medication cart and placed it on a piece of wax paper with a few test strips, alcohol pads, and lancets. LVN E performed hand hygiene, put on gloves, and entered Resident #9's room and placed the wax paper with the supplies on the resident's bedside table. LVN E pricked Resident #9's finger and obtained a blood sample with a reading of 204. LVN E returned to the medication cart, disposed of the lancet and test strip and placed the used glucometer back in the top drawer of the mediation cart. LVN E removed her gloves and performed hand hygiene, checked the computer, and stated the resident would be receiving 5 units of Novolin R per sliding scale. LVN E opened the medication cart reached into the medication cart and retrieved the insulin pen and dialed in 5 units. LVN E re-entered Resident #9's room and administered the insulin. LVN E returned to the medication cart and placed the insulin pen back into the medication cart and then proceeded to the next resident's room.During an observation on 03/17/26 at 11:01 a.m. LVN E was observed at the medication cart preparing to obtain a fingerstick blood sugar on Resident #96. LVN E opened the medication cart and pulled out a piece of wax paper and placed the un-sanitized glucometer, a few test strips, alcohol pads, and lancets on the wax paper. LVN E performed hand hygiene, put on gloves, and entered Resident #96's room and placed the supplies on the resident's bedside table. LVN E pricked the resident's finger and obtained a blood sugar sample with a reading of 214. LVN returned to the medication cart, disposed of the lancet and used supplies, and placed the used glucometer back in the top of the mediation cart without disinfecting the glucometer. LVN E then checked the computer and stated Resident #96 would receive 3 units of Lispro per sliding scale. LVN E reached into the medication drawer and retrieved the insulin pen and dialed in 3 units. LVN E then re-entered the resident's room and administered the insulin. During an interview on 03/17/26 at 11:10 a.m., LVN E stated she was supposed to sanitize the glucometer between each resident and stated she had failed to do that. She stated by placing the glucometer back in the cart she contaminated the medication cart. She stated she just got so nervous and had just forgotten that step. She stated the risk of not disinfecting the glucometer was the spread of blood borne pathogens. 2. Record review of Resident #69' face sheet, dated 03/19/26, reflected a [AGE] year-old female, admitted [DATE]. Diagnosis included type 2 diabetes mellitus (chronic condition where high blood sugar results from insufficient insulin production).During an observation on 03/17/26 at 11:12 a.m., LVN D was observed at the medication cart preparing to obtain a fingerstick blood sugar on Resident #69. LVN D opened the medication cart and pulled out a piece of wax paper and placed the glucometer, alcohol pads, lancets and the whole bottle of test strips onto the paper and entered Resident #69's room. LVN D placed the wax paper with the supplies onto Resident #69's bedside table. LVN D pricked the resident's finger to obtain a blood sample and obtained a reading of 476. LVN D then placed the used test strip and lancet on the wax paper and then moved the glucometer and bottle of test strips onto the resident bedside table and wadded up the wax paper. LVN D then carried the glucometer and the test strips and placed them on top of the mediation cart while she disposed of the lancet and used test strip. LVN D performed hand hygiene, put on gloves, and retrieved a sani-wipe (germicidal wipe) and cleaned the glucometer. LVN D removed her gloves, performed hand hygiene, and checked the computer. She stated the resident would receive 20 units of Novolog per sliding scale and she would have to re-check her blood sugar in 3 hours and if it was still over 400 she would need to call the MD. LVN D opened the top of the medication cart and put the bottle of test strips back into the cart and retrieved the insulin pen, re-entered the resident's room, and dialed 20 units and administered the insulin.During an interview on 03/17/2026 at 11:20 a.m., LVN D stated she should not have laid the used glucometer or the bottle of test strips on the resident's bedside table. She stated she should have carried the necessary supplies into the room and should have left the glucometer and the bottle of strips on the wax paper until she sanitized them. She stated the risk was cross contamination of the medication cart.3. Record review of Resident #70's face sheet, dated 03/19/26, reflected a [AGE] year-old female, admitted [DATE]. Diagnoses included Alzheimer's disease and dysphagia (difficulty swallowing).An observation on 03/1/8/26 at 7:40 a.m. of G-Tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) medication administration revealed Agency RN C at the medication cart outside of Resident #70's room. An Enhanced Barrier sign was posted outside of the door and a cart containing gowns was inside of the resident's room. RN C prepared the medication for Resident #70, sanitized her hands but did not put on gloves and gown. RN C checked for residual, flushed the tube with water, and then administered the medication and flushed with water following the medication administration and then provided Resident #70 her bolus feeding (a large amount of liquid administered over a short period of time). RN C then returned to the medication cart and performed hand hygiene.During an interview with RN C on 03/18/26 at 8:00 a.m., she stated any resident with a G-tube was required to be on Enhanced Barrier Precautions. She stated she should have worn a gown and gloves and just overlooked it when she entered the room. She stated she had the gloves in her pocket. She stated the risk of not following Enhanced Barrier Precautions was the spread of MDROs.4. Record review of Resident #46's face sheet, dated 03/19/26, reflected a [AGE] year-old female admitted [DATE]. Diagnoses included Alzheimer's Disease and multiple sclerosis (chronic autoimmune disease of the central nervous system causing communication issues between the brain and body).During an observation on 03/17/26 at 9:30 a.m., a sign was posted outside of Resident #46's room which indicated she was on Enhanced barrier precautions. Upon entering the room, CNA G and CNA M were observed placing a clean brief under Resident #46 and then placed the mechanical lift sling under the resident to get her up for the day. The staff did not have a gown during this observation. Resident #46 was observed to have a dressing on her inner left leg calf and knee with a date of 03/17/26. Once the resident was positioned on the sling, CNA G and CNA M raised her up with the mechanical lift and positioned her in her wheelchair. Both staff removed their gloves and washed their hands before leaving the room.During an interview on 03/17/2026 at 9:55 a.m., CNA H stated she realized they both forgot to put on a gown when they went in to provide Resident #46 care. She stated Resident #46 was on Enhanced barrier precautions due to her wounds. She stated the risk of not following the requirements was the spread of infection. During an interview on 03/17/2026 at 10:00 a.m., CNA F stated she realized they both forgotten to put on a gown when they went in to get Resident #46 up for the day. She stated any type of care they provided for someone who was on enhanced barrier precautions required them to wear a gown and gloves. She stated the purpose was to decrease the risk of the spread of germs and infections.During an observation on 03/18/2026 at 1:15 p.m., CNAs G and CNA M were requested by ADON A to lay Resident #46 down so wound care could be provided. Upon entering Resident #46's room, CNA G and CNA M were observed at the bedside placing a clean brief under the resident. Both staff had on gloves but were not wearing a gown. A soiled brief with bowel movement and multiple soiled wipes were noted on the floor. Both staff positioned the resident in the bed and then CNA G picked up the soiled brief and wipes and placed them in the trash can and removed the bag from the trash can. Both staff removed their gloves and washed their hands and notified ADON A, who was outside the resident's door, she was ready for wound care. During an interview on 03/18/2026 at 1:40 p.m., CNA G and CNA M stated they were supposed to have a gown on to transfer the resident plus provide incontinence care due to the resident wounds and had failed to so. They stated they had received training on the purpose of Enhanced barrier precautions and knew any resident with a wound required the use of gown and gloves. CNA G stated she had thrown the dirty brief and wipes on the floor because she was not prepared to change Resident #46 when they went to lay her down, and once they had gotten her into bed realized she had a bowel movement and needed to be changed. She stated she could have used the trash can but stated she just was not thinking. 5. Record review of Resident #8's face sheet, dated 03/19/26, reflected a [AGE] year-old female admitted [DATE]. Diagnosis included a fracture left femur (thigh bone).During an observation on 03/17/2026 at 2:45 p.m., CNA J and CNA I entered Resident #8's room, washed their hands and put on gloves. CNA J unfasted the resident's brief and stated she was not wet. Both staff rolled the resident on her left side revealing she had a small bowel movement. CNA I wiped from the front to back. Resident started having more bowel movement and CNA I stated she needed to go to the cart to get some more wipes and gloves. CNA I removed her gloves and left the room without performing hand hygiene. CNA I returned to the room and put on gloves without performing hand hygiene and continued to perform peri care to the resident. With the same gloves used to clean Resident #8's buttocks, CNA I applied barrier cream. CNA I then removed her gloves and re-gloved without performing hand hygiene and placed a clean brief under the resident. Both staff repositioned the resident onto her back and fastened the brief. Both staff removed their gloves and performed hand hygiene.During an interview on 03/17/2026 at 2:45 p.m., CNA J and CNA I, both stated they were supposed to perform hand hygiene before care, after they changed their gloves and before they left the room. CNA J stated she had failed to perform hand hygiene when she left the room to get more supplies and stated she should have changed her gloves and performed hand hygiene before she put the barrier cream on the resident. She stated the risk was the spread of infection and germs. During an interview on 03/19/26 at 09:45 a.m., the DON stated staff were to change their gloves and perform hand hygiene after they performed incontinence care and before applying the clean brief and always before going from clean to dirty. She stated they were never to throw soiled briefs, wipes or linens on the floor and would expect them to be prepared for incontinence care anytime they laid a resident down. She stated by not following proper hand hygiene it placed residents at risk of urinary tract infections. She stated they had done extensive in-services with the staff on infection control, especially hand hygiene and the use of Enhanced barrier precautions. She stated any resident with a wound, a catheter or a G-tube required the use of gown and gloves during any high contact care, including G-tube medication administration. She stated in addition they made rounds and watched care to ensure the staff were following correct procedures. She stated the staff had also been trained on the proper sanitizing of glucometers and when to perform hand hygiene during glucose monitoring and they were to only carry in the supplies needed to perform the necessary test. She stated the risk of not following the proper procedures was cross contamination and potential for the spread of blood borne pathogens. Record review of the facility's undated policy titled, Fundamentals of Infection Control Precautions, reflected, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility.Hand Hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situation that require hand hygiene.When hands are visibly soiled.Before and after assisting a resident with personal care.After handling soiled or used linens, dressing, bedpans, catheters and urinals.After contact with a resident's mucous membranes and body fluids or excretions.After removing gloves.Resident Care equipment and articles.Equipment that is visibly soiled with blood or body fluids will be cleaned immediately with an approved disinfectant by the nursing assistant.Record review of the facility's policy titled, Enhanced Barrier Precautions, dated April 2024, reflected, Multidrug-resistant organism (MDRO) transmission is common.Enhanced Barrier Precautions (EBP) refer to an infection control intervention design to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during having contact resident care activities.EBP are indicated for residents with any of the following.Wounds and/or indwelling medical devices.examples.urinary catheters, feeding tubes.Facilities should remember to have an appropriate disposal container available in the resident room to allow for removal of PPE inside the room.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's 1 of 1 kitchen.: The dietary staff failed to ensure temperatures were taken of all cooked and cold food before serving them to residents during lunch meal service on 3/17/26.The dietary staff failed to properly sanitize the thermometer while taking the temperature of each food. The dietary staff failed to use proper hand hygiene during lunch service on 3/17/26. These failures could place residents at risk for food-borne illness if consumed and food contamination. Findings included: Record review of two grievances filed by two anonymous residents on 2/23/26 reflected food was always undercooked, especially on the weekends. During an observation of the Dietary Manager of taking the temperature of the food on 3/17/26 at 11:40 a.m. revealed he took the temperature of the Gumbo, wiped the thermometer with a sanitizing pad and placed it on the counter. The Dietary Manager then stuck the thermometer in the rice to take the temperature The Dietary Manager then removed the thermometer and placed it on the counter. The Dietary Manager picked up the thermometer again and stuck it in the corn bread without sanitizing it. At 11:50 a.m. the Dietary Manager poured chicken strips and French fries that had been sitting in the metal baskets on the fryer into the metal trays on the warming table. The Dietary Manager was not observed taking the temperature of the chicken strips or French fries. The Dietary Manager and Dietary Aide B were observed serving plates of food on trays that had salads. The Dietary Manager was not observed taking the temperature of the salads on the food trays. At 12:05 p.m. the Dietary Manager served some chicken strips and French fries from the warming table without taking the temperature of them. During an observation of Dietary Aide B on 3/17/26 at 11:58 a.m., revealed Dietary Aide B stopped assisting with serving food and left to the pantry to obtain hamburger buns. Dietary Aide B was observed returning to the serving area with hamburger buns and a box of gloves. Dietary Aide B removed a glove from the box, put it on her right hand and proceeded to pull out a hamburger bun and placed it on a plate. Dietary Aide B removed her glove and proceeded to serve food. Dietary Aide B was not observed washing her hands or sanitizing her hands after removing her glove. During an interview with the Dietary Manager on 3/17/26 at 12:51 p.m., interview revealed all foods, hot or cold, should have the temperature taken before serving to residents. The Dietary Manager stated he had not taken the temperature of the salad because it had just been removed from the refrigerator. The Dietary Manager stated he should have taken the temperature anyway. The Dietary Manager stated he took the temperature of the fries and chicken tenders as soon as they came out of the fryer ,while they were in the basket, but he should have taken the temperature again when they were placed on the heating table. The Dietary Manager stated the thermometer should have been sanitized before and after each food and he should not have placed the thermometer on the counter because it had not been sanitized and the thermometer could have gotten contaminated. The Dietary Manager stated if he placed the thermometer on any surface the thermometer should have been sanitized again before using it. The Dietary Manager stated dietary staff were not required to wear gloves during meal service but they needed to follow proper handwashing and sanitizing. The Dietary Manager stated dietary staff should wash their hands between handling raw meats, after gloves were used or when they left the serving area and returned to resume food service. The Dietary Manger stated Dietary Aide B should have washed her hands when she returned from the pantry with the bread to serve the food and she should have washed her hands every time she removed her glove. The Dietary Manager stated the risk to the residents of not temping all foods was it could have made them sick. The Dietary Manager stated the risk of not properly sanitizing the thermometer after putting it on a surface that was not sanitized was cross contamination and possible illness. The Dietary Manager stated there was also a risk of cross contamination from not washing hands after having left the serving area and returning. During an interview with Dietary Aide B on 3/17/26 at 1:10 p.m., interview revealed hands should have been washed when staff left the kitchen or serving area, touched their clothes and when gloves were removed. Dietary Aide B stated she had not washed her hands after she returned from having gotten the bread and stated she should have washed her hands. Dietary Aide B stated she should have washed her hands every time she took the glove off while serving the hamburgers. Dietary Aide B stated because she had not washed her hands . Dietary Aide B stated it was unsanitary and could have caused the spread of infection. During an interview with the Administrator on 03/19/2026 at 12:15 p.m., interview revealed he had been in the position for a month and had started to work on properly training dietary staff. The Administrator stated he would work with the Dietician to ensure the appropriate in-services and training were provided for dietary staff. The Administrator stated the expectation was for dietary staff to have proper hand hygiene, temp all foods and maintain a clean and sanitized kitchen to prevent the spread of illness. Record review of the facility's policy titled, Infection Control, dated revised 2012 reflected, .Careful hand washing by personnel will be done in the following situations: a. prior to entering the work area and reporting to the workstation. B. between handling of dirty dishes boxes or equipment and handling clean food or utensils. Record review of the facility's policy titled, Daily Food Temperature Control, dated revised 2012 reflected, We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log.Procedure: 1. There is a thermometer available for use in the department to test the temperatures of foods which is sanitized between food testing. 2. Prior to meal service, the cook shall take the temperature of all hot and cold foods.4. All hot foods shall be cooked and held for service at temperatures of 140 degrees Fahrenheit or above.6. Cold foods shall be less that 41 degrees Fahrenheit. Record Review of Review of Food and Drug Administration Food Code, dated 2022, reflected, . 2 - 19 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands. Record Review of Review of Food and Drug Administration Food Code, dated 2022, reflected, .3-501.19 Time as a Public Health Control. (A) Except as specified under (D) of this section, if time without temperature control is used as the public health control for a working supply of TIME/TEMPERATURE CONTROL FOR SAFETY FOOD before cooking, or for READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is displayed or held for sale or service. (B) If time without temperature control is used as the public health control up to a maximum of 4 hours: (1) Except as specified in (B)(2), the FOOD shall have an initial temperature of 5 C (41 F) or less when removed from cold holding temperature control, or 57 C (135 F) or greater when removed from hot holding temperature control.Record Review of Review of Food and Drug Administration Food Code, dated 2022, reflected . 4-7 Sanitization of Equipment and Utensils 4-701 Objective 4-701.10 Food-Contact Surfaces and Utensils. Equipment food-contact surfaces and utensils shall be sanitized.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring and administering of all medications to meet the needs of each resident for three of six residents (Resident #9, Resident #96, and Resident #69) reviewed for pharmacy services. 1. The facility failed to ensure LVN E followed the manufacturer's instructions to prime the Novolin R Insulin (hormone) Pen for prior to dialing in the required amount of insulin to administered to Resident #9. 2. The facility failed to ensure LVN E followed the manufacturer's instructions to prime theHumalog pen (Insulin Lispro) (Hormone) prior to dialing in required amount of insulin to be administered to Resident #96. 3. The facility failed to ensure LVN D followed the manufacturer's instructions to prime theNovolog pen (Insulin Aspart) (Hormone) prior to dialing in required amount of insulin to be administered to Resident #69. These failures could place residents at risk of not receiving full dosage of medication. Findings included: 1. Record review of Resident #9's face sheet, dated 03/19/26, reflected a [AGE] year-old female admitted [DATE], diagnosis included type 2 diabetes mellitus (chronic condition where high blood sugar results from insufficient insulin production). Record review of Resident #9's Physician's Order for March 2026, reflected, Novolin R injection Solution 100 unit/ml.Inject per sliding scale; If . 201-230=5 units ( the amount of insulin to be administered).before meals and at bedtime. with a start date of 02/27/26. Record review of Resident #96's face sheet, dated 03/19/26, reflected a [AGE] year-old female, admitted [DATE]. Diagnosis included type 2 diabetes mellitus (chronic condition where high blood sugar results from insufficient insulin production). Record review of Resident #96's Physician's Order for March 2026, reflected, Humalog KwikPen.100 unit/ml (Insulin Lispro) .Inject as per sliding scale; If.201-230=3 units.before meals and at bedtime. with a start date of 03/14/26. During an observation on 03/17/26 at 10:56 a.m., revealed LVN E was at the medication cart preparing to perform Resident #9's fingers stick blood sugar. LVN E entered Resident #9's room and pricked Resident #9's finger and obtained a blood sample with a reading of 204. LVN E checked the computer and stated the resident would be receiving 5 units of Novolin R per sliding scale. LVN E opened the medication cart reached into the medication cart and retrieved the insulin pen and dialed in 5 units without first priming (meaning removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly) the pen. She re-entered Resident #9's room and administered the insulin. During an on 03/17/26 at 11:01 a.m., LVN E was observed at the medication cart preparing to obtain a fingerstick blood sugar on Resident #96. LVN E entered Resident #96's room, pricked the resident's finger and obtained a blood sugar sample with a reading of 214. LVN E returned to the medication cart, checked the computer, and stated Resident #96 would receive 3 units of Lispro per sliding scale. LVN E reached into the medication drawer and retrieved the insulin pen and dialed in 3 units without first priming the pen. LVN E then re-entered the resident's room and administered the insulin. During an interview on 03/17/26 at 11:10 a.m., LVN E stated she only primed the insulin pen when it was first opened and was not aware it needed to be primed each time. She stated the purpose of priming the pen was to ensure the insulin was all the way to the end of the pen. She stated she could see where it should be done each time to prevent giving an air shot. She stated going forward she would always prime the pen. 2. Record review of Resident #69' face sheet, dated 03/19/26, reflected a [AGE] year-old female, admitted [DATE]. Diagnosis included type 2 diabetes mellitus (chronic condition where high blood sugar results from insufficient insulin production). Record review of Resident #69's Physician's Order for March 2026, reflected, Novolog Flexpen subcutaneous solution (Insulin Aspart) 100 unit/ml.Inject per sliding scale; Do not call DR unless it's over 400 twice in a row 400 > give 20 units. Recheck in 3 hrs. and if 400> call MD.before meals and at bedtime. with a start date of 11/23/25. During an observation on 03/17/26 at 11:12 a.m., LVN D was observed at the medication cart preparing to obtain a fingerstick blood sugar on Resident #69. LVN D opened the medication cart and pulled out a piece of wax paper and placed the glucometer, alcohol pads, lancets and the whole bottle of test strips onto the paper and entered Resident #69's room. LVN D placed the wax paper with the supplies onto Resident #69's bedside table. LVN D pricked the resident's finger to obtain a blood sample and obtained a reading of 476. LVN D then placed the used test strip and lancet on the wax paper and then moved the glucometer and bottle of test strips onto the resident bedside table and wadded up the wax paper. LVN D then carried the glucometer and the test strips and placed them on top of the mediation cart while she disposed of the lancet and used test strip. LVN D performed hand hygiene, put on gloves, and retrieved a sani-wipe (germicidal wipe) and cleaned the glucometer. LVN D removed her gloves, performed hand hygiene, and checked the computer. She stated the resident would receive 20 units of Novolog per sliding scale and she would have to re-check her blood sugar in 3 hours and if it was still over 400 she would need to call the MD. LVN D opened the top of the medication cart and put the bottle of test strips back into the cart and retrieved the Insulin pen, re-entered the resident's room, and dialed 20 units without first priming the pen. LVN D administered the insulin and while leaving the room she stated, I forgot a step. She stated she was supposed to prime the pen with 2 units before dialing in the prescribed amount. During an interview on 03/17/2026 at 11:20 a.m., LVN D stated she was supposed to prime the pen with 2 units to ensure the air was out of the pen and make sure the resident received the full amount of insulin. She stated the risk of not priming the pen could be a resident not receiving the full amount of insulin prescribed. During an interview on 03/19/26 at 09:55 a.m., the DON stated the insulin pen was to be primed with 2 units before each injection to ensure the air was out of the pen and to determine if it was working correctly. She stated failure to do so could result in the resident receiving too little medication which could result in ineffective treatments and uncontrolled blood sugars. She stated all of the facility staff were trained on the proper protocol but stated they will In-service the staff again as well to ensure compliance. The DON stated they do not have a policy specific for insulin pens. She stated they follow the manufacturer's guidelines on the correct procedure for administration. Record review of the manufacture instructions for (Humalog)Lispro obtained from https://www.lillyinsulinlispro.com/ searched on 03/24/26 reflected, .Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your Pen, turn the Dose Knob to select 2 units. Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the Needle, and repeat priming steps. Record review of the manufacture instructions for (Novolog) Aspart obtained from https://www.novolog.com/ searched on 03/24/26 reflected, .Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your Pen, turn the Dose Knob to select 2 units. Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the Needle, and repeat priming steps. Record review of the manufacturer's instructions for Novolin R obtained from https://www.novo-pi.com/novolinr.pdf searched on 03/24/26, reflected, Giving the air shot before each injection Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to make sure you take the right dose of insulin: E. Turn the dose selector to select 2 units. Hold your Novolin(R) R FlexPen(R) with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge.Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times.

Based on observation, interview and record review, the facility failed to ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must provide foot care and treatment, in accordance with professional standards of practice for two resident of six residents (Resident #23, and Resident #35) reviewed for quality of care.1.The facility failed to ensure Resident #23's feet did not have dry, flaky skin.2.The facility failed to ensure Resident #35 had his toenails trimmed.This failure could place residents at risk of decline in quality of care, increased skin irritation and skin breakdown. Findings included: 1.Record review of Resident #23's face sheet, undated, reflected was a [AGE] year-old female admitted [DATE] and readmitted [DATE], with diagnoses of closed fracture of neck of left femur (hip bone), heart failure (chronic, progressive condition where the heart could not pump enough blood to meet the body's needs), acute respiratory failure with hypoxia (life-threatening condition where the lungs could not adequately supply oxygen to the blood or remove carbon dioxide). Record review of Resident #23's quarterly MDS assessment, dated 03/09/26, reflected Resident #23 had a BIMS of 11 indicating she was moderately cognitively impaired. Resident #23 required partial/moderate assistance with ADLs of lower body dressing, showers, and footwear. During an observation and interview on 03/17/2026 at 9:58 a.m., Resident #23 was observed lying in bed. Observation revealed both feet were white, flaky, and dry skin. Interview with Resident #23 revealed staff did not put any lotion on her feet but would like them to. Resident #23 stated the podiatrist had not seen her at the facility, but she had a podiatrist when she lived at home. She stated she was not a diabetic. During an observation on 03/18/2026 at 1:23 p.m., Resident #23's feet were dry with flaky skin on both feet, especially more near the toes. During an interview on 03/18/2026 at 1:25 p.m., LVN N stated she would get lotion for Resident #23's feet. LVN N stated she noticed edema on Resident #23's feet and the dry, flaky skin on her feet, since admission. During an interview on dated?? at 1:29 p.m., LVN N stated Resident #23 had dry, flaky skin on both feet. LVN N stated Resident #23's daughter might put lotion on resident's feet. LVN N stated the facility had lotion to put on Resident #23's feet or she could reach out to the doctor to inquire about a prescription for lotion for residents with dry flaky skin. LVN N stated she should have gotten lotion for her to help with the dry, flaky skin on the resident's feet. During an interview on 03/19/2026 at 12:50 p.m., the DON stated she expected CNAs to put lotion on residents when they noticed dry, flaky skin. The DON stated they did not have in-house lotion they could use on shower days and as needed. She stated the risk to a resident was the skin could stay dry/flaky and could cause more skin concerns.2. Record review of Resident #35's face sheet, dated 03/19/2026, revealed a [AGE] year-old male, admitted [DATE]. Diagnoses included cerebral palsy (a group of conditions that affect movement and posture), unspecified lack of coordination (inability to control or coordinate muscle movements), muscle weakness, unspecified convulsions (sudden, involuntary, muscle contraction or jerking motions), and moderate intellectual disabilities (deficits in cognitive abilities and adaptive skills). Record review of Resident #35's MDS, dated [DATE], reflected a BIMs score of 00, indicating severe cognitive impairment. Resident #35 was dependent (helper does all the effort) for personal hygiene. Record review of Resident #35's care plan, dated revised 1/06/2026, revealed Resident #35 had ADL self-care performance deficit related to Cerebral Palsy. Record review revealed interventions for bathing included checking nail length and trim and clean on bath day and as necessary. Further record review revealed interventions for personal hygiene included the resident required total assistance with personal hygiene care. During an observation of Resident #35 on 03/17/2026 at 10:18 a.m. revealed Resident #35 was sitting in his wheelchair with his bare feet uncovered. Resident #35's toenails were observed to be about an inch longer than nailbed. Resident #35 was not interviewable. During an interview on 3/18/26 at 9:06 a.m., CNA K stated Resident #35's toenails were not cut because she felt he needed a Podiatrist, a medical professional who specializes in care for feet and ankles. CNA K stated that residents' groomed toenails were part of residents' dignity. During an interview on 3/18/26 at 9:15 a.m., CNA L revealed CNAs were responsible for nail care unless the resident was diabetic. CNA L stated she cut Resident #35's fingernails but because his feet looked bad, she left cutting his toenails to the Podiatrist. During an interview on 3/18/2026 at 1:48 p.m., ADON A revealed CNAs cut resident's toenails unless the resident was diabetic in which case the Podiatrist cuts them. Resident #35 was not diabetic. ADON A stated she was unsure why Resident #35's toenails were not cut. She stated her expectation was for residents to be assessed and provided nail care on their shower days. During an interview on 3/18/2026 at 2:00 p.m., LVN E revealed she was unaware if CNAs assisted with nail care although they were responsible for hygiene. LVN E stated she thought Podiatry cut the toenails of all residents. LVN E stated she was unsure of her expectation regarding nail care. LVN E stated it was her responsibility to ensure residents received proper nail care. During an interview on 3/19/2026 at 12:44 p.m., the DON revealed CNAs were responsible for providing nail care for non-diabetic residents. The DON stated the expectation was for finger and toenails to be cut/trimmed as needed on shower days. The DON stated she, ADONs, and charge nurses were responsible for ensuring CNAs provided hygiene, including nail care for residents. The DON stated residents could have skin and dignity issues regarding uncut finger and toenails. Record review of facility's policy titled, Foot Care, undated, reflected, Foot Management is the daily assessment, bathing, lubrication and protection of the feet. It is done to promote cleanliness and peripheral circulation of the feet. Foot care is especially important in those residents with diabetes mellitus or peripheral circulatory condition because of their susceptibility to infection and skin breakdown.Procedure, 10. Apply lotion or oil preparation to dry areas. Record review of facility's policy titled, Nail Care from the Nail Policy and Procedure Manual, dated ??, revealed, Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticles are and is usually done during the bath. Goals: 1. Nail care will be performed regularly and safely.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and in compliance with the state laws, which included the appropriate accessory and cautionary instructions and the expiration date when applicable for the facility's one of two (ADON C's office refrigerator) refrigerators reviewed for medication storage. The facility failed to ensure a vial of Tuberculin Purified protein derivative that was opened and used, was dated in ADON C's refrigerator used for medication storage. This failure could place residents at risk of diminished effectiveness and not receiving the therapeutic benefits of the medications. Findings included:During an observation on 03/19/26 at 7:55 a.m., ADON C office refrigerator with ADON C revealed an undated opened vial of Tuberculin Purified protein derivative (used to detect tuberculosis infection) which was filled on 07/22/25.During an interview on 03/19/26 at 8:00 a.m., ADON C stated the Tuberculin Purified protein derivative (substance used for skin test for tuberculosis), had to be dated when opened. She stated once it was opened it would only be good for 30 days. She stated the risk of not dating it once opened was the potential for false positive or an inaccurate test, which could lead to a missed infection. She stated since she had been at the facility the Tuberculin Purified Protein, flu vaccines, pneumonia, and Hepatitis C vaccines were stored in the refrigerator in her office. She stated she was responsible for ensuring the medications were not expired. She stated she could not recall the last time she used the Tuberculin Purified protein derivative but stated she would discard this vial since she had no way of knowing how long it was opened.During an interview on 03/19/26 at 9:00 a.m., the DON stated she and the ADONs were responsible for monitoring the medication storage room and refrigerators to ensure expired medications were removed from possible use. She stated any multiple use vial was required to be dated once opened. She stated the Tuberculin Purified protein was only good for 30 days after it was opened. Record review of the facility's undated policy titled, Medication Storage in the Facility, reflected, Medications and biologicals are stored safely, securely and properly following manufacturers recommendations or those of the supplier.Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secures closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exist.

Based on observation, interview, and record review, the facility failed to store, prepare, and handle food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure all hot and cold held food temperatures were taken and record on the Supper (dinner) temperature log for dates 12/29/2025, 01/02/2026, 01/05/2025, 01/07/2026, and 01/08/2026.2. The facility failed to ensure staff followed food safety and sanitation protocols to prevent cross contamination of raw chicken and ready to eat sliced cheese. 3. The facility failed to ensure the milk temperature was held at least 41 F or less. These failures could place residents at risk for foodborne illness and foodborne intoxication.Findings included: During an observation on 01/21/2026 at 8:31 A.M. of the facility's only kitchen, this surveyor requested to review temperature logs for hot and cold held food items. Record review at this time, revealed hot and cold held food temperatures were not thoroughly taken on 12/29/2025, 01/02/2026, 01/05/2025, 01/07/2026, and 01/08/2026.Temperatures were not recorded for food items including milk and juice beverages, side dishes of fruits and vegetables, and meat entrees.Interview at this time with the Dietary Manager revealed he acknowledged the incomplete temperature logs. He stated any food items in bold on the temperature log were supposed to have been temperature checked. The Dietary Manager stated the hot held food items must be 145 F and higher, and cold food items must be 41 F and lower. He stated the importance of taking temperatures was to prevent spread of illness and contamination. The Dietary Manager indicated he would train dietary staff on how to properly take temperatures. During an observation and interview on 01/21/2026 at 11:25 A.M. of the lunch preparation in the kitchen, [NAME] C took the temperatures of all food items. [NAME] C discussed to accurately take food temperature, she would place the thermometer in the center of the food item, and what the appropriate temperature for hot held food items was. Observation further revealed 2 lunch trays had cups of milk on them, and they were not held to maintain cold temperatures. Observation on 01/21/2026 at 12:01 P.M. revealed the Dietary Aide F put on new gloves to grab and place raw chicken tenders in the fryer. With the same gloves on, she then touched sliced cheese and placed the sliced cheese on a hamburger. The rest of the meal was assembled and was going to be given to the resident it was made for. When asked the risk of touching raw meat and then touching the sliced cheese, the diet aide stated it could get someone sick. During an observation and interview on 01/21/2026 at 12:10 P.M., this surveyor asked what the temperature of the cups of milk on the 2 tray were. The Dietary Manager proceeded to check the temperature of the milk. The temperature of the milk was 52.7 F. The Dietary Manager stated that he wanted to keep the milk under 40 F; he proceeded to discard the milks sitting on the trays and get new cups of milk. Record review of the facility's Daily Food Temperature Control, dated 04/09/2025, reflected: We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges.Procedure:1. There is a thermometer available for use in the department to test the temperature of foods which is sanitized between food testing.2. Prior to meal service, the cook shall take the temperature of all hot and cold foods.3. Temperatures are recorded on the Temperature Log or Production sheet form.4. All hot foods shall be cooked and held for service at temperatures of 140 degrees F or above.5. Any hot or cold food which does not meet the minimum acceptable temperature shall be heated to a temperature of 165 degrees F and held at least 15 seconds. These instances should be recorded on the HAACP form.6. Cold foods shall be less than 41 degrees F. Record review of the U.S. FDA Food Code 2022 reflected: 3-304 Preventing Contamination from Equipment, Utensils, and Linens. 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above.(2) At 5 C (41 F) or less.

Based on observation, interview, and record review, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality for 1 (Resident #19) of 10 resident reviewed for food and nutrition services. The facility failed to follow physician-ordered diet changes to ensure Resident #19's dessert was mechanical soft, and included crushed pineapple, as the meal ticket stated, and not wafer cookies. This failure could place residents at risk of becoming malnourished and choking. Findings included:Record review of Resident #19's face sheet revealed a [AGE] year-old man, with a primary diagnosis of dementia, unspecified severity, with psychotic disturbance (decline in cognitive function, with symptoms that may include hallucinations or delusions). Other pertinent diagnoses include dysphagia (difficulty swallowing) and unspecified protein-calorie malnutrition (body does not receive enough protein and calories). Record review of Resident #19's quarterly MDS (Minimum Data Set) assessment, dated 12/27/2025, reflected a BIMS (Brief Interview for Mental Status) score of 12, indicating moderate cognitive impairment. Record review of Resident #19's care plan, dated 12/30/2025, reflected:Resident #19 had a potential nutritional problem; staff were to monitor, document, report for signs and symptoms of dysphagia, with the goal to maintain adequate nutritional status. Resident #19 had a swallow problem related to dysphagia; staff were to monitor/document/report difficulty swallowing, holding food in mouth, prolonged swallow time, repeated wallows per bite, coughing, throat clearing, drooling, and pocketing food in mouth, and for the diet to be followed as prescribed. Goals included Resident #19 would have no choking episodes and no signs of aspiration. Resident #19 required the use of dentures.Record review of Resident #19's orders reflected: Order: Renal diet, Regular Texture, Regular consistency Status: Active Start Date: 6/7/2025. Order: Renal diet, Mechanical Soft Texture, Regular consistencyStatus: Discontinued Start Date: 1/8/2025.During an observation on 01/21/2026 at 11:40 A.M of meal tray preparations, in the facility's only kitchen, revealed Resident #19's diet order on the meal ticket reflected [Resident #19] Renal 80 gm Pro/Mechanical Soft. Dessert 1/2 C Crushed Pineapple. The meal tray included a cup of Nilla Wafer cookies as the dessert. The meal tray was given to RN A and then given to the activities director to give to Resident #19. An observation and interview on 01/21/2026 at 12:14 P.M. with Resident #19, revealed he did not have teeth. He said he could eat the Nilla Wafer cookies if he drank enough water when eating cookies. Resident #19 indicated he preferred to have the crushed pineapple that was on his meal ticket.During an interview with the Dietary Manager, he stated Nilla Wafers cookies were considered safe for mechanical soft diets when given with pudding. The Dietary Manager stated resident diet orders were communicated with dietary staff through nursing or speech therapy staff. He stated dietary staff only accepted diet order changes through the communication form, and it could be filled out by both nursing and speech therapy staff. He indicated he did not have a communication form for Resident #19, and the order would have been from before he started working at the facility. During an interview on 01/21/2026 at 2:07 P.M. with the DOR, she stated Resident #19 was not currently on the speech therapy case load. She said that Resident #19 was referred to speech therapy for an evaluation on 01/06/2026 and he was on a regular (diet) with thin liquids, and the evaluation recommendations were regular (diet) with thin liquids. The DOR said speech therapy or nursing could write diet orders for the resident's chart. She further stated speech therapy did not communicate diet orders with the kitchen, and nursing staff were supposed to complete (diet order form) and give it to the kitchen. An interview on 01/21/2026 at 2:35 P.M. with RN A revealed she thought she looked at Resident #19's meal ticket. She said dietary staff told her Nilla Wafer cookies were mechanical soft. RN A indicated she was not aware Nilla Wafer cookies were considered safe for mechanical soft diets if they were served with pudding. She said it was important for residents to receive the right diet order to make sure they did not choke and they had the right diet. When asked about Resident #19's order for a regular diet in his chart, RN A indicated she did not know that there was an order for a regular diet. RN A said she did not know if Resident #19 could eat a regular (diet) because he did not have teeth; and residents who did not wear dentures, could not eat much (regular diet food items). When asked about the process of communicating diet orders in a resident's chart with the kitchen, RN A stated when nursing staff get the orders, they make a diet sheet for the kitchen and give it to the dietary staff (to adjust meal tickets to match diet orders). RN A said it was important to give correct diet orders so residents could actually eat their meals and not choke.During an interview on 01/21/2026 at 2:50 P.M. with RN B, she revealed she was the nurse for Resident #19. RN B stated Resident #19 could eat a regular diet but was supposed to be on mechanical soft diet. She said he did not like to use his dentures while eating, so he could eat a mechanical soft diet. RN B said the diet order should be mechanical soft, but it needed to be discussed with the resident because it was his right if he wanted a regular diet. RN B said she did not recall filling out a communication form regarding the regular diet order for Resident #19. She further stated speech therapy had never come to her regarding a diet order for Resident #19. RN B indicated it was important for residents to have the correct diet order for treatment, health, and their disease processes; medications can be given all day but adequate nutrition was important.During an interview on 01/21/2026 at 5:30 P.M. with the Regional Nurse, she revealed dietary staff were expected to check meal tickets and meals first, then nurses checked meal tickets, and then the meal trays were delivered to residents. She further indicated if speech initiated a diet order change, they should have entered it into the residents' orders in their chart; the nursing staff confirmed the orders and delivered it to dietary staff. Record review of the facility's Diet Manual, dated 2025 reflected: The next pages of information are designed for dietary employees to acquaint you with the rules and personnel procedures of this department. It is important that these be followed at all times in order to maintain the efficiency of the department and make this a pleasant place for you and others to work. The resident is the reason that we are here and our job in the residents' care plan is to serve attractive, appetizing, nourishing, and high-quality food to help keep them healthy.Your Food Service Management staff includes:.Dietary Service ManagerThis person is responsible for scheduling of employees, supervising the department, and purchasing food and supplies. Consult with manager regarding the preparation of food items, tray assembly procedures, cleaning procedures, or any related questions. Inform the manager of any unusual situations. Preventing problems is everyone's responsibility.

Based on interviews and record review the facility failed to ensure residents were free from abuse for two (Resident #1 and Resident # 2) of 9 residents reviewed for abuse. The facility failed to protect Resident #1, who was on mental health services, from mental anguish on 05/21/25 at 9:30 PM when, when despite her refusals, she was physically lifted, under her armpits, by CNA A from her bed to the shower chair was given a shower by despite her refusals. As a result, Resident #1 experienced mental anguish and anger. Resident #2 who was on mental health services experienced mental anguish/being upset after hearing her roommate being forced to shower by facility aides. This failure could place residents at risk for not having measures in place to protect them from serious harm, mental anguish, abuse, or neglect. The noncompliance was identified as Immediate Jeopardy Past Noncompliance (PNC). The Immediate Jeopardy began on 05/21/25 at 9:30 PM and ended on 05/28/25. The facility had taken actions noted in the findings that corrected the noncompliance before the incident investigation began on 06/17/25. Findings included: Review of Resident #1's Quarterly MDS, dated [DATE], reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. She had the diagnoses of Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation (a lung disease with a sudden worsening symptoms including breathlessness, mucus, and cough), Alzheimer's disease (loss of cognition), chronic pain syndrome, and anxiety disorder (excessive or persistent worry or fear). Her BIMS score was a 5 (severely impaired cognition). Further review of Section GG-Functional Abilities reflected she usually required substantial/maximal assistance for bed to chair transfers. Record review of Resident #1's care plan reflected the resident had an activity of daily living (ADL) performance deficit and required one staff to assist with bathing and bed mobility, dated initiated 02/13/25. Further review reflected a focus area, dated initiated 05/23/25, The resident has a history of trauma that may have a negative impact. The trauma is [due to]: Feeling angry [due to] shower being done after she refused. Interventions included: .If resident refuses her shower stop immediately . If the resident has escalated, if at all possible do not touch the resident unless absolutely necessary for resident's or others safety ., dated initiated 05/23/25. Record review of Resident #2's Quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. She had the diagnoses of cancer, heart failure, stroke with paralysis on her left non-dominant side, and major depression disorder (persistent feelings of sadness). Her BIMS score was a 7 (severely impaired cognition). Record review of Resident #2's care plan reflected the resident had impaired cognitive function/dementia or impaired thought processes; interventions included .Use residents preferred name . face the resident when speaking .Provide the resident with necessary cues- stop and return if agitated ., dated initiated 10/07/24. Record review of the Provider Investigation Report (PIR) (Form 3613-A of Texas Health and Human Services) reflected an incident date and time of 05/21/25 at 9:30 PM, dated reported 05/22/25 at 10:15 AM and signed by the Administrator on 05/28/25. Further review revealed on 05/21/25 around 8:40 AM, Resident #1 told her nurse that she needed to talk to someone in charge because she was upset about her care last night. Further review revealed on 05/21/25 around 9:30 PM Resident #1 told CNA A several times she did not want a shower and without Resident #1's consent, CNA A physically lifted Resident #1 from the armpits from the bed into the shower chair and Resident #1 was given a shower by CNA A with assistance in the shower room by CNA B. Resident #1 did not have a history of similar allegations and was interviewable and had the capacity to make informed decisions. Resident #1 had a head-to-toe assessment on 05/22/25 at 10 AM and had no injuries. The facility immediately suspended CNA A and CNA B and obtained interviews from both CNA's and Resident #1, completed resident safe surveys on 05/22/25 with no other concerns, and started staff monitoring for 4 weeks (05/22/25-06/18/25). Staff were in-serviced on abuse and neglect and resident rights, including a resident's right to refuse a shower, and trauma informed care on 05/22/25. Record review of Resident #1's verbal statement written by the Administrator, undated, reflected that two CNA's came to her room to take her to the shower and she told them she did not want a shower and she was cold: Two aides came into my room to take me to the shower . I told them that I am cold and don't want a shower. [CNA A] said you are getting a shower tonight. I was begging to not get a shower and told her to stop and go away. They grabbed me by my wrist and pulled me up to put me in the chair. The first shower was cold and then she put me in the other shower[,] it was fine [the shower water temperature] but I kept saying I did not want a shower. [They] put me in the shower and started washing me. Barely gave me a towel to dry off and put me in a gown took me back to my room and put me to bed. I just did not like it. Record review of CNA A's verbal statement, undated, written by the Administrator reflected the following: .(Resident #1) was like do I even have to have a shower and I said yes you will feel better. She was being like her energy was she did not want a shower . Did she have an attitude? Yes, but she got a shower and will feel better. I picked her up under her armpits slid back in chair and took her to the shower room. When asked how many times did (Resident #1) say she did not want a shower? Her response was twice and I told her she would feel better after her shower . Do you know that [residents] have the right to refuse a shower? Yes, knows about the papers and getting a nurse to assist with refusal of showers. Record review of resident safe surveys, dated 05/22/25 reflected Resident #1 safe survey: 1. Do you feel safe at this facility: 'Yes and No' 2. Has anyone mistreated you or anyone in this facility: 'Yes last night' 3. If you have been mistreated or witnessed mistreatment, would you report it to someone: 'Yes I did' 4. Who did you report it to? 'My attorney and the police' . Further review of resident safe surveys with 17 residents revealed no concerns regarding abuse, they felt safe at the facility, and knew how to report mistreatment. In an interview and observation on 06/17/25 at 11:38 AM, Resident #1 was in bed and dressed wearing a nasal cannula, she was a poor historian. She stated there was an incident about a month ago, a staff member told her she had to get up out of bed and Resident #1 did not want to get up, she had pain and was not feeling good. She stated that the staff member told her she was getting up even though she kept saying no. She stated the staff member grabbed her by the wrists and put her in her wheelchair and was not sure was else happened. She stated she felt very angry, was swinging her hands around and tried to swat at and hit the staff member away and repeated she did not want to get up and said no but they got her up anyway. She stated she told her nurse. She stated she was not able to recall anything about a shower except for a time that her hair was left wet. She stated that she did not like to get up out of bed because she had pain and declined health and preferred bed baths. She stated she was an [AGE] year-old woman in her dying days and wanted to stay in bed. She stated she felt safe at the facility knowing the staff member was not there because someone from the facility told her they were not working for the facility anymore. Record review of Resident #1's progress notes from 05/01/25-06/17/25, reflected the following: A nursing progress note dated 05/22/25 at 8:45 AM written by ADON D: Resident reported to Charge Nurse an incident that happened last night. Resident stated that 2 CNA Staff grabbed her by the wrist, put her on the shower chair and took her to the shower room even though res. told the CNAs that she is not feeling well multiple times. Administrator and MD notified. A nursing progress note dated 05/22/25 at 9 AM with the note text of Trauma Informed Assessment written by the ADON D reflected Resident #1 had no previous trauma or diagnosis of PTSD and reported she had not experienced or witnessed a situation that was extremely frightening, and she had felt angry: has felt angry. Description: Yes what happened last night still make me angry. A nursing progress note dated 05/22/25 at 10:42 AM, written by ADON D, reflected Resident #1 had a head-to-toe skin assessment and resident had bruising to her right forearm 3 x 2.5 cm and on the right lateral side of her abdomen. Resident #1 was asked about how they obtained bruising and stated the bruise on her abdomen was from her applying pressure to the area when she coughed and was not sure how she obtained the bruise on her forearm. A nursing progress note dated 05/22/25 at 11:18 AM written by ADON D reflected Resident #1's physician was notified about the bruising to the resident's abdomen at 11 AM and the resident was their own responsible party, and there were no new orders and the resident was encouraged to avoid grabbing or pushing on her abdomen when coughing and reminded to call nursing if she had any pain or increased coughing so that PRN medications would be given. A nursing progress note dated 05/22/25 at 12:33 PM written by ADON D reflected a title of Event-Other reflected Resident #1's vitals were checked with no concerns and her cognition was oriented/no problem, she had no pain or injury and included the following Resident reported to Charge Nurse an incident that happened last night. Resident stated that 2 CNA Staff grabbed her by the wrist, put her on the shower chair and took her to the shower room even though [resident] told the CNAs that she is not feeling well multiple times .Resident Statement: Last night 2 ladies came to my room, one of them is big, the other is tiny. They asked me to shower but I refused. They grabbed me by my wrist, put me on the chair then took me to the shower room . ADON D notified Resident #1's physician on 05/22/25 at 9 AM, and there were no new orders. Resident #1 was their own representative with a date and time of notification as 05/22/25 at 8:45 AM, and the Administrator was notified. A social services progress note, dated 05/22/25 at 3:56 PM, written by the Social Worker: This [Social Worker] met w/ resident Re: complaint of two female staff that reportedly made resident participate in a shower when she verbally declined. Resident requested that these two female staff not be assigned to her again. [The Administrator] informed this [Social Worker] that both female staff have been removed from this facility permanently. This [Social Worker] assured resident that she would not encounter these two female staff in this facility again. This [Social Worker] also reached out to [the Psychologist] to request a post trauma follow up visit with resident as soon as possible. A nursing progress note dated 05/23/25 at 11:32 AM, written by the Social Worker, reflected she assisted Resident #1 with a post trauma therapeutic call with resident and [the Psychologist]. A general progress note dated 05/23/25 at 5:23 PM written by the Psychologist: (Resident #1) is a participant in a telehealth appointment per administrator request in regard to an incident that occurred Thursday (05/22/25). This patient is consulted with via phone assisted by the facility social worker. (Resident #1) is AOx4 [alert and oriented to person, place, time, and event] and able to articulate said needs. patient reported to me that yesterday she was feeling ill and had been in pain due to her couching and COPD symptomology. she reported that two aids came in to give her a shower and she requested to be left alone today, that she did not feel up to taking shower. she proceeded to explain to me one aid grabbed my right arm, and one grabbed my left arm and pulled me out of bed and into a shower chair. I said to them, I'm hurting and do not want a shower. they said to me you will be getting one regardless. the administrator was alerted promptly that patient requested to meet with who was in charge of facility. the administrator suspended both employees immediately pending further investigation. Patient was very happy and appeased to hear employees were suspended and said she does feel safe in building. she admits the incident was very upsetting to her when it occurred. she said when she returned to her room, she was not assisted by the two employees . In an observation and interview on 06/17/25 at 11:55 AM with Resident #1's roommate, Resident # 2, she was lying in bed and stated that about a month ago, she heard a female staff member come into their room, the privacy curtain was closed so she did not see who the staff member was and could hear the exchange. Resident #2 stated the staff member told Resident #1 it was time for her shower and Resident #1 responded that she did not want to take a shower- she did not feel good and had pain, and the staff member told Resident #1 that she was getting up for a shower. She stated it was exactly as Resident #1 described it, that was what she heard. She stated she did not think it was right that Resident #1 was made to get up and take a shower and no one had forced Resident #2 to take a shower or forced her to get up. She stated there are shower sheets residents sign when residents refused to take a shower. She stated she felt safe at the facility. Record review of Resident #2 progress notes from 05/01/25 to 06/18/25 reflected the following: A general note written by the Psychologist, dated 05/23/25 at 6:36 PM, (Resident #2) is seen while maintaining routine rounds at facility. (Resident #2) is on mental health services as advised by care plan team for adjustment and optimal well-being while residing in long term care. (Resident #2) was assisted with phone consult due to an incident that occurred the evening prior. (Resident #2) said she was upset because her roommate was being forced to take a shower, and she did not want to. (Resident #2) said they were rough with her which upset her even though she says she feels safe in the building. (Resident #2) gets very emotional due to her diagnosis and emotional instability . Record review of Resident #2's progress notes reflected a late entry general note written by the Psychologist, dated 05/28/25 at 3 PM, reflected: (Resident #2) is seen while maintaining routine rounds at facility. (Resident #2) is on mental health services as advised by care plan team for adjustment and optimal well-being while residing in long term care. Resident #2 was doing well, expressed no new concerns . In an interview on 06/17/25 at 12:10 PM with LVN C she stated that she was a charge nurse for Resident #1's hall. She stated she was in-serviced on the types of abuse and neglect including who to report to and resident rights including the resident's right to refuse a shower on 05/22/25 and did not work with Resident #1 until a day or two after the incident and when she saw Resident #1 next, her hair was knotted, and she was upset. She said Resident #1 told her that she was made to take a shower by staff when she did not want to take a shower. She stated that Resident #1 commonly refused showers and she offered to brush out her hair and Resident #1 let her brush her hair. She stated resident's had the right to refuse a shower and physically picking up a resident from under their armpits or wrists and showering them despite their refusals was abuse and could have caused physical harm or mental harm to the resident. In an interview on 06/17/25 at 12:45 PM with ADON D she stated she received a phone call from staff who relayed what Resident #1 had said about being forced to take a shower and she instructed staff to also contact the Administrator immediately. ADON D stated that she completed a head-to-toe assessment of Resident #1 on 05/22/25 and there were no bruises on her wrist, a small bruise on her forearm, and she had an unrelated bruise to the side of her abdomen. ADON D stated Resident #1 told her the bruise was on her abdomen was due to Resident #1 pushing on her side while coughing and she was sent out the same day due to an increase in COPD symptoms. ADON D stated she completed a trauma assessment and Resident #1 expressed she was still very angry about the incident and she was referred to counseling services. She stated that in a conference call with one of the CNA's and the Administrator CNA A or CNA B said something like she needed a shower anyway. ADON D stated she considered the incident to be abuse. She stated that physically moving a resident by lifting under their armpits, despite their refusals, from the bed to a shower chair and showering them could have resulted in physical harm or mental distress. Attempts to interview CNA A via phone on 06/17/25 at 1:44 PM and on 06/18/25 at 12:46 PM were unsuccessful with a disconnected tone. In an interview on 06/17/25 at 2:10 PM with the Social Worker she stated she spoke with Resident #1 with the Administrator on 05/22/25 and she told them that there were aides that got her ready for a shower despite her telling them she did not want a shower. The Social Worker stated Resident #1 was very distraught when talking about the incident and she told Resident #1 that a psychologist was going to come in and meet with her. She stated that the Administrator had said in a morning meeting that the employees were not going to come back to the facility. She stated they are in-serviced regularly on abuse and neglect and was able to name the types and reporting requirements. She stated that she considered the incident Resident #1 described as abuse. She stated that Resident #1 seemed to be fine now and she met with her about a week after on 05/30/25 and she did not indicate she was still upset about the shower. In an interview on 06/17/25 at 3:49 PM with CNA B she stated that on the evening of 05/21/25 CNA A flagged her down and asked for help with showering Resident #1. She stated did not assist CNA A in getting the resident out of bed, they were already in the shower room at the time she was asked to be a witness. CNA B stated when she entered the shower room Resident #1 was in the shower room and said multiple times she was going to call her lawyers, CNA B told CNA A that Resident #1 had been saying that since CNA A had gotten her up. CNA B stated she took the residents hair out of a ponytail and washed and conditioned her hair- she had a big knot in her hair and refused CNA B to brush it and said she was going to do it herself. CNA B stated she assisted with washing Resident #1 and dried her off and CNA A took her to her room. CNA B stated that she was not concerned about abuse because she had not worked with Resident #1 before and thought she was demented. When given a scenario of a resident who did not want to get up for a shower and was physically picked up by their armpits and taken to be showered despite their refusals, CNA B stated that would be abuse and the resident could have been physically harmed. She stated she would have intervened and told her nurse and the Abuse Coordinator who was the Administrator immediately. She stated she was called by the Administrator on 05/22/25, was informed she was suspended pending the investigation and gave her statement, she no longer worked at the facility. In an interview on 06/17/25 at 4:10 PM with a family member of Resident #1, she stated Resident #1 called her the day the incident happened and told her she was forced to take a shower and sounded very angry. She stated that Resident #1 is her own representative and she had not spoken with the administrator or Resident #1 about the incident since it occurred. In an interview on 06/17/25 at 4:41 PM with the Psychologist she stated she received a phone call from the Administrator last month around 05/22/25 and was told an incident had occurred and was asked to come see the resident because it seemed very important. The Psychologist stated the Social Worker assisted in a telehealth visit via phone because she was out of town an unable to visit in person. She stated Resident #1 seemed very with it, sounded alert and oriented, and told her that aides had pulled her by the wrist from her bed and one aide told her you're going to get a shower today no matter what despite her telling them that she was hurting and did not want the aides back. The Psychologist stated that their call was cut short because Resident #1 was going to the hospital related to their COPD and increased coughing. She stated she followed up with Resident #1 the following week (05/28/25) and Resident #1 had concerns of the aides not coming back to the facility. The Psychologist stated she reassured Resident #1 that the aides were not coming back and she felt better. She stated she also saw Resident #1 on 04/02/25 and she was focused on discharging from the facility which was unrealistic due to her being non-ambulatory and increased COPD symptoms. She stated she was following up with the resident today on 06/17/25. In an interview on 06/17/25 at 6:10 PM with LVN F he stated he was the charge nurse for Resident #1's hall on the evening shift (6 PM-6 AM) 05/21/25. He stated he was familiar with Resident #1 and had worked with her when she was on the rehabilitation side of the facility. He stated that Resident #1 used to be a nurse and she did not want to be a bother to anyone and was particular about her care. He stated that at the beginning of the shift on 05/21/25, he was passing medications to residents and did not hear anything at the time but did notice she was not in her room and was pleasantly surprised that she had gotten up to take a shower because she typically did not want to get out of bed- she had a cough for a while and was not feeling well. He stated that he saw her later and her hair was still a little wet and she complained that they gave her a shower and left her hair damp. He stated that Resident #1 and seemed focused on her hair and he wanted to make her comfortable, so he offered to look for a hair dryer to dry her hair. He stated that CNA A only told him that she got her to take a shower. He stated Resident #1 did not disclose to him anything about what had happened and neither CNA told him anything other than she got a shower, and he found out the following day and was in-serviced on 05/22/25 on identifying and reporting abuse and neglect, resident rights including the right to refuse showers, and trauma informed care. He stated that if he had known what had happened, he would have immediately ensured the resident felt safe, ensured the CNA did not provide her any care, and would have contacted the Administrator who was the abuse coordinator. He stated that physically transferring a resident, under their armpits, and giving them a shower despite their refusals, was abuse and could have caused physical and mental harm to the resident. In an interview on 06/18/25 at 9:28 AM with the Regional Compliance Nurse, she stated that she was contacted by the Administrator on 05/22/25 regarding an allegation of abuse. She stated that she assisted the Administrator via phone to ensure they followed their abuse and neglect policy. She stated that the Administrator suspended the two employees (CNA A & CNA B) pending the investigation and she updated Resident #1's care plan due to her anger at being made to shower despite her refusals. She stated that the facility's policy was to update the resident's care plan to indicate a traumatic event occurred and did not think Resident #1 had lasting trauma due to the incident and it was care planned as a trauma event due to the resident's expression of anger and to ensure staff were aware how to care for the resident and to stop immediately if the resident refused a shower. She stated physically moving a resident from under her armpits or wrists and showering them despite their refusals was abuse and could have caused physical and psychosocial harm to the resident. In an interview on 06/18/25 at 11:28 AM with LVN I revealed Resident #1 typically stayed in her bed and sometimes would ask to get up. She stated on 05/22/25 during her rounds, Resident #1 appeared furious told her that the previous night (05/21/25), two girls came into Resident #1's room and told her it was her shower day, she refused, and they picked her up anyway and took her to the shower room and washed her, and said she was going to sue the aides. LVN I stated Resident #1 stated that the aides picked her up by the wrists and looked at her wrists and saw no marks or bruising, made sure she was okay, and told the resident she was going to get someone to talk to her and immediately went to get the Administrator and the Administrator and Social Worker went to talk with Resident #1. She stated that she considered it to be abuse. She stated that a resident could be harmed by being picked up from her bed under her armpits or by her wrists and made to take a shower despite their refusals both psychologically and physically. She stated that when resident's refused a shower CNA's were supposed to let the nurse know and talked to the resident to see if they might change their mind and if the resident still refused then they have a shower refusal sheet they had them sign. In an interview on 06/18/25 at 1:45 PM with the Administrator she stated a nurse came to her at the end of morning meeting and told her she needed to speak with Resident #1. The Administrator stated she immediately spoke with Resident #1 who told her, the night before (05/21/25), she was in her bed and it was her shower day, she didn't really want to take a shower, aides grabbed her by the wrists and put her in her chair and made her take a shower even though she didn't want to. She stated that Resident #1 told the Administrator that she did not want the aides to take care of her again and the Administrator assured her that they would not take care of her anymore. The Administrator stated she interviewed Resident #1's roommate, Resident #2, and she told the Administrator that everything Resident #1 told her happened- was what Resident #2 heard happen, and the privacy curtain was closed so she did not visually see the incident. The Administrator stated that Resident #1 provided a description that fit with two aides (CNA A & CNA B) that worked on 05/21/25 6 PM- 6 AM shift, CNA A was assigned to Resident #3's hall. She stated she called and suspended both CNA A and CNA B pending the investigation on 05/22/25, they had not come back to the facility, and she interviewed them regarding the incident. She stated that CNA A told her that she had showered Resident #1 the evening of 05/21/25 and asked CNA B to help because Resident #1 was being difficult. She stated CNA A told her that Resident #1 said several times that she did not want a shower. CNA A told the Administrator Resident #1 kept saying she was going to call her lawyers and she had not worked with Resident #1 and thought she had dementia so she did not think much of it. The Administrator stated that resident's had a right to refuse a shower and physically moving a resident, under their armpits, to a shower chair and showering them despite their refusals could be considered abuse and could physically or psychologically harm the resident. She stated she expected when resident's refused showers for CNA's to wait a little while and try again later or get someone else to ask the resident, and then inform the charge nurse so they could attempt and document it with a refusal sheet. She stated that she in-serviced all staff on abuse and neglect including recognizing abuse and reporting to her immediately, and on trauma informed care. Resident #1's physician was notified. She stated she attended an AD Hoc QAPI meeting on 05/22/25 with corporate involvement and the Medical Director, regarding the incident and what the Administrator needed to do. In an interview on 06/18/25 at 6:25 PM with CNA K she stated that she worked the evening shifts on Resident #1's hall and worked the evening after the incident on 05/22/25. CNA K stated Resident #1 was able to voice her needs and had never seen her out of bed in the year she had worked at the facility. She stated she had asked Resident #1 if she wanted a shower in the past and Resident #1 would reply no I'm not taking a shower. She stated when resident's refused showers she had the resident sign a refusal form, informed the charge nurse who also signed the sheet, and there was a box they put it in at near the ADON's office. She was able to name types of abuse including reporting to the Abuse Coordinator. When provided the scenario of an aide physically transferring a resident by lifting under their armpits and giving them a shower despite their refusals, she stated it was abuse and the resident could have experienced physical harm. She stated she would have intervened immediately and ensured the resident felt safe and report to the Abuse Coordinator who was the Administrator. In interviews on 06/17/25 and 06/18/25 across both shifts (6 AM- 6 PM & 6 PM-6 AM) with various staff members (ADON D, CNA E, CNA G, CNA H, CNA J, CNA K, LVN C, LVN F, LVN I, LVN L, LVN M, LVN P, MA N, and Social Worker) revealed staff had been in-serviced on abuse and neglect, resident rights (including residents had a right to refuse showers), and trauma informed care on 05/22/25. The above-mentioned staff members were able to verbalize abuse and different forms of abuse and neglect including reporting to the Administrator who was the facility's abuse coordinator. The above mentioned staff members stated they had received in-services on resident rights and trauma informed care and when a resident declined showers that meant no and they did not force resident's to do something they did not want to do. When provided a scenario where a resident refused a shower and a CNA transferred them by their wrists or under their armpits and gave a resident a shower despite the resident's refusals- all stated they considered it to be abuse and would ensure the resident was safe and immediately report it to the Abuse Coordinator. They stated physically transferring a resident under the armpits from the bed to shower chair and showering the resident despite refusals could result in physical and mental harm to the resident. Record review of the facility's AD Hoc QAPI (an unscheduled, as needed meeting for a Quality Assurance and Performance Improvement (QAPI) program) meeting, dated 05/22/25, attended by the Administrator, Medical Director, Regional Compliance Nurse regarding the incident and what steps they needed to take next. Record review of CNA A's personnel file reflected she was hired on 05/01/25 with a last worked date of 05/21/25 and was terminated from employment on 05/23/25. The facility had conducted Texas Department of Public Safety Criminal History verification and Employee Misconduct Registry Employability status check without any concerns. Record review of CNA B's personnel file reflected she was hired on 04/18/25 with a last worked date of 05/21/25 and was terminated from employment on 06/05/25. The facility had conducted Texas Department of Public Safety Criminal History verification and Employee Misconduct Registry Employability status check without any concerns. Record review of abuse and neglect in-services conducted by the facility on 05/22/25 reflected the facility staff were trained on abuse and neglect, types of abuse, who was the abuse coordinator and when abuse should be reported. Reco[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure the right to a dignified existence and self-determination facility for 1 of 9 (Resident #1) residents reviewed for resident rights. The facility failed to ensure Resident #1 was treated with respect and dignity when she refused a shower on 05/21/25 around 9:30 PM and was showered despite her refusals by CNA A. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth, psychosocial harm and distrust with staff. The noncompliance was identified as Immediate Jeopardy Past Noncompliance (PNC). The Immediate Jeopardy began on 05/21/25 at 9:30 PM and ended on 05/28/25. The facility had taken actions noted in the findings that corrected the noncompliance before the incident investigation began on 06/17/25. Findings included: Review of Resident #1's Quarterly MDS, dated [DATE], reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. She had the diagnoses of Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation (a lung disease with a sudden worsening symptoms including breathlessness, mucus, and cough), Alzheimer's disease (loss of cognition), chronic pain syndrome, and anxiety disorder (excessive or persistent worry or fear). Her BIMS score was a 5 (severely impaired cognition). Further review of Section GG-Functional Abilities reflected she usually required substantial/maximal assistance for bed to chair transfers. Record review of Resident #1's care plan reflected the resident had an activity of daily living (ADL) performance deficit and required one staff to assist with bathing and bed mobility, dated initiated 02/13/25. Further review reflected a focus area, dated initiated 05/23/25, The resident has a history of trauma that may have a negative impact. The trauma is [due to]: Feeling angry [due to] shower being done after she refused. Interventions included: .If resident refuses her shower stop immediately . If the resident has escalated, if at all possible do not touch the resident unless absolutely necessary for resident's or others safety ., dated initiated 05/23/25. Record review of Resident #2's Quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. She had the diagnoses of cancer, heart failure, stroke with paralysis on her left non-dominant side, and major depression disorder (persistent feelings of sadness). Her BIMS score was a 7 (severely impaired cognition). Record review of Resident #2's care plan reflected the resident had impaired cognitive function/dementia or impaired thought processes; interventions included .Use residents preferred name . face the resident when speaking .Provide the resident with necessary cues- stop and return if agitated ., dated initiated 10/07/24. Record review of the Provider Investigation Report (PIR) (Form 3613-A of Texas Health and Human Services) reflected an incident date and time of 05/21/25 at 9:30 PM, dated reported 05/22/25 at 10:15 AM and signed by the Administrator on 05/28/25. Further review revealed on 05/21/25 around 8:40 AM, Resident #1 told her nurse that she needed to talk to someone in charge because she was upset about her care last night. Further review revealed on 05/21/25 around 9:30 PM Resident #1 told CNA A several times she did not want a shower and without Resident #1's consent, CNA A physically lifted Resident #1 from the armpits from the bed into the shower chair and Resident #1 was given a shower by CNA A and CNA B. Resident #1 did not have a history of similar allegations and was interviewable and had the capacity to make informed decisions. Resident #1 had a head-to-toe assessment on 05/22/25 at 10 AM and had no injuries. The facility immediately suspended CNA A and CNA B and obtained interviews from both CNA's and Resident #1, completed resident safe surveys on 05/22/25 with no other concerns, and started staff monitoring for 4 weeks (05/22/25-06/18/25). Staff were in-serviced on resident rights, including a resident's right to refuse a shower, and trauma informed care on 05/22/25. Record review of Resident #1's verbal statement written by the Administrator, undated, reflected that two CNA's came to her room to take her to the shower and she told them she did not want a shower and she was cold: Two aides came into my room to take me to the shower . I told them that I am cold and don't want a shower. [CNA A] said you are getting a shower tonight. I was begging to not get a shower and told her to stop and go away. They grabbed me by my wrist and pulled me up to put me in the chair. The first shower was cold and then she put me in the other shower[,] it was fine [the shower water temperature] but I kept saying I did not want a shower. [They] put me in the shower and started washing me. Barely gave me a towel to dry off and put me in a gown took me back to my room and put me to bed. I just did not like it. Record review of CNA A's verbal statement, undated, written by the Administrator reflected the following: .(Resident #1) was like do I even have to have a shower and I said yes you will feel better. She was being like her energy was she did not want a shower . Did she have an attitude? Yes, but she got a shower and will feel better. I picked her up under her armpits slid back in chair and took her to the shower room. When asked how many times did (Resident #1) say she did not want a shower? Her response was twice and I told her she would feel better after her shower . Do you know that [residents] have the right to refuse a shower? Yes, knows about the papers and getting a nurse to assist with refusal of showers. Record review of resident safe surveys, dated 05/22/25 reflected Resident #1 safe survey: 1. Do you feel safe at this facility: 'Yes and No' 2. Has anyone mistreated you or anyone in this facility: 'Yes last night' 3. If you have been mistreated or witnessed mistreatment, would you report it to someone: 'Yes I did' 4. Who did you report it to? 'My attorney and the police' . Further review of resident safe surveys with 17 residents on 05/22/25 revealed no concerns regarding abuse, they felt safe at the facility, and knew how to report mistreatment. In an interview and observation on 06/17/25 at 11:38 AM, Resident #1 was in bed and dressed wearing a nasal cannula, she was a poor historian. She stated there was an incident about a month ago, a staff member told her she had to get up out of bed and Resident #1 did not want to get up, she had pain and was not feeling good. She stated that the staff member told her she was getting up even though she kept saying no. She stated the staff member grabbed her by the wrists and put her in her wheelchair and was not sure was else happened. She stated she felt very angry, was swinging her hands around and tried to swat at and hit the staff member away and repeated she did not want to get up and said no but they got her up anyway. She stated she told her nurse. She stated she was not able to recall anything about a shower except for a time that her hair was left wet. She stated that she did not like to get up out of bed because she had pain and declined health and preferred bed baths. She stated she was an [AGE] year-old woman in her dying days and wanted to stay in bed. She stated she felt safe at the facility knowing the staff member was not there because someone from the facility told her they were not working for the facility anymore. She stated she was aware of her resident rights including to refuse a shower. Record review of Resident #1's progress notes from 05/01/25-06/17/25, reflected the following: A nursing progress note dated 05/22/25 at 8:45 AM written by ADON D: Resident reported to Charge Nurse an incident that happened last night. Resident stated that 2 CNA Staff grabbed her by the wrist, put her on the shower chair and took her to the shower room even though res. told the CNAs that she is not feeling well multiple times. Administrator and MD notified. A nursing progress note dated 05/22/25 at 9 AM with the note text of Trauma Informed Assessment written by the ADON D reflected Resident #1 had no previous trauma or diagnosis of PTSD and reported she had not experienced or witnessed a situation that was extremely frightening, and she had felt angry: has felt angry. Description: Yes what happened last night still make me angry. A nursing progress note dated 05/22/25 at 10:42 AM, written by ADON D, reflected Resident #1 had a head-to-toe skin assessment and resident had bruising to her right forearm 3 x 2.5 cm and on the right lateral side of her abdomen. Resident #1 was asked about how they obtained bruising and stated the bruise on her abdomen was from her applying pressure to the area when she coughed and was not sure how she obtained the bruise on her forearm. A nursing progress note dated 05/22/25 at 11:18 AM written by ADON D reflected Resident #1's physician was notified about the bruising to the resident's abdomen at 11 AM and the resident was their own responsible party, and there were no new orders and the resident was encouraged to avoid grabbing or pushing on her abdomen when coughing and reminded to call nursing if she had any pain or increased coughing so that PRN medications would be given. A nursing progress note dated 05/22/25 at 12:33 PM written by ADON D reflected a title of Event-Other reflected Resident #1's vitals were checked with no concerns and her cognition was oriented/no problem, she had no pain or injury and included the following Resident reported to Charge Nurse an incident that happened last night. Resident stated that 2 CNA Staff grabbed her by the wrist, put her on the shower chair and took her to the shower room even though [resident] told the CNAs that she is not feeling well multiple times .Resident Statement: Last night 2 ladies came to my room, one of them is big, the other is tiny. They asked me to shower but I refused. They grabbed me by my wrist, put me on the chair then took me to the shower room . ADON D notified Resident #1's physician on 05/22/25 at 9 AM, and there were no new orders. Resident #1 was their own representative with a date and time of notification as 05/22/25 at 8:45 AM, and the Administrator was notified. A social services progress note, dated 05/22/25 at 3:56 PM, written by the Social Worker: This [Social Worker] met w/ resident Re: complaint of two female staff that reportedly made resident participate in a shower when she verbally declined. Resident requested that these two female staff not be assigned to her again. [The Administrator] informed this [Social Worker] that both female staff have been removed from this facility permanently. This [Social Worker] assured resident that she would not encounter these two female staff in this facility again. This [Social Worker] also reached out to [the Psychologist] to request a post trauma follow up visit with resident as soon as possible. A nursing progress note dated 05/23/25 at 11:32 AM, written by the Social Worker, reflected she assisted Resident #1 with a post trauma therapeutic call with resident and [the Psychologist]. A general progress note dated 05/23/25 at 5:23 PM written by the Psychologist: (Resident #1) is a participant in a telehealth appointment per administrator request in regard to an incident that occurred Thursday (05/22/25). This patient is consulted with via phone assisted by the facility social worker. (Resident #1) is AOx4 [alert and oriented to person, place, time, and event] and able to articulate said needs. patient reported to me that yesterday she was feeling ill and had been in pain due to her couching and COPD symptomology. she reported that two aids came in to give her a shower and she requested to be left alone today, that she did not feel up to taking shower. she proceeded to explain to me one aid grabbed my right arm, and one grabbed my left arm and pulled me out of bed and into a shower chair. I said to them, I'm hurting and do not want a shower. they said to me you will be getting one regardless. the administrator was alerted promptly that patient requested to meet with who was in charge of facility. the administrator suspended both employees immediately pending further investigation. Patient was very happy and appeased to hear employees were suspended and said she does feel safe in building. she admits the incident was very upsetting to her when it occurred. she said when she returned to her room, she was not assisted by the two employees . In an observation and interview on 06/17/25 at 11:55 AM with Resident #1's roommate, Resident # 2, she was lying in bed and stated that about a month ago, she heard a female staff member come into their room, the privacy curtain was closed so she did not see who the staff member was and could hear the exchange. Resident #2 stated the staff member told Resident #1 it was time for her shower and Resident #1 responded that she did not want to take a shower- she did not feel good and had pain, and the staff member told Resident #1 that she was getting up for a shower. She stated it was exactly as Resident #1 described it, that was what she heard. She stated she did not think it was right that Resident #1 was made to get up and shower and no one had forced Resident #2 to take a shower or forced her to get up. She stated there are shower sheets residents sign when residents refused to take a shower. She stated she felt safe at the facility and understood her rights including her right to refuse a shower. In an interview on 06/17/25 at 12:10 PM with LVN C she stated that she was a charge nurse for Resident #1's hall. She stated she was in-serviced on the types of abuse and neglect including who to report to and resident rights including the resident's right to refuse a shower on 05/22/25 and did not work with Resident #1 until a day or two after the incident and when she saw Resident #1 next, her hair was knotted, and she was upset. She said Resident #1 told her that she was made to take a shower by staff when she did not want to take a shower. She stated that Resident #1 commonly refused showers and she offered to brush out her hair and Resident #1 let her brush her hair. She stated resident's had the right to refuse a shower and physically picking up a resident and showering them despite their refusals a violation of the resident's rights. In an interview on 06/17/25 at 12:45 PM with ADON D she stated she received a phone call from staff who relayed what Resident #1 had said about being forced to take a shower and she instructed staff to also contact the Administrator immediately. ADON D stated that she completed a head-to-toe assessment of Resident #1 on 05/22/25 and there were no bruises on her wrist, a small bruise on her forearm, and she had an unrelated bruise to the side of her abdomen. ADON D stated Resident #1 told her the bruise was on her abdomen was due to Resident #1 pushing on her side while coughing and she was sent out the same day due to an increase in COPD symptoms. ADON D stated she completed a trauma assessment and Resident #1 expressed she was still very angry about the incident, and she was referred to counseling services. She stated that in a conference call with one of the CNA's and the Administrator CNA A or CNA B said something like she needed a shower anyway. ADON D stated she considered the incident to be a violation of the resident's rights because residents had the right to refuse a shower and it could have caused physical or mental harm to the resident. Attempts to interview CNA A via phone on 06/17/25 at 1:44 PM and on 06/18/25 at 12:46 PM were unsuccessful with a disconnected dial tone. In an interview on 06/17/25 at 2:10 PM with the Social Worker she stated she spoke with Resident #1 with the Administrator on 05/22/25 and told them that there were aides that got her ready for a shower despite her telling them she did not want a shower. The Social Worker stated Resident #1 was very distraught when talking about the incident and she told Resident #1 that a psychologist was going to come in and meet with her. She stated that the Administrator had said in a morning meeting that the employees were not going to come back to the facility. She stated that she considered the incident Resident #1 described as a violation of the resident's rights and residents had the right to refuse a shower. She stated that Resident #1 seemed to be fine now and she met with her about a week after on 05/30/25 and she did not indicate she was still upset about the shower. In an interview on 06/17/25 at 3:49 PM with CNA B she stated that on the evening of 05/21/25 CNA A flagged her down and asked for help with showering Resident #1. She stated did not assist CNA A in getting the resident out of bed was they were already in the shower room at the time she was asked to be a witness. CNA B states when she entered the shower room Resident #1 was in the shower room and said multiple times she was going to call her lawyers, CNA A told CNA B that Resident #1 had been saying that since CNA A had gotten her up. CNA B stated she took the residents hair out of a ponytail and washed and conditioned her hair- she had a big knot in her hair and refused CNA B to brush it and said she was going to do it herself. CNA B stated she assisted with washing Resident #1 and dried her off and CNA A took her to her room. CNA B stated she had not worked with Resident #1 before and thought she was demented. When given a scenario of a resident who did not want to get up for a shower and was showered despite their refusals, CNA A stated that would be a violation of the resident right's. She stated she would have intervened and told her nurse and the Abuse Coordinator who was the Administrator immediately. She stated residents had the right to refuse a shower. She stated she was called by the Administrator on 05/22/25, was informed she was suspended pending the investigation and gave her statement, she no longer worked at the facility. In an interview on 06/17/25 at 4:10 PM with a family member of Resident #1, she stated Resident #1 called her the day the incident happened and told her she was forced to take a shower and sounded very angry. She stated that Resident #1 is her own representative and she had not spoken with the administrator or Resident #1 about the incident since it occurred. In an interview on 06/17/25 at 4:41 PM with the Psychologist she stated she received a phone call from the Administrator last month around 05/22/25 and was told an incident had occurred and was asked to come see the resident because it seemed very important. The Psychologist stated the Social Worker assisted in a telehealth visit via phone because she was out of town an unable to visit in person. She stated Resident #1 seemed very with it, sounded alert and oriented, and told her that aides had pulled her by the wrist from her bed and one aide told her you're going to get a shower today no matter what despite her telling them that she was hurting and did not want the aides back. The Psychologist stated that their call was cut short because Resident #1 was going to the hospital related to their COPD and increased coughing and she followed up with Resident #1 the following week and Resident #1 had concerns of the aides not coming back to the facility. The Psychologist stated she reassured Resident #1 that the aides were not coming back and she felt better. She stated that a resident being showered despite their refusals was a violation of their rights because they had the right to refuse a shower. In an interview on 06/17/25 at 6:10 PM with LVN F he stated he was the charge nurse for Resident #1's hall on the evening shift (6 PM-6 AM) 05/21/25. He stated he was familiar with Resident #1 and had worked with her when she was on the rehabilitation side of the facility. He stated that Resident #1 used to be a nurse and she did not want to be a bother to anyone and was particular about her care. He stated that at the beginning of the shift on 05/21/25, he was passing medications to residents and did not hear anything at the time but did notice she was not in her room and was pleasantly surprised that she had gotten up to take a shower because she typically did not want to get out of bed- she had a cough for a while and was not feeling well. He stated that he saw her later and her hair was still a little wet and she complained that they gave her a shower and left her hair damp. He stated that Resident #1 and seemed focused on her hair and he wanted to make her comfortable so he offered to look for a hair dryer to dry her hair. He stated that CNA A only told him that she got her to take a shower. He stated Resident #1 did not disclose to him anything about what had happened and neither CNA told him anything other than she CNA A said she got a shower, and he found out the following day and was in-serviced on 05/22/25 on resident rights including the right to refuse showers, and trauma informed care. He stated that if he had known what had happened he would have immediately ensured the resident felt safe, ensured the CNA did not provide her any care, and would have contacted the Administrator who was the abuse coordinator. He stated that giving a resident a shower despite their refusals could have caused physical or mental harm to the resident. LVN F stated that residents had the right to refuse showers. He stated the facility was the residents home, and if they are home they might not want anyone to get them up or to take a shower. In an interview on 06/18/25 at 9:28 AM with the Regional Compliance Nurse, she stated that she was contacted by the Administrator on 05/22/25 regarding an allegation of abuse. She stated that she assisted the Administrator via phone to ensure they followed their abuse and neglect policy. She stated that the Administrator suspended the two employees (CNA A & CNA B) pending the investigation and she updated Resident #1's care plan due to her anger at being made to shower despite her refusals. She stated that the facility's policy was to update the resident's care plan to indicate a traumatic event occurred and did not think Resident #1 had lasting trauma due to the incident and it was care planned as a trauma event due to the resident's expression of anger and to ensure staff were aware how to care for the resident and to stop immediately if the resident refused a shower. She stated showering a resident despite their refusals was a violation of the resident rights and could have caused physical and psychosocial harm to the resident. In an interview on 06/18/25 at 11:28 AM with LVN I revealed Resident #1 typically stayed in her bed and sometimes would ask to get up. She stated on 05/22/25 during her rounds, Resident #1 appeared furious told her that the previous night (05/21/25), two girls came into Resident #1's room and told her it was her shower day, she refused, and they picked her up anyway and took her to the shower room and washed her, and said she was going to sue the aides. LVN I stated Resident #1 stated that the aides picked her up by the wrists and looked at her wrists and saw no marks or bruising, made sure she was okay, and told the resident she was going to get someone to talk to her and immediately went to get the Administrator and the Administrator and Social Worker went to talk with Resident #1. She stated that she considered it was a violation of the resident's rights and a resident could be physically or mentally harmed by being showered despite her refusals. She stated that when resident's refused a shower CNA's were supposed to let the nurse know and talk to the resident to see if they might change their mind and if the resident still refused then they have a shower refusal sheet they had them sign. In an interview on 06/18/25 at 1:45 PM with the Administrator she stated a nurse came to her at the end of morning meeting and told her she needed to speak with Resident #1. The Administrator stated she immediately spoke with Resident #1 who told her, the night before (05/21/25), she was in her bed and it was her shower day, she didn't really want to take a shower, aides grabbed her by the wrists and put her in her chair and made her take a shower even though she didn't want to. She stated that Resident #1 told the Administrator that she did not want the aides to take care of her again and the Administrator assured her that they would not take care of her anymore. The Administrator stated she interviewed Resident #1's roommate, Resident #2, and she told the Administrator that everything Resident #1 told her happened- was what Resident #2 heard happen, and the privacy curtain was closed so she did not visually see the incident. The Administrator stated that Resident #1 provided a description that fit with two aides (CNA A & B) that worked on 05/21/25 6 PM- 6 AM shift, CNA A was assigned to Resident #3's hall. She stated she called and suspended both CNA A and CNA B pending the investigation on 05/22/25, they had not come back to the facility, and she interviewed them regarding the incident. She stated that CNA A told her that she had showered Resident #1 the evening of 05/21/25 and asked CNA B to help because Resident #1 was being difficult. She stated CNA A told her that Resident #1 said several times that she did not want a shower and CNA A told Resident #1 that she had to take a shower because she would feel better and CNA A physically picked her up under her armpits, slid her back into her chair and took her to the shower room. CNA A told the Administrator that she knew that resident's had the right to refuse a shower and knew about the refusal papers and they were to involve the nurse, but the resident got a shower and would feel better. The Administrator stated when she interviewed CNA B she told the Administrator that she heard the resident did say she didn't want a shower and CNA A told Resident #1 that she would feel better after a shower. CNA A told the Administrator Resident #1 kept saying she was going to call her lawyers. CNA A told the Administrator she had not worked with Resident #1 and thought she had dementia so she did not think much of what Resident #1 said and residents needed to take showers. The Administrator stated that resident's had a right to refuse a shower. She stated she expected when resident's refused showers for CNA's to wait a little while and try again later or get someone else to ask the resident, and then informed the charge nurse so they could attempt and document it with a refusal sheet. She stated that she in-serviced all staff on trauma informed care and that resident's had a right to refuse showers. Resident #1's physician was notified. She stated she attended an AD Hoc QAPI meeting on 05/22/25 with the Regional Compliance Nurse, Regional Director of Operations, the Medical Director, regarding the incident and what the Administrator needed to do. She stated that she had psychological services speak with Resident #1 and her care plan was updated. The Administrator stated the social worker completed safe surveys of residents with no other concerns. In an interview on 06/18/25 at 6:25 PM with CNA K she stated that she worked the evening shifts on Resident #1's hall and worked the evening after the incident on 05/22/25. CNA K stated Resident #1 was able to voice her needs and had never seen her out of bed in the year she had worked at the facility. She stated she had asked Resident #1 if she wanted a shower in the past and Resident #1 would reply no I'm not taking a shower and she had the resident sign a refusal form, informed the charge nurse who also signed the sheet, and there was a box they put it in at near the ADON's office. When provided the scenario of an aide giving a resident a shower despite their refusals, she stated it was a violation of the resident's rights and the resident could have been harmed physically and mentally. She stated she would have intervened immediately and ensured the resident felt safe and report to the Abuse Coordinator who was the Administrator. She stated that resident's have rights, the facility was the residents home and what they say goes. Interviews on 06/17/25 (12:10 PM) and 06/18/25 across both shifts (6 AM- 6 PM & 6 PM-6 AM) with various staff members (ADON D, CNA E, CNA G, CNA H, CNA J, CNA K, LVN C, LVN F, LVN I, LVN L, LVN M, LVN P, MA N, and Social Worker) revealed staff had been in-serviced on resident rights on 05/22/25. When provided a scenario where a resident refused a shower and a CNA transferred them by their wrists or under their armpits and gave a resident a shower despite the resident's refusals- all stated it was a violation of the resident's right to refuse a shower and would have intervened and ensured the resident was safe and immediately report it to the Abuse Coordinator. They staff were aware of the shower refusal process of having the resident and the nurse and aide signed the refusal sheet and they were turned into a box near the ADON D's office. Record review of facility's resident rights policy titled Resident Rights, undated, reflected: The resident has a right to a dignified existence, self-determination .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident . Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. 1. The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. 2. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. Respect and dignity - The resident has a right to be treated with respect and dignity . Self-determination - The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. 1.The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, plan of care and other applicable provisions of this part. 2.The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident . Record review of the facility's Bathing/Shower Policy titled Bath, Tub/Shower, undated, reflected .The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed . Procedure 1. The resident will receive assistance with bathing according to their resident centered plan of care. 2. Become familiar with type and pattern of bathing, assistance or aids needed, skin condition, presence of dressing or casts . Record review of CNA A's personnel file reflected she was hired on 05/01/25 with a last worked date of 05/21/25 and was terminated from employment on 05/23/25. The facility had conducted Texas Department of Public Safety Criminal History verification and Employee Misconduct Registry Employability status check without any concerns. Record review of CNA B's personnel file reflected she was hired on 04/18/25 with a last worked date of 05/21/25 and was terminated from employ[TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure all residents received assistance devices to prevent accidents for one (Resident #1) of nine residents reviewed for assistance devices to prevent accidents. The facility failed to place Resident #1's bed in the lowest position and place her fall mat beside her bed in order to minimize injury if the resident sustained [REDACTED].#1 suffered a laceration to the head that required three staples due to a fall from her bed. This failure could place the 23 residents who were a fall risk at risk for injury if the appropriate devices were not used. Findings included: Review of Resident #1's MDS Assessment, dated 07/05/147, revealed an [AGE] year old female that admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident suffered a fall in the facility since admission. Resident #1's BIMS score indicated a severe cognitive impairment and she required extensive assistance with one person assistance for ADL's. Review of Resident #1's Care Plan, updated, 07/13/17, reflected she was a fall risk and suffered multiple falls in the facility since admission. Interventions included: frequent visual checks, call light within reach, low bed and mat in place to minimize injury. Review of Incident/Accident Report, dated 09/18/17, revealed LVN A was called to room by Hospice Aide B and found Resident #1 on floor next to bed at 12:45 p.m. LVN A noted a 1.3cm laceration to the right upper back of head. Resident #1 was sent to ER for evaluation. The post fall review, effective 09/19/17, revealed the facility will continue to lower the bed and keep mat in place. The facility will continue with frequent visual checks. Cushions were placed on the sides and corner of nightstand. Mat was placed to corner the oxygen concentrator and nightstand. Review of Investigation Summary , undated, revealed in an interview with Hospice Aide B she revealed she assisted Resident #1 between 8:00 a.m. and 8:15 a.m. Hospice Aide B revealed she did not remember if she returned the bed to the lowest position or if she placed the fall mat next to the bed when she was finished providing care. Review of Investigation Summary revealed in an interview with CNA C she revealed she checked on Resident #1 around 10:45 a.m. She does not recall if the bed was in the lowest position, but she did remember that she could not find the fall mat. Interview on 09/26/17 at 11:10 a.m. with LVN A revealed she was called to Resident #1's room by Hospice Aide B. LVN A stated she found Resident #1 on the floor and the resident was bleeding from her head. LVN A stated the fall mat was not in place beside the bed. The fall mat was rolled up and in the corner of the room beside the closet. LVN A stated the bed was lowered, but was not in its lowest position. Interview on 09/26/17 at 12:45 p.m. with the DON revealed Resident #1 returned to the facility on the same day she was sent out. Resident #1 received three staples to her head due to the injury. Review of an undated staff list, provided by the Administrator on 09/27/17, revealed 58 nursing staff (CNAs, MAs, LVNs, and RNs) were currently employed by the facility. Review of Sign-in sheet for Fall/Fall Prevention in-service, dated 09/19/17, revealed only 25 nursing staff received the training including LVN A and CNA C. Observations of Resident #1 on 09/27/17 at 9:45 a.m. of Resident #1 revealed resident in bed asleep. The bed was lowered to lowest possible position and fall mat was placed beside bed. Review of the undated Falling Star Worksheet revealed there were 23 residents in the facility who were identified as a fall risk and required their beds to be lowered and/or a fall mat in place.

Based on observation, interview and record review, the facility failed to ensure the proper treatment and care for IVs was provided for four (Residents #3, #4, #12, and #15) of four residents reviewed with IV access. 1) While providing care for Resident #3's double lumen PICC line and administering IV antibiotics, LVN B failed to: --aspirate for blood to ensure patentcy of the PICC line; --secure the dressing covering the PICC line insertion site to prevent infection; --use separate syringes each time he flushed both lumens of the PICC with Normal Saline and/or [MEDICATION NAME] to prevent cross-contamination; --clamped the lumens of the PICC line after flushing them to prevent contamination; --provide a sterile dressing change for the PICC line to prevent contamination; --conduct hand hygiene after removing contaminated gloves and prior to putting on clean/sterile gloves; and --ensure he did not put Resident #3 at risk for cross-contamination and infection while providing care. The DON did not verify LVN B's IV skills prior to assigning him residents, who were receiving IV antibiotics. 2) LVN C failed to aspirate for blood from Resident #12's peripheral IV line to determine patentcy prior to administering [MEDICATION NAME] (antibiotic) on 09/25/13 and on 09/26/13, did not try to remove bubbles from a syringe before trying to check for patentcy of his peripheral IV line. 3) RN F failed to: --reinforce Resident #4's dressing over the insertion site to the resident's port-a-cath; --prevent contamination of the port to the Huber needle accessing the resident's port-a-cath; and --dispose of blood-contaminated syringes in a biohazard sharps container. 4) RN CC failed to: --clean Resident #4's port to the Huber needle before flushing; and --adequately reinforce Resident #4's dressing over the insertion site to the resident's port-a-cath leaving it unprotected from contamination and infection. 5) While providing care for Resident #15's PICC line three different times, RN F failed to: --prime the NS-filled syringe before flushing Resident #15's port/lumen to his PICC line prior to administering her antibiotic; --prime the NS-filled syringe and [MEDICATION NAME]-filled syringe before flushing following the administration of the antibiotic; --clamp the port/lumen tubing prior to removing the antibiotic infusion tubing; --clean the port/lumen after it was contaminated and had come into contact with Resident #15's skin; --aspirate for blood flow back prior to the [MEDICATION NAME] flush; and --dispose of blood-contaminated syringes in a biohazard sharps container two different times. An Immediate Jeopardy (IJ) was identified on 09/25/13 at 5:15 PM. While the IJ was removed on 09/28/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm that is not immediate jeopardy," because the facility was still ensuring licensed nurses were receiving IV certification with an IV performance check-off and monitoring the Plan of Removal. These failures could affect the four residents with PICC (Residents #1 and #3) and/or central lines (Residents #2 and #4), identified upon entry to the facility on [DATE], including Resident #3, and two residents who were admitted with a PICC line (Resident #15) and a peripheral line (Resident #12) on 09/24/13, by placing them at risk for worsening infections, increased debility due to infection and possible death from improper procedures. Findings included: The Texas Administrative Code (TAC) Title 22 Examining Boards, Part 11 Texas Board of Nursing, Chapter 217 Licensure, Peer Assistance and Practice, Rule 217.11 Standards of Nursing Practice reflected: "The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice...(C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same...(G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations...(O) Implement measures to prevent exposure to infectious pathogens...(R) Be responsible for one's own continuing competence in nursing practice and individual professional growth; (S)Make assignments to others that take into consideration client safety and that are commensurate with the educational preparation, experience, knowledge...of the person to whom the assignments are made; (T) Accept only those nursing assignments that take into consideration client safety and that are commensurate with the educational preparation, experience, knowledge... (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and...(iv) implementing appropriate aspects of care within the LVN's scope of practice...." The Texas Board of Nurse Examiner's Position Statement 15.28 The Registered Nurse Scope of Practice last revised on January 2013 reflected: "...Planning...the RN, who has the overall responsibility to coordinate nursing care for patients...Implementation...The RN's duty to patient safety when making assignments to other nurses ... is to consider the education, training, skill, competence...of those to whom the assignments or delegation is made. The RN is responsible for reasonable and prudent decisions regarding assignments and delegation. The RN scope of practice may include the supervision of LVNs. Supervision of LVN staff is defined as the process of directing, guiding...The RN may have to directly observe and evaluate the nursing care provided depending on the LVN's skills and competence...Employment Setting...The RN's duty is to always provide safe, [MEDICATION NAME], and comprehensive nursing care to patients. The Texas Board of Nurse Examiner's Position Statement 15.3 LVNs Engaging in Intravenous Therapy, Venipuncture, or PICC Lines last reviewed on January 2012 by the Board reflected: "The basic educational curriculum for Licensed Vocational Nurses (LVNs) does not mandate teaching of principles and techniques of insertion for peripheral intravenous catheters, or the administration of fluids and medications via the intravenous route. Knowledge and skills relating to maintaining patency and performing dressing changes of central line intravenous catheters is also not mandated as part of basic LVN education. As such, basic competency in management of intravenous lines/intravenous therapy is not a given for any specific LVN licensee. Applicable Nursing Standards LVN practice is guided by the Nursing Practice Act (NPA) and Board Rules. Rule 217.11, Standards of Nursing Practice, is the rule most often applied to nursing practice issues. Two standards applicable in all practice scenarios include...217.11(1)(T) accept only those assignments that take into consideration client safety and that are commensurate with the nurse's educational preparation, experience, knowledge, and physical and emotional ability. Additional standards in Rule 217.11 that may be applicable when a LVN chooses to engage in an IV therapy-related task include (but are not limited to): ...(1)(C) Know the rationale for and effects of medications and treatments and shall correctly administer the same...(1)(G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices...(2)(C)...perform other acts that require education and training as prescribed by board rules and policies, commensurate with the LVN's experience, continuing education, and demonstrated LVN competencies." The Texas Board of Nurse Examiners' Position Statement 15.27 last reviewed January 2012 by the Board reflected: "The Licensed Vocational Nurse Scope of Practice provides additional clarification of the Standards Rule as it applies to LVN Scope of Practice. Instruction and skill evaluation relating to LVNs performing insertion of peripheral IV catheters and/or administering IV fluids and medications as prescribed by an authorized practitioner may allow a LVN to expand his/her scope of practice to include intravenous therapy. It is the opinion of the Board that the LVN shall not engage in IV therapy related to either peripheral or central venous catheters, including venipuncture, administration of IV fluids, and/or administration of IV push medications, until successful completion of a validation course that instructs the LVN in the knowledge and skills applicable to the LVN's IV therapy practice. The BON (Board of Nurse Examiners) does not define or set qualifications for an "IV Validation Course" or for "LVN IV certification." The LVN who chooses to engage in intravenous therapy must first have been instructed in the principles of intravenous therapy congruent with prevailing nursing practice standards... Administration of IV Fluids and Medications The ability of a LVN to administer specific IV fluids or drugs, to prepare and/or administer IV 'piggy-back' or IV 'push' medications, or to monitor and titrate "IV drip" medications of any kind is up to facility policy. The LVN's practice relative to IV therapy must also comply with any other regulations that may exist under the jurisdiction of other regulatory agencies or entities. The LVN who accepts an assignment to engage in any aspect of intravenous therapy is responsible for adhering to the NPA and the Board rules, particularly 217.11 Standards of Nursing Practice, including excerpted standards listed above and any other standards or rules applicable to the individual LVN's practice. All nursing actions related to peripheral and/or central intravenous lines, as well as IV administration of medications, must be completed in accordance with the orders of the prescribing practitioner, as well as written policies, procedures and job descriptions approved by the health care employer." 1) Resident #3's undated Face Sheet reflected the resident, an [AGE] year-old female, was admitted on [DATE]. An interim care plan (date not known) was located in Resident #3's chart addressing the antibiotics she was receiving for [MEDICAL CONDITION] of the right ankle. During an interview with LVN G on 09/24/13 at 4:00 PM, she revealed there was no care plan addressing the care of Resident #3's PICC line. Resident #3 was identified by LVN G on 09/24/13 at 10:45 AM, as having a PICC line with an insertion site on her left upper arm. The resident was receiving antibiotics through the PICC line for an infected right lower leg venous stasis ulcer. LVN G stated Resident #3 required two persons for transfers, was depressed and cried out, did not come out of her room for activities, was incontinent of bowel and bladder at times, her right leg was non-weight bearing, she wore glasses and consumed her meals in her room after staff had set the meal tray up. LVN G stated Resident #3 was currently out of the facility for an appointment at the wound care physician's office. Resident #3's admission physician's orders [REDACTED]. Resident #3's [DIAGNOSES REDACTED]. Resident #3's Physician's Telephone Order, dated 09/16/13, reflected to change the PICC line dressing every week and PRN. LVN B was observed on 09/25/13 from 7:46 AM through 8:15 AM, administering medication to Resident #3. LVN B performed hand hygiene and donned gloves. LVN B checked Resident #3's legs and feet and repositioned the oxygen tubing. LVN B removed his gloves and regloved without performing hand hygiene. LVN B activated/mixed the Ceftaroline 600 mg medication with 100 ml of NS, shaking it well. LVN B pushed back Resident #3's left sleeve exposing the PICC line site. The dressing, which was supposed to cover the PICC line site was coming off, and the PICC line insertion site was exposed. The PICC line had a length of catheter with an independent loop between the insertion site and the catheter hub anchor site. The catheter was not marked to indicate the original insertion length, making it impossible to determine if the PICC line had become dislodged with the dressing. LVN B stated at that time he would secure the dressing with an ace wrap until the dressing could be changed. LVN B connected the blue port/lumen of the double port/lumen PICC line with a 10 cc syringe of NS. LVN B unclamped the line and flushed the line without aspirating for blood backflow (obtaining a backflow of blood ensures the line was still in place and patent) and re-clamped the line. LVN B prepared the IVPB (containing the antibiotic) by spiking the bag with the tubing and then realized there was no "dial-a-flow" device (used to infuse the medication at a certain rate of speed using gravity) available. LVN B de-gloved, performed hand hygiene and left the room to gather the needed supplies. LVN B returned to Resident #3's room with a dial-a-flow. He performed hand hygiene and put on gloves. LVN B connected a 10 cc syringe of NS to the blue port/lumen of the PICC line, unclamped the line and again flushed the PICC line port/lumen with 10 cc of NS without aspirating for blood backflow first to ensure the PICC line was patent. LVN B re-clamped the PICC line tubing, connected the IVPB, unclamped the line and began the infusion. Observation on 09/25/13 at 10:00 AM with LVN B (after the IVPB antibiotic had infused), revealed Resident #3's PICC line site had not been secured with the ace bandage as the LVN had said he was going to do. LVN B performed hand hygiene and left Resident #3's room to retrieve gloves. LVN B returned to Resident #3's room and donned the gloves without performing hand hygiene. LVN B disconnected the IVPB tubing without clamping closed the blue port/lumen of the PICC line. LVN B connected the syringe and flushed the blue port/lumen (line the IVPB had infused into) with 5 cc of NS without aspirating for blood backflow prior to flushing. LVN B did not clamp the blue port/lumen line closed. LVN B then cleaned the red port/lumen with an alcohol wipe and disconnected the syringe from the blue port/lumen and, using the same syringe he had just used to flush the blue port/lumen line, connected the syringe to the red port/lumen line. LVN B flushed the red port/lumen with 5 cc of NS without aspirating for blood backflow prior to flushing. When finished, LVN B did not clamp the red port/lumen line closed. LVN B disconnected the NS flush syringe from the red port/lumen and then connected a syringe containing [MEDICATION NAME] for the [MEDICATION NAME] flush. LVN B flushed the red port/lumen with 2.5 cc of [MEDICATION NAME] without aspirating for blood backflow prior to the flush. LVN B then clamped the red port/lumen line closed. LVN B then disconnected the [MEDICATION NAME] flush syringe and, using the same syringe containing [MEDICATION NAME], connected the syringe to the blue port/lumen line. Without aspirating for blood backflow, LVN B flushed the blue port/lumen with 2.5 cc of [MEDICATION NAME]. LVN B clamped the blue port/lumen line closed. LVN B wiped the overbed table with a Sani-cloth wipe and then opened the sterile Central Venous Catheter (CVC) dressing change kit, placing it on Resident #3's overbed table. LVN B applied a face mask and applied sterile gloves. LVN B set up the sterile work field utilizing the drape in the kit. LVN B continued the set up by placing the [MEDICATION NAME] swab, alcohol wipe and transparent dressing onto the sterile drape. LVN B stated he forgot something, reached over Resident #3 and pressed the call light button located on the wall at 10:15 AM. At 10:20 AM, LVN B left Resident #3's room, leaving the sterile set-up on the overbed table uncovered and unattended, thereby breaking sterility. LVN B returned with another unopened CVC dressing change kit and applied non-sterile gloves after performing hand hygiene. LVN B did not reapply a face mask. LVN B removed the previous PICC line dressing from Resident #3's left upper arm. LVN B removed the non-sterile gloves. LVN B did not perform any hand hygiene. LVN B picked up the (new) sterile CVC dressing change kit, opened it and took out the sterile gloves. LVN B threw the rest of the just-opened CVC sterile dressing change kit onto the floor. LVN B donned the sterile gloves, without performing any hand hygiene. LVN B picked up the Chloroprep wipe from the previously set-up sterile field and began to wipe the peri-wound of the PICC site, without cleaning the actual insertion site of the PICC line. LVN B then applied a transparent dressing over the PICC line insertion site and the independent loop in the catheter. When asked by the surveyor, LVN B measured the independent loop, which had a length of 14 cm from insertion site to catheter hub. LVN B, while wearing his soiled/contaminated gloves, gathered the contaminated supplies, including those thrown to the floor, lowered the bed, positioned the overbed table in a lower position, picked up the container of Sani-cloths, offered Resident #3 the water pitcher (picked the pitcher up), gave Resident #3 a pen and piece of paper, repositioned a second overbed table, repositioned the linens at the foot of the bed, pulled the covers back to feel Resident #3's upper, inner thighs (resident had complained of leg pain), left the room and disposed of the bag of soiled/used items in the container located in the hallway. LVN B then removed the now-contaminated sterile gloves worn during the sterile dressing change. LVN B did not perform any hand hygiene after removing the soiled gloves. Interview with LVN B on 09/25/13 at 10:30 AM, revealed he had not received any IV training nor had a competency skills checks conducted since he began his employment at the facility in early August 2013. LVN B stated he had had previous IV training, just not at this facility. An interview with the DON on 09/25/13 at 3:00 PM, revealed when asked regarding LVN B's IV training and competency, a nurse was out on maternity leave and LVN B, when asked, told her (the DON) he had IV experience. When asked by the surveyor about his IV certification, the DON stated she had not required LVN B to bring a copy of his IV training certificate, which would have included peripheral, PICC and CVC line training. The DON further stated she and facility nursing administrative staff had not conducted any IV competency skills checks prior to assigning LVN B to provide care for residents with an IV, administer IV medications, provide site care and/or dressing changes. She continued to state no competency skills check had been completed for LVN B until today (09/25/13), after the surveyor informed her of the issues she (the surveyor) had observed. The DON then said she should have conducted a skills check for LVN B's IV skills (before assigning him to a hall with residents who had IVs). On 09/25/13 at 3:00 PM, when the surveyor requested certification of LVN B's IV training, the Corporate RN was unable to provide evidence of the LVN's certification. The Corporate RN stated LVN B did not have an IV training certificate on file with the facility, that he was going home to retrieve a copy for the facility. On 09/25/13 at 4:00 PM, the Corporate RN provided copies of IV training certification for LVN B, with copies of a Peripheral Vascular Competency, dated 12/06/12, and a Central Vascular Competency, dated 12/07/12, both performed at another facility. 2) The Face Sheet, dated 09/25/13, reflected Resident #12, a [AGE] year-old male, was admitted to the facility on [DATE] at 6:00 PM. Resident #12 had two care plans, dated 09/24/13, for receiving IV and oral antibiotic therapy and having an IV saline lock. The care plan included the following approaches: to observe the access site every shift and monitor for patency; flush as per ordered; monitor the IV site for signs and symptoms of infiltration or infection; follow regimen when caring for IV site and flush per protocol; monitor for complications from IV including localized infection, systemic infection, air [MEDICATION NAME], dislodgement, infiltration, extravasation (blood into the surrounding tissue) and phlebitis (inflammation); and to monitor the IV site for swelling, redness, tenderness and warmth. Resident #12's care plan, dated 09/24/13, revealed he was receiving IV and oral antibiotics for Staphylococcus epidermdis bacteremia. Taber's Cyclopeidc Medical Dictionary, Edition 21, Copyright 2005, page 2194 reflected Staphylococcus epidermdis is a coagulase-negative species that is part of the normal flora of the skin. It may colonize, form biofilms on, and infect indwelling catheters. Retrieved on 10/09/13 from htt-p://emedicine.medscape.com/article/ 6-overview revealed the incidence of infections due to Staphylococcus epidermdis has been steadily increasing in recent years. Resident #12's admission physician's orders [REDACTED]. Resident #12's admission physician's orders [REDACTED]. An observation on 09/25/13 at 2:10 PM, revealed LVN C was administering Resident #12's [MEDICATION NAME] via a peripheral IV (saline lock) located on the right hand. LVN C flushed the saline lock line with 5 cc of NS prior to connecting and infusing the [MEDICATION NAME]. LVN C did not aspirate the saline lock for blood return prior to flushing with NS (to ensure patency). An observation on 09/26/13 at 1:15 PM, revealed LVN C was about to administer Resident #12's [MEDICATION NAME]. LVN C did not prime (remove the air bubbles) from the NS-filled syringe before connecting it to the peripheral saline lock. LVN C was not able to aspirate any blood backflow. LVN C began talking to RN CC (the facility's Clinical Coordinator), who was in the resident's room, about what to do since she could not get any blood backflow. Resident #12 was looking between LVN C and RN CC with a curious look, but no explanation was given to the resident. RN CC left the room and retrieved another NS-filled syringe, and LVN C again connected the syringe without priming it first. 3) During an interview with the DON on 09/25/13 at 3:00 PM, she was queried what her expectations were for nursing staff when flushing IV lines. The DON responded she expected the nurses to aspirate for blood return prior to flushing the site (to determine patency). When queried about the procedure she expected nursing staff to use when changing the dressing on the PICC line insertion site, she stated she expected the nurses to use aseptic or sterile technique without breaks in sterility. She added dressing changes were scheduled weekly (for PICC lines) but should be done as needed when coming loose and/or were soiled. 4) On 09/25/13 at 3:00 PM, following a request from the surveyor for proof of the facility's LVNs' IV training, the Corporate RN provided a IV training certificate for LVN C. 5) Review of the facility's current Infection Control Policies and Procedures dated, March 2006, revealed: "...Procedures ...2. Standard Precautions, sometimes known as Universal Precautions A. Hand washing ...2) Wash hands immediately after gloves are removed... 3) May be necessary to wash hands between tasks and procedures on the same patient/resident to prevent cross-contamination of different body sites... B. Gloves ...3) Change gloves between tasks and procedures on the same patient/resident... 4) Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces... 5) Wash hands immediately after removing gloves...." 6) On 09/25/13 at 10:40 AM, the surveyor requested from the Corporate RN the facility's current policies and procedures covering IVs, sterile dressing changes, IV training certificates and facility competency skills checks for all LVNs. 7) An interview on 09/25/13 at 12:25 PM with RN CC (the facility's Clinical Coordinator) revealed that she was a resource for nursing staff for any clinical issues. On 09/25/13 at 1:40 PM, the Corporate RN provided a (blank) competency for IV Medication Administration and Care of Central Venous Catheters (External). The specific policy for flushing IV sites was requested from the Corporate RN at that time. The Corporate RN stated the facility used Perry and Potter as a reference for any issues for which they did not have a current policy and procedure. On 09/25/13 at 3:25 PM, the Corporate RN provided a procedure from Perry and Potter, Clinical Nursing Skills and Techniques, 8th Edition, February 2, 2013, for an IV push, which would be the same procedure used for an IV flush. It reflected the following: "Skill 22-5 Administering Medications by Intravenous [MEDICATION NAME] 9 IV push (IV lock):...a Prepare flush solutions according to agency policy...b Administer medication:...(3) Pull back gently on syringe plunger and check for blood return..." On 09/25/13 at 4:00 PM, the Corporate RN provided a policy, provided by Omnicare for "4.3 Peripheral Catheter Dressing Change...Revision Dates October 1, 2005; March 19, 2007; August 15, 2008; July 1, 2012...Original Date: January 15, 2004...To Be Performed By:...The nurse shall be competent in the safe delivery of infusion therapy within her or his scope of practice...Considerations: 1. The peripheral catheter insertion site is a potential entry site for bacteria that could produce a catheter-related infection...3. Licensed nurses caring for residents receiving infusion therapies are expected to follow infection control and safety compliance procedures. Guidance: 1. Transparent dressings are changed with each site rotation, or sooner if the integrity of the dressing is compromised (wet, loose or soiled)...5. Assessment of peripheral catheter site is performed: 5.1 During dressing changes...5.3 Before and after administration of intermittent infusions...5.5 Routinely for signs and symptoms of infiltration and extravagation at a frequency based on resident condition, age and type of medication and rate of flow. 6. Assessment is to include the absence or presence of, but is not limited to:...6.6 Integrity of transparent dressing...Procedure:...3. Wash hands...6. Don gloves...8. Assess site for complications...12. Vigorously cleanse around the catheter insertion site with antimicrobial solution according to the manufacturer's instructions. Allow to air dry...14. Apply transparent dressing, covering catheter insertion site and securement device, with insertion site at center of the dressing. Smooth around the catheter starting at the insertion site and moving to the periphery..." On 09/26/13 at 9:35 AM, the Corporate RN again provided the above policy, stating this policy would be used for both peripheral and central venous lines including PICC lines. 8) An IJ was identified on 09/25/13. The Administrator, the DON, and Corporate RN (Clinical Services Director) were notified of the IJ on 09/25/13 at 5:15 PM, and a Plan of Removal was requested at that time. 9) On 09/26/13 at 1:30 PM, a copy of the In-service dated 09/25/13 from 5:30 PM to 6:00 PM, reflected it covered the previously mentioned policies and procedures from Omnicare. 10) Resident #4's undated Face Sheet reflected the resident, an [AGE] year-old male, was admitted on [DATE]. Resident #4's care plans, dated 09/19/13, reflected they addressed his receiving IV antibiotic therapy for a urinary tract infection [MEDICAL CONDITION] and was receiving [MEDICATION NAME] 3.375 gm IV every 8 hours for 7 days. Approaches included: observe access site and monitor for patency; flush as per orders; and monitor site for signs and symptoms of infiltration or infection. An additional care plan, dated 09/25/13, reflected Resident #4 required IV medication and had a Port-a-Cath with approaches including: follow regimen when caring for IV site and flush per protocol; monitor for complication from IV (localized infection, systemic infection, air [MEDICATION NAME], dislodgement, infiltration, extravasation, phlebitis and monitor IV site for swelling, redness, tenderness and warmth. During an interview on 09/24/13 at 11:02 AM, LVN G stated Resident #4 had a Port-a-Cath (Central Line) in his right chest wall and received IV antibiotics through the port for a UTI. She stated Resident #4 needed extensive assistance for all ADLs, did not attend activities out of his room, received bedside blood glucose testing and insulin, was hard of hearing and wore glasses, had an indwelling Foley catheter, received therapy services and ate all his meals in his room. Resident #4's admission physician's orders [REDACTED]. [DIAGNOSES REDACTED]. An observation was made on 09/26/13 at 2:15 PM, for Resident #4's [MEDICATION NAME] IV antibiotic with RN F. The sterile transparent dressing, which was supposed to cover the insertion site of the Huber needle (a needle that is bent at a 90-degree angle), into Resident #4's Port-a-Cath, was not completely adhered to the skin and was not providing a sterile, occlusive barrier. The dressing had not been pinched around needle/tubing accessing the Port-a-cath and left a finger-sized gap/tunnel from the open edge of the dressing through to the needle insertion site. RN F did not secure the transparent dressing. RN F cleaned the port and while priming the NS-filled syringe, touched the tip of the port with her unsterile gloves. RN F did not reclean the port prior to connecting the NS-filled syringe. Once she finished starting the IV antibiotic, RN F threw the contaminated syringes, which contained NS and blood obtained during aspiration, into Resident #4's trash can instead of a biohazard sharps container. An observation of RN CC (the facility's Clinical Coordinator) on 09/26/13 at 3:05 PM in Resident #4's room, after the IVPB antibiotic had infused, revealed she clamped the IV infusion tubing, primed a NS-filled syringe, disconnected the IV tubing, connected the NS-filled syringe and flushed the port/line with 5 cc of NS. RN CC clamped the port/line and disconnected the NS syringe. She then connected the [MEDICATION NAME]-filled syringe, released the clamp on the port/line a

Based on observation, interview and record review, it was determined that the facility failed to maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of disease and infection for three (Residents #3, #13, and #21) of five residents observed during the medication pass. 1) While providing care for Resident #3's double lumen PICC line and administering IV antibiotics, LVN B failed to: --secure the dressing covering the PICC line insertion site to prevent infection; --use separate syringes each time he flushed both lumens of the PICC with Normal Saline and/or [MEDICATION NAME] to prevent cross-contamination; --clamped the lumens of the PICC line after flushing them to prevent contamination; --provide a sterile dressing change for the PICC line to prevent contamination; --conduct hand hygiene after removing contaminated gloves and prior to putting on clean/sterile gloves; and --ensure he did not put Resident #3 at risk for cross-contamination and infection while providing care. An Immediate Jeopardy (IJ) was identified on 09/25/13 at 5:15 PM. While the IJ was removed on 09/28/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm that is not immediate jeopardy," because the facility was still ensuring licensed nurses were receiving IV certification with an IV performance check-off and monitoring the Plan of Removal. These failures could affect the four residents with PICC (Residents #1 and #3) and/or central lines (Residents #2 and #4), identified upon entry to the facility on [DATE], including Resident #3, and two residents who were admitted with a PICC line (Resident #15) and a peripheral line (Resident #12) on 09/24/13, by placing them at risk for worsening infections, increased debility due to infection and possible death from improper procedures. 2) LVN E failed to perform any hand hygiene prior to pouring/popping out Resident #21's medications and after she entered the resident's room before donning gloves and administering the medications via gastrostomy tube. 3) RN D failed to did not perform any hand hygiene prior to pouring/popping out Resident #13's medications. These failures could affect the 45 residents on Halls A and D, including Residents #13 and #21, by placing them at risk for cross-contamination and the possible spread of infection. Findings included: 1) Resident #3's undated Face Sheet reflected the resident, an [AGE] year-old female, was admitted on [DATE]. An interim care plan (date not known) was located in Resident #3's chart addressing the antibiotics she was receiving for cellulitis of the right ankle. During an interview with LVN G on 09/24/13 at 4:00 PM, she revealed there was no care plan addressing the care of Resident #3's PICC line. Resident #3 was identified by LVN G on 09/24/13 at 10:45 AM, as having a PICC line with an insertion site on her left upper arm. The resident was receiving antibiotics through the PICC line for an infected right lower leg venous stasis ulcer. LVN G stated Resident #3 required two persons for transfers, was depressed and cried out, did not come out of her room for activities, was incontinent of bowel and bladder at times, her right leg was non-weight bearing, she wore glasses and consumed her meals in her room after staff had set the meal tray up. LVN G stated Resident #3 was currently out of the facility for an appointment at the wound care physician's office. Resident #3's admission physician's orders [REDACTED]. Resident #3's [DIAGNOSES REDACTED]. Resident #3's Physician's Telephone Order, dated 09/16/13, reflected to change the PICC line dressing every week and PRN. LVN B was observed on 09/25/13 from 7:46 AM through 8:15 AM, administering medication to Resident #3. LVN B performed hand hygiene and donned gloves. LVN B checked Resident #3's legs and feet and repositioned the oxygen tubing. LVN B removed his gloves and regloved without performing hand hygiene. LVN B pushed back Resident #3's left sleeve exposing the PICC line site. The dressing, which was supposed to cover the PICC line site was coming off, and the PICC line insertion site was exposed. The PICC line had a length of catheter with an independent loop between the insertion site and the catheter hub anchor site. The catheter was not marked to indicate the original insertion length, making it impossible to determine if the PICC line had become dislodged with the dressing. LVN B stated at that time he would secure the dressing with an ace wrap until the dressing could be changed. LVN B de-gloved, performed hand hygiene and left the room to gather the needed supplies. Observation on 09/25/13 at 10:00 AM with LVN B, revealed Resident #3's PICC line site had not been secured with the ace bandage as the LVN had said he was going to do. LVN B performed hand hygiene and left Resident #3's room to retrieve gloves. LVN B returned to Resident #3's room and donned the gloves without performing hand hygiene. LVN B disconnected the IVPB tubing without clamping closed the blue port/lumen of the PICC line. LVN B connected the syringe and flushed the blue port/lumen (line the IVPB had infused into) with 5 cc of NS without aspirating for blood backflow prior to flushing. LVN B did not clamp the blue port/lumen line closed. LVN B then cleaned the red port/lumen with an alcohol wipe and disconnected the syringe from the blue port/lumen and, using the same syringe he had just used to flush the blue port/lumen line, connected the syringe to the red port/lumen line. LVN B flushed the red port/lumen with 5 cc of NS without aspirating for blood backflow prior to flushing. When finished, LVN B did not clamp the red port/lumen line closed. LVN B disconnected the NS flush syringe from the red port/lumen and then connected a syringe containing [MEDICATION NAME] for the [MEDICATION NAME] flush. LVN B flushed the red port/lumen with 2.5 cc of [MEDICATION NAME] without aspirating for blood backflow prior to the flush. LVN B then clamped the red port/lumen line closed. LVN B then disconnected the [MEDICATION NAME] flush syringe and, using the same syringe containing [MEDICATION NAME], connected the syringe to the blue port/lumen line. Without aspirating for blood backflow, LVN B flushed the blue port/lumen with 2.5 cc of [MEDICATION NAME]. LVN B clamped the blue port/lumen line closed. LVN B wiped the overbed table with a Sani-cloth wipe and then opened the sterile Central Venous Catheter (CVC) dressing change kit, placing it on Resident #3's overbed table. LVN B applied a face mask and applied sterile gloves. LVN B set up the sterile work field utilizing the drape in the kit. LVN B continued the set up by placing the [MEDICATION NAME] swab, alcohol wipe and transparent dressing onto the sterile drape. LVN B stated he forgot something, reached over Resident #3 and pressed the call light button located on the wall at 10:15 AM. At 10:20 AM, LVN B left Resident #3's room, leaving the sterile set-up on the overbed table uncovered and unattended, thereby breaking sterility. LVN B returned with another unopened CVC dressing change kit and applied non-sterile gloves after performing hand hygiene. LVN B did not reapply a face mask. LVN B removed the previous PICC line dressing from Resident #3's left upper arm. LVN B removed the non-sterile gloves. LVN B did not perform any hand hygiene. LVN B picked up the (new) sterile CVC dressing change kit, opened it and took out the sterile gloves. LVN B threw the rest of the just-opened CVC sterile dressing change kit onto the floor. LVN B donned the sterile gloves, without performing any hand hygiene. LVN B picked up the Chloroprep wipe from the previously set-up sterile field and began to wipe the peri-wound of the PICC site, without cleaning the actual insertion site of the PICC line. LVN B then applied a transparent dressing over the PICC line insertion site and the independent loop in the catheter. LVN B, while wearing his soiled/contaminated gloves, gathered the contaminated supplies, including those thrown to the floor, lowered the bed, positioned the overbed table in a lower position, picked up the container of Sani-cloths, offered Resident #3 the water pitcher (picked the pitcher up), gave Resident #3 a pen and piece of paper, repositioned a second overbed table, repositioned the linens at the foot of the bed, pulled the covers back to feel Resident #3's upper, inner thighs (resident had complained of leg pain), left the room and disposed of the bag of soiled/used items in the container located in the hallway. LVN B then removed the now-contaminated sterile gloves worn during the sterile dressing change. LVN B did not perform any hand hygiene after removing the soiled gloves. Interview with LVN B on 09/25/13 at 10:30 AM, revealed he had not received any IV training nor had a competency skills checks conducted since he began his employment at the facility in early August 2013. LVN B stated he had had previous IV training, just not at this facility. An interview with the DON on 09/25/13 at 3:00 PM, revealed when asked regarding LVN B's IV training and competency, a nurse was out on maternity leave and LVN B, when asked, told her (the DON) he had IV experience. When asked by the surveyor about his IV certification, the DON stated she had not required LVN B to bring a copy of his IV training certificate, which would have included peripheral, PICC and CVC line training. The DON further stated she and facility nursing administrative staff had not conducted any IV competency skills checks prior to assigning LVN B to provide care for residents with an IV, administer IV medications, provide site care and/or dressing changes. She continued to state no competency skills check had been completed for LVN B until today (09/25/13), after the surveyor informed her of the issues she (the surveyor) had observed. The DON then said she should have conducted a skills check for LVN B's IV skills (before assigning him to a hall with residents who had IVs). On 09/25/13 at 3:00 PM, when the surveyor requested certification of LVN B's IV training, the Corporate RN was unable to provide evidence of the LVN's certification. The Corporate RN stated LVN B did not have an IV training certificate on file with the facility, that he was going home to retrieve a copy for the facility. On 09/25/13 at 4:00 PM, the Corporate RN provided copies of IV training certification for LVN B, with copies of a Peripheral Vascular Competency, dated 12/06/12, and a Central Vascular Competency, dated 12/07/12, both performed at another facility. During an interview with the DON on 09/25/13 at 3:00 PM, when queried about the procedure she expected nursing staff to use when changing the dressing on the PICC line insertion site, she stated she expected the nurses to use aseptic or sterile technique without breaks in sterility. She added dressing changes were scheduled weekly (for PICC lines) but should be done as needed when coming loose and/or were soiled. Review of the facility's current Infection Control Policies and Procedures dated, March 2006, revealed: "...Procedures ...2. Standard Precautions, sometimes known as Universal Precautions A. Hand washing ...2) Wash hands immediately after gloves are removed... 3) May be necessary to wash hands between tasks and procedures on the same patient/resident to prevent cross-contamination of different body sites... B. Gloves ...3) Change gloves between tasks and procedures on the same patient/resident... 4) Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces... 5) Wash hands immediately after removing gloves...." On 09/25/13 at 10:40 AM, the surveyor requested from the Corporate RN the facility's current policies and procedures covering IVs and sterile dressing changes, IV training certificates and facility competency skills checks for all LVNs. An interview on 09/25/13 at 12:25 PM with RN CC, the facility's Clinical Coordinator, revealed that she was a resource for nursing staff for any clinical issues. On 09/25/13 at 4:00 PM, the Corporate RN provided a policy, provided by Omnicare for "4.3 Peripheral Catheter Dressing Change...Revision Dates October 1, 2005; March 19, 2007; August 15, 2008; July 1, 2012...Original Date: January 15, 2004...To Be Performed By:...The nurse shall be competent in the safe delivery of infusion therapy within her or his scope of practice...Considerations: 1. The peripheral catheter insertion site is a potential entry site for bacteria that could produce a catheter-related infection...3. Licensed nurses caring for residents receiving infusion therapies are expected to follow infection control and safety compliance procedures. Guidance: 1. Transparent dressings are changed with each site rotation, or sooner if the integrity of the dressing is compromised (wet, loose or soiled)...5. Assessment of peripheral catheter site is performed: 5.1 During dressing changes...5.3 Before and after administration of intermittent infusions...5.5 Routinely for signs and symptoms of infiltration and extravagation at a frequency based on resident condition, age and type of medication and rate of flow. 6. Assessment is to include the absence or presence of, but is not limited to:...6.6 Integrity of transparent dressing...Procedure:...3. Wash hands...6. Don gloves...8. Assess site for complications...12. Vigorously cleanse around the catheter insertion site with antimicrobial solution according to the manufacturer's instructions. Allow to air dry...14. Apply transparent dressing, covering catheter insertion site and securement device, with insertion site at center of the dressing. Smooth around the catheter starting at the insertion site and moving to the periphery..." On 09/26/13 at 9:35 AM, the Corporate RN again provided the above policy, stating this policy would be used for both peripheral and central venous lines including PICC lines. An IJ was identified on 09/25/13. The Administrator, the DON, and Corporate RN (Clinical Services Director) were notified of the IJ on 09/25/13 at 5:15 PM, and a Plan of Removal was requested at that time. On 09/26/13 at 1:30 PM, a copy of the In-service dated 09/25/13 from 5:30 PM to 6:00 PM, reflected it covered the previously mentioned policies and procedures from Omnicare. During an interview on 09/27/13 at 4:45 PM, the Administrator stated he knew better than to have the issues with hand washing and breaks in the sterile field, and he was not a nurse. He stated the facility routinely covered nursing and resident care issues during their monthly QAPI (Quality Assurance and Performance Improvement) meetings. He continued to state he and the DON disseminated the information to floor/line staff via either group in-services, one-on-one in-services and memos posted at the time clock and employee break room. The Administrator stated each Performance Improvement Project identified would have approaches implemented, then evaluated and continued or re-assessed and re-implemented. An interview with the Medical Director on 09/27/13 at 3:50 PM revealed he had been informed of the IJ being called, but was unaware that there was a problem with PICC lines and the care of them. The facility's Plan of Removal was accepted on 09/28/13, and reflected the following: LVN B was suspended pending evaluation of his skills on 09/26/13, and would be reinstated to active status on 09/27/13. LVN B would be attending the IV certification class on 09/30/13 and 10/01/13. LVN B would not be allowed to administer IV medication, change IV dressings, or provide any care related to IV sites until completion of the class and IV medication administration, maintenance and dressing care competency check offs including hand washing and further re-education by the DON. Resident #3's physician was notified of the problems with infection control related to the resident's IV care on 09/25/13 at approximately 4:30 PM. No new orders were given at that time. Thirteen LVNs were identified without IV certification and would be completing one of the two IV certification classes, which were scheduled for 09/30/13 at 8:30 AM [MEDICATION NAME] for two days, and 10/03/13 at 8:30 AM [MEDICATION NAME] two days. All attendees would have their IV skills competency check offs completed by the pharmacy nurse at the conclusion of their class. The IV education would include dressing change/reinforcement with return demonstration. All Licensed/Registered Nurses and LVNs certified in IV care will have a competency evaluation completed prior to being allowed to administer IV medications. The DON, RN CC, the facility's Clinical Coordinator, and Corporate RN will observe each nurse administering IV medication at least once per week for four weeks; once every two weeks for two months; once monthly for three months; once quarterly for six months and once every six months thereafter. Observation will include: IV medication administration to include care of the IV site including infection control, and performing dressing changes without an infection control break and properly securing sterile IV dressing site. IV medication administration, maintenance and dressing care competency check offs and re-education were completed by the Corporate RN on 09/26/13 from approximately 8:30 PM to 9:00 PM, for RN CC, the facility's Clinical Coordinator, and RN Z, a Charge Nurse. On 09/25/13 at 7:30 PM, the Corporate RN supplied facility competency skills check for three of seven RNs providing IV care, including RNs D, K, and Z. On 09/26/13 at 9:35 AM, the Corporate RN provided IV training certificates including PICC and Central lines for LVNs I and J. On 09/26/13 at 9:35 AM, the Corporate RN provided a copy of the Omnicare 4.3 Peripheral Catheter Dressing Change Policy, Skills Checklist 7: Midline/CVC Dressing Change, 4.2 Peripheral Catheter Flushing, Skills Checklist: IV Medication Administration, Skills Checklist 18: Accessing and De-accessing an Implanted Port. The Corporate RN said this would be the policy and procedures used for both peripheral and central line access. On 09/26/13 at 11:00 AM, the Corporate RN provided IV training certificates including PICC and Central lines for LVN L. On 09/27/13 at 8:20 PM, a nursing skills checklist for LVN L for Peripheral Catheter Removal, Setting up a Secondary Infusion, Flushing a Vascular Access Device, Midline/Central Line Dressing Change and Inserting a Peripheral IV Catheter, all dated 05/24/10, were also received from the Corporate RN Copies of the curriculum and an IV Competency for LVN I, dated 07/11/07 (more than four years old), both from another facility were received from the Corporate RN on 09/26/13 at 1:30 PM. On 09/26/13 at 4:30 PM, the Corporate RN provided IV Training Certificates for LVNs A and M with curriculum information attached. On 09/27/13 at 2:50 PM, the Corporate RN provided IV competency skills checks, including medication administration and CVC dressing changes for RN F (three checks, but only one dated and timed for 09/27/13 at 12:15 PM), RN CC (the Clinical Coordinator) (dressing change check, dated 09/26/13, and medication administration was undated), RN Z (dressing change check dated 09/26/13, and medication administration was undated), RN AA (dressing change check dated 09/27/13, and medication administration was undated), LVN H (dressing change check dated 09/27/13 and medication administration was undated), and the facility DON (dated 09/27/13). On 09/27/13 at 8:30 PM, the Corporate RN provided IV competency skills checks, including medication administration and CVC dressing changes for LVN J (dated 09/27/13), LVN I (dressing change check dated 09/26/13 and medication administration was undated), LVN M (dated 09/27/13), RN D (dressing change check dated 09/27/13 and medication administration was undated), and RN K (dated 09/27/13). Observation of Resident #15's sterile dressing change to the PICC line site was performed by LVN H on 09/27/13 at 7:25 PM. No breaks in sterility or infection control procedures were observed. LVN H then retrieved the [MEDICATION NAME] 2 gm IV antibiotic for infusion. LVN H cleaned, aspirated for blood backflow and flushed the port/lumen without infection control breaks or IV procedural breaks. Observation on 09/27/13 at 9:30 PM, after the IVPB antibiotic had infused, revealed LVN H disconnected the empty Cefapime bag and cleaned, connected a flush syringe, aspirated for blood backflow and flushed with NS, per physician's orders [REDACTED]. LVN H then repeated the process for the [MEDICATION NAME] flush without breaks in procedure and infection control procedures. Observation of Resident #12's [MEDICATION NAME] 1 gm IVPB administration by LVN I on 09/27/13 at 8:00 PM revealed LVN I cleaned, aspirated for blood backflow and flushed the port/lumen without infection control breaks or IV procedural breaks prior to connecting the IVPB. Observation on 09/28/13 at 8:30 AM with RN F for Resident #15's Cefapime 2 mg IV antibiotic, revealed RN F cleaned, aspirated for blood backflow and flushed the port/lumen without infection control breaks or IV procedural breaks. The IJ was removed on 09/28/13 at 2:20 PM. The Administrator, the DON, and the Corporate RN (Clinical Services Director) were notified at that time the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern"and a severity level of "potential for more than minimal harm that is not immediate jeopardy," because the facility was still ensuring licensed nurses were receiving IV certification with an IV performance check-off and monitoring the Plan of Removal. 2) Observation on 09/25/13 at 8:39 AM revealed RN D did not perform any hand hygiene prior to pouring/popping out Resident #13's medications. RN D popped the pills from the blister cards into her bare hands and then transferred those pills to a plastic medication cup. 3) Observation on 09/25/13 at 2:15 PM revealed LVN E did not perform any hand hygiene prior to pouring/popping out Resident #21's medications nor did LVN E perform any hand hygiene upon entering Resident #21's room before donning gloves and administering the medications via gastrostomy tube. 4) Review of the facility's current policy and procedure titled "Manual: Nursing Manual ...Section H...Title: Hand Hygiene/Handwashing 1...Procedures: 1. Hand hygiene/hand washing is done:...After:...H. After removal of medical/surgical or utility gloves...." Review of the facility's current Infection Control policies and procedures, dated March 2006 revealed: "...Procedures...2. Standard Precautions, sometimes known as Universal Precautions A. Hand washing...2) Wash hands immediately after gloves are removed...3) May be necessary to wash hands between tasks and procedures on the same patient/resident to prevent cross-contamination of different body sites...B. Gloves...3) Change gloves between tasks and procedures on the same patient/resident...4) Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces...5) Wash hands immediately after removing gloves...." Review of CDC Guidelines for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16 revealed: "...Specific Indications for Hand Hygiene...After:...Removing gloves...." 5) The facility's Form CMS 672, Resident Census and Conditions of Residents, dated 09/26/13, revealed a census of 95 residents, and three residents who received intravenous therapy. The facility's midnight census dated 09/24/13 reflected 20 residents who resided on D Hall and 25 residents resided on Hall A A facility order report by category, dated 09/28/13 reflected 13 residents received insulin.

Based on observation, interview and record review, the facility failed to ensure the proper treatment and care for IVs was provided for four (Residents #3, #4, #12, and #15) of four residents reviewed with IV access. 1) While providing care for Resident #3's double lumen PICC line and administering IV antibiotics, LVN B failed to: --aspirate for blood to ensure patentcy of the PICC line; --secure the dressing covering the PICC line insertion site to prevent infection; --use separate syringes each time he flushed both lumens of the PICC with Normal Saline and/or [MEDICATION NAME] to prevent cross-contamination; --clamped the lumens of the PICC line after flushing them to prevent contamination; --provide a sterile dressing change for the PICC line to prevent contamination; --conduct hand hygiene after removing contaminated gloves and prior to putting on clean/sterile gloves; and --ensure he did not put Resident #3 at risk for cross-contamination and infection while providing care. The DON did not verify LVN B's IV skills prior to assigning him residents, who were receiving IV antibiotics. 2) LVN C failed to aspirate for blood from Resident #12's peripheral IV line to determine patentcy prior to administering [MEDICATION NAME] (antibiotic) on 09/25/13 and on 09/26/13, did not try to remove bubbles from a syringe before trying to check for patentcy of his peripheral IV line. 3) RN F failed to: --reinforce Resident #4's dressing over the insertion site to the resident's port-a-cath; --prevent contamination of the port to the Huber needle accessing the resident's port-a-cath; and --dispose of blood-contaminated syringes in a biohazard sharps container. 4) RN CC failed to: --clean Resident #4's port to the Huber needle before flushing; and --adequately reinforce Resident #4's dressing over the insertion site to the resident's port-a-cath leaving it unprotected from contamination and infection. 5) While providing care for Resident #15's PICC line three different times, RN F failed to: --prime the NS-filled syringe before flushing Resident #15's port/lumen to his PICC line prior to administering her antibiotic; --prime the NS-filled syringe and [MEDICATION NAME]-filled syringe before flushing following the administration of the antibiotic; --clamp the port/lumen tubing prior to removing the antibiotic infusion tubing; --clean the port/lumen after it was contaminated and had come into contact with Resident #15's skin; --aspirate for blood flow back prior to the [MEDICATION NAME] flush; and --dispose of blood-contaminated syringes in a biohazard sharps container two different times. An Immediate Jeopardy (IJ) was identified on 09/25/13 at 5:15 PM. While the IJ was removed on 09/28/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm that is not immediate jeopardy," because the facility was still ensuring licensed nurses were receiving IV certification with an IV performance check-off and monitoring the Plan of Removal. These failures could affect the four residents with PICC (Residents #1 and #3) and/or central lines (Residents #2 and #4), identified upon entry to the facility on [DATE], including Resident #3, and two residents who were admitted with a PICC line (Resident #15) and a peripheral line (Resident #12) on 09/24/13, by placing them at risk for worsening infections, increased debility due to infection and possible death from improper procedures. Findings included: 1) Resident #3's undated Face Sheet reflected the resident, an [AGE] year-old female, was admitted on [DATE]. An interim care plan (date not known) was located in Resident #3's chart addressing the antibiotics she was receiving for [MEDICAL CONDITION] of the right ankle. During an interview with LVN G on 09/24/13 at 4:00 PM, she revealed there was no care plan addressing the care of Resident #3's PICC line. Resident #3 was identified by LVN G on 09/24/13 at 10:45 AM, as having a PICC line with an insertion site on her left upper arm. The resident was receiving antibiotics through the PICC line for an infected right lower leg venous stasis ulcer. LVN G stated Resident #3 required two persons for transfers, was depressed and cried out, did not come out of her room for activities, was incontinent of bowel and bladder at times, her right leg was non-weight bearing, she wore glasses and consumed her meals in her room after staff had set the meal tray up. LVN G stated Resident #3 was currently out of the facility for an appointment at the wound care physician's office. Resident #3's admission physician's orders [REDACTED]. Resident #3's [DIAGNOSES REDACTED]. Resident #3's Physician's Telephone Order, dated 09/16/13, reflected to change the PICC line dressing every week and PRN. LVN B was observed on 09/25/13 from 7:46 AM through 8:15 AM, administering medication to Resident #3. LVN B performed hand hygiene and donned gloves. LVN B checked Resident #3's legs and feet and repositioned the oxygen tubing. LVN B removed his gloves and regloved without performing hand hygiene. LVN B activated/mixed the Ceftaroline 600 mg medication with 100 ml of NS, shaking it well. LVN B pushed back Resident #3's left sleeve exposing the PICC line site. The dressing, which was supposed to cover the PICC line site was coming off, and the PICC line insertion site was exposed. The PICC line had a length of catheter with an independent loop between the insertion site and the catheter hub anchor site. The catheter was not marked to indicate the original insertion length, making it impossible to determine if the PICC line had become dislodged with the dressing. LVN B stated at that time he would secure the dressing with an ace wrap until the dressing could be changed. LVN B connected the blue port/lumen of the double port/lumen PICC line with a 10 cc syringe of NS. LVN B unclamped the line and flushed the line without aspirating for blood backflow (obtaining a backflow of blood ensures the line was still in place and patent) and re-clamped the line. LVN B prepared the IVPB (containing the antibiotic) by spiking the bag with the tubing and then realized there was no "dial-a-flow" device (used to infuse the medication at a certain rate of speed using gravity) available. LVN B de-gloved, performed hand hygiene and left the room to gather the needed supplies. LVN B returned to Resident #3's room with a dial-a-flow. He performed hand hygiene and put on gloves. LVN B connected a 10 cc syringe of NS to the blue port/lumen of the PICC line, unclamped the line and again flushed the PICC line port/lumen with 10 cc of NS without aspirating for blood backflow first to ensure the PICC line was patent. LVN B re-clamped the PICC line tubing, connected the IVPB, unclamped the line and began the infusion. Observation on 09/25/13 at 10:00 AM with LVN B (after the IVPB antibiotic had infused), revealed Resident #3's PICC line site had not been secured with the ace bandage as the LVN had said he was going to do. LVN B performed hand hygiene and left Resident #3's room to retrieve gloves. LVN B returned to Resident #3's room and donned the gloves without performing hand hygiene. LVN B disconnected the IVPB tubing without clamping closed the blue port/lumen of the PICC line. LVN B connected the syringe and flushed the blue port/lumen (line the IVPB had infused into) with 5 cc of NS without aspirating for blood backflow prior to flushing. LVN B did not clamp the blue port/lumen line closed. LVN B then cleaned the red port/lumen with an alcohol wipe and disconnected the syringe from the blue port/lumen and, using the same syringe he had just used to flush the blue port/lumen line, connected the syringe to the red port/lumen line. LVN B flushed the red port/lumen with 5 cc of NS without aspirating for blood backflow prior to flushing. When finished, LVN B did not clamp the red port/lumen line closed. LVN B disconnected the NS flush syringe from the red port/lumen and then connected a syringe containing [MEDICATION NAME] for the [MEDICATION NAME] flush. LVN B flushed the red port/lumen with 2.5 cc of [MEDICATION NAME] without aspirating for blood backflow prior to the flush. LVN B then clamped the red port/lumen line closed. LVN B then disconnected the [MEDICATION NAME] flush syringe and, using the same syringe containing [MEDICATION NAME], connected the syringe to the blue port/lumen line. Without aspirating for blood backflow, LVN B flushed the blue port/lumen with 2.5 cc of [MEDICATION NAME]. LVN B clamped the blue port/lumen line closed. LVN B wiped the overbed table with a Sani-cloth wipe and then opened the sterile Central Venous Catheter (CVC) dressing change kit, placing it on Resident #3's overbed table. LVN B applied a face mask and applied sterile gloves. LVN B set up the sterile work field utilizing the drape in the kit. LVN B continued the set up by placing the [MEDICATION NAME] swab, alcohol wipe and transparent dressing onto the sterile drape. LVN B stated he forgot something, reached over Resident #3 and pressed the call light button located on the wall at 10:15 AM. At 10:20 AM, LVN B left Resident #3's room, leaving the sterile set-up on the overbed table uncovered and unattended, thereby breaking sterility. LVN B returned with another unopened CVC dressing change kit and applied non-sterile gloves after performing hand hygiene. LVN B did not reapply a face mask. LVN B removed the previous PICC line dressing from Resident #3's left upper arm. LVN B removed the non-sterile gloves. LVN B did not perform any hand hygiene. LVN B picked up the (new) sterile CVC dressing change kit, opened it and took out the sterile gloves. LVN B threw the rest of the just-opened CVC sterile dressing change kit onto the floor. LVN B donned the sterile gloves, without performing any hand hygiene. LVN B picked up the Chloroprep wipe from the previously set-up sterile field and began to wipe the peri-wound of the PICC site, without cleaning the actual insertion site of the PICC line. LVN B then applied a transparent dressing over the PICC line insertion site and the independent loop in the catheter. When asked by the surveyor, LVN B measured the independent loop, which had a length of 14 cm from insertion site to catheter hub. LVN B, while wearing his soiled/contaminated gloves, gathered the contaminated supplies, including those thrown to the floor, lowered the bed, positioned the overbed table in a lower position, picked up the container of Sani-cloths, offered Resident #3 the water pitcher (picked the pitcher up), gave Resident #3 a pen and piece of paper, repositioned a second overbed table, repositioned the linens at the foot of the bed, pulled the covers back to feel Resident #3's upper, inner thighs (resident had complained of leg pain), left the room and disposed of the bag of soiled/used items in the container located in the hallway. LVN B then removed the now-contaminated sterile gloves worn during the sterile dressing change. LVN B did not perform any hand hygiene after removing the soiled gloves. Interview with LVN B on 09/25/13 at 10:30 AM, revealed he had not received any IV training nor had a competency skills checks conducted since he began his employment at the facility in early August 2013. LVN B stated he had had previous IV training, just not at this facility. An interview with the DON on 09/25/13 at 3:00 PM, revealed when asked regarding LVN B's IV training and competency, a nurse was out on maternity leave and LVN B, when asked, told her (the DON) he had IV experience. When asked by the surveyor about his IV certification, the DON stated she had not required LVN B to bring a copy of his IV training certificate, which would have included peripheral, PICC and CVC line training. The DON further stated she and facility nursing administrative staff had not conducted any IV competency skills checks prior to assigning LVN B to provide care for residents with an IV, administer IV medications, provide site care and/or dressing changes. She continued to state no competency skills check had been completed for LVN B until today (09/25/13), after the surveyor informed her of the issues she (the surveyor) had observed. The DON then said she should have conducted a skills check for LVN B's IV skills (before assigning him to a hall with residents who had IVs). On 09/25/13 at 3:00 PM, when the surveyor requested certification of LVN B's IV training, the Corporate RN was unable to provide evidence of the LVN's certification. The Corporate RN stated LVN B did not have an IV training certificate on file with the facility, that he was going home to retrieve a copy for the facility. On 09/25/13 at 4:00 PM, the Corporate RN provided copies of IV training certification for LVN B, with copies of a Peripheral Vascular Competency, dated 12/06/12, and a Central Vascular Competency, dated 12/07/12, both performed at another facility. 2) The Face Sheet, dated 09/25/13, reflected Resident #12, a [AGE] year-old male, was admitted to the facility on [DATE] at 6:00 PM. Resident #12 had two care plans, dated 09/24/13, for receiving IV and oral antibiotic therapy and having an IV saline lock. The care plan included the following approaches: to observe the access site every shift and monitor for patency; flush as per ordered; monitor the IV site for signs and symptoms of infiltration or infection; follow regimen when caring for IV site and flush per protocol; monitor for complications from IV including localized infection, systemic infection, air [MEDICATION NAME], dislodgement, infiltration, extravasation (blood into the surrounding tissue) and phlebitis (inflammation); and to monitor the IV site for swelling, redness, tenderness and warmth. Resident #12's care plan, dated 09/24/13, revealed he was receiving IV and oral antibiotics for Staphylococcus epidermdis bacteremia. Taber's Cyclopeidc Medical Dictionary, Edition 21, Copyright 2005, page 2194 reflected Staphylococcus epidermdis is a coagulase-negative species that is part of the normal flora of the skin. It may colonize, form biofilms on, and infect indwelling catheters. Retrieved on 10/09/13 from htt-p://emedicine.medscape.com/article/ 6-overview revealed the incidence of infections due to Staphylococcus epidermdis has been steadily increasing in recent years. Resident #12's admission physician's orders [REDACTED]. Resident #12's admission physician's orders [REDACTED]. An observation on 09/25/13 at 2:10 PM, revealed LVN C was administering Resident #12's [MEDICATION NAME] via a peripheral IV (saline lock) located on the right hand. LVN C flushed the saline lock line with 5 cc of NS prior to connecting and infusing the [MEDICATION NAME]. LVN C did not aspirate the saline lock for blood return prior to flushing with NS (to ensure patency). An observation on 09/26/13 at 1:15 PM, revealed LVN C was about to administer Resident #12's [MEDICATION NAME]. LVN C did not prime (remove the air bubbles) from the NS-filled syringe before connecting it to the peripheral saline lock. LVN C was not able to aspirate any blood backflow. LVN C began talking to RN CC (the facility's Clinical Coordinator), who was in the resident's room, about what to do since she could not get any blood backflow. Resident #12 was looking between LVN C and RN CC with a curious look, but no explanation was given to the resident. RN CC left the room and retrieved another NS-filled syringe, and LVN C again connected the syringe without priming it first. 3) During an interview with the DON on 09/25/13 at 3:00 PM, she was queried what her expectations were for nursing staff when flushing IV lines. The DON responded she expected the nurses to aspirate for blood return prior to flushing the site (to determine patency). When queried about the procedure she expected nursing staff to use when changing the dressing on the PICC line insertion site, she stated she expected the nurses to use aseptic or sterile technique without breaks in sterility. She added dressing changes were scheduled weekly (for PICC lines) but should be done as needed when coming loose and/or were soiled. 4) On 09/25/13 at 3:00 PM, following a request from the surveyor for proof of the facility's LVNs' IV training, the Corporate RN provided a IV training certificate for LVN C. 5) Review of the facility's current Infection Control Policies and Procedures dated, March 2006, revealed: "...Procedures ...2. Standard Precautions, sometimes known as Universal Precautions A. Hand washing ...2) Wash hands immediately after gloves are removed... 3) May be necessary to wash hands between tasks and procedures on the same patient/resident to prevent cross-contamination of different body sites... B. Gloves ...3) Change gloves between tasks and procedures on the same patient/resident... 4) Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces... 5) Wash hands immediately after removing gloves...." 6) On 09/25/13 at 10:40 AM, the surveyor requested from the Corporate RN the facility's current policies and procedures covering IVs, sterile dressing changes, IV training certificates and facility competency skills checks for all LVNs. 7. An interview on 09/25/13 at 12:25 PM with RN CC, the facility's Clinical Coordinator, revealed that she was a resource for nursing staff for any clinical issues. On 09/25/13 at 1:40 PM, the Corporate RN provided a (blank) competency for IV Medication Administration and Care of Central Venous Catheters (External). The specific policy for flushing IV sites was requested from the Corporate RN at that time. The Corporate RN stated the facility used Perry and Potter as a reference for any issues for which they did not have a current policy and procedure. On 09/25/13 at 3:25 PM, the Corporate RN provided a procedure from Perry and Potter, Clinical Nursing Skills and Techniques, 8th Edition, February 2, 2013, for an IV push, which would be the same procedure used for an IV flush. It reflected the following: "Skill 22-5 Administering Medications by Intravenous [MEDICATION NAME] 9 IV push (IV lock):...a Prepare flush solutions according to agency policy...b Administer medication:...(3) Pull back gently on syringe plunger and check for blood return..." On 09/25/13 at 4:00 PM, the Corporate RN provided a policy, provided by Omnicare for "4.3 Peripheral Catheter Dressing Change...Revision Dates October 1, 2005; March 19, 2007; August 15, 2008; July 1, 2012...Original Date: January 15, 2004...To Be Performed By:...The nurse shall be competent in the safe delivery of infusion therapy within her or his scope of practice...Considerations: 1. The peripheral catheter insertion site is a potential entry site for bacteria that could produce a catheter-related infection...3. Licensed nurses caring for residents receiving infusion therapies are expected to follow infection control and safety compliance procedures. Guidance: 1. Transparent dressings are changed with each site rotation, or sooner if the integrity of the dressing is compromised (wet, loose or soiled)...5. Assessment of peripheral catheter site is performed: 5.1 During dressing changes...5.3 Before and after administration of intermittent infusions...5.5 Routinely for signs and symptoms of infiltration and extravagation at a frequency based on resident condition, age and type of medication and rate of flow. 6. Assessment is to include the absence or presence of, but is not limited to:...6.6 Integrity of transparent dressing...Procedure:...3. Wash hands...6. Don gloves...8. Assess site for complications...12. Vigorously cleanse around the catheter insertion site with antimicrobial solution according to the manufacturer's instructions. Allow to air dry...14. Apply transparent dressing, covering catheter insertion site and securement device, with insertion site at center of the dressing. Smooth around the catheter starting at the insertion site and moving to the periphery..." On 09/26/13 at 9:35 AM, the Corporate RN again provided the above policy, stating this policy would be used for both peripheral and central venous lines including PICC lines. 8) An IJ was identified on 09/25/13. The Administrator, the DON, and Corporate RN (Clinical Services Director) were notified of the IJ on 09/25/13 at 5:15 PM, and a Plan of Removal was requested at that time. 9) On 09/26/13 at 1:30 PM, a copy of the In-service dated 09/25/13 from 5:30 PM to 6:00 PM, reflected it covered the previously mentioned policies and procedures from Omnicare. 10) Resident #4's undated Face Sheet reflected the resident, an [AGE] year-old male, was admitted on [DATE]. Resident #4's care plans, dated 09/19/13, reflected they addressed his receiving IV antibiotic therapy for a urinary tract infection [MEDICAL CONDITION] and was receiving [MEDICATION NAME] 3.375 gm IV every 8 hours for 7 days. Approaches included: observe access site and monitor for patency; flush as per orders; and monitor site for signs and symptoms of infiltration or infection. An additional care plan, dated 09/25/13, reflected Resident #4 required IV medication and had a Port-a-Cath with approaches including: follow regimen when caring for IV site and flush per protocol; monitor for complication from IV (localized infection, systemic infection, air [MEDICATION NAME], dislodgement, infiltration, extravasation, phlebitis and monitor IV site for swelling, redness, tenderness and warmth. During an interview on 09/24/13 at 11:02 AM, LVN G stated Resident #4 had a Port-a-Cath (Central Line) in his right chest wall and received IV antibiotics through the port for a UTI. She stated Resident #4 needed extensive assistance for all ADLs, did not attend activities out of his room, received bedside blood glucose testing and insulin, was hard of hearing and wore glasses, had an indwelling Foley catheter, received therapy services and ate all his meals in his room. Resident #4's admission physician's orders [REDACTED]. [DIAGNOSES REDACTED]. An observation was made on 09/26/13 at 2:15 PM, for Resident #4's [MEDICATION NAME] IV antibiotic with RN F. The sterile transparent dressing, which was supposed to cover the insertion site of the Huber needle (a needle that is bent at a 90-degree angle), into Resident #4's Port-a-Cath, was not completely adhered to the skin and was not providing a sterile, occlusive barrier. The dressing had not been pinched around needle/tubing accessing the Port-a-cath and left a finger-sized gap/tunnel from the open edge of the dressing through to the needle insertion site. RN F did not secure the transparent dressing. RN F cleaned the port and while priming the NS-filled syringe, touched the tip of the port with her unsterile gloves. RN F did not reclean the port prior to connecting the NS-filled syringe. Once she finished starting the IV antibiotic, RN F threw the contaminated syringes, which contained NS and blood obtained during aspiration, into Resident #4's trash can instead of a biohazard sharps container. An observation of RN CC, the facility's Clinical Coordinator, on 09/26/13 at 3:05 PM in Resident #4's room, after the IVPB antibiotic had infused, revealed she clamped the IV infusion tubing, primed a NS-filled syringe, disconnected the IV tubing, connected the NS-filled syringe and flushed the port/line with 5 cc of NS. RN CC clamped the port/line and disconnected the NS syringe. She then connected the [MEDICATION NAME]-filled syringe, released the clamp on the port/line and flushed with the [MEDICATION NAME]. RN CC did not clean the port prior to flushing the port/line with the NS or [MEDICATION NAME] or aspirate for blood backflow to ensure patency before flushing. RN CC stated she would get some tape and secure the transparent dressing. An observation by the surveyor on 09/26/13 at 4:35 PM of Resident #4's transparent dressing, revealed additional tape had been applied to the dressing, but the dressing was still not completely adhered to the skin to form an impermeable barrier against possible cross-contamination and possible infection. The surveyor requested the DON to view the site and upon observing Resident #4's Port-a-Cath site on 09/26/13 at 4:45 PM, she stated it was a hard angle to get it done right, but it needed to be done. She stated she would figure it out and get it taken care of. 11) Resident #15's admission physician's orders [REDACTED]. Resident #15, a [AGE] year-old female, had the following [DIAGNOSES REDACTED]. On 09/26/13 at 1:00 PM, while the surveyor was waiting to observe IV medication administration, Resident #15 revealed to the surveyor, she had issues with [MEDICAL CONDITION] Reflux Disease (GERD), which had resulted in surgery. The wound would not heal and had gotten infected. She stated she had actually eaten her meal that day, which was unusual for her since surgery. She added she was able to do most ADLs for herself when she was not "hooked up" to the IV. Resident #15's admission physician's orders [REDACTED]. Resident #15's Physician's Telephone Order, dated 09/25/13, reflected a clarification order to flush the PICC line with 5 cc of NS before medication and after medication, followed by 5 cc of [MEDICATION NAME] 10 units/ml and to change the dressing for the PICC line site every week and PRN. An observation on 09/26/13 at 1:00 PM, revealed RN F was administering Resident #15's IV antibiotic, [MEDICATION NAME] 2 mg. RN F exposed Resident #15's right upper, inner arm at the PICC line site. The dressing covering the site was dated 09/17/13 (nine days since it was changed). RN F released the clamp on the port/lumen, cleaned the port/lumen with alcohol wipes and connected the NS flush-filled syringe without first priming the syringe. RN F threw the contaminated syringes into Resident #15's trash can as they were used, instead of disposing of them in the biohazard sharps container. An observation on 09/26/13 at 1:43 PM, revealed RN F was flushing Resident #15's PICC line after the IV antibiotic infusion. RN F did not prime the NS-filled syringe before connecting it to the PICC line port/lumen and flushing the port/lumen. RN F did not prime the [MEDICATION NAME]-filled syringe before connecting it to the PICC line port/lumen and flushing the port/lumen. Again, RN F threw the contaminated syringes into Resident #15's trash can as they were used, instead of disposing of them in the biohazard sharps container. Observation on 09/28/13 at 9:40 AM revealed RN F disconnected Resident #15's IV antibiotic Cefapime 2 mg infusion tubing without first clamping the PICC line port/lumen. RN F then cleaned the port/lumen, aspirated for blood backflow and flushed the port/lumen with NS. RN F left the port/lumen laying on Resident #15's right arm while she retrieved the syringe of [MEDICATION NAME]. RN F attached the syringe of [MEDICATION NAME], released the clamp on the port/lumen and flushed the port/lumen with the [MEDICATION NAME]. RN F did not wipe/clean the port/lumen with an alcohol wipe prior to attaching the [MEDICATION NAME]-filled syringe. RN F did not aspirate for blood backflow before flushing with the [MEDICATION NAME]. 12) During an interview on 09/27/13 at 4:45 PM, the Administrator stated he knew better than to have the issues with hand washing and breaks in the sterile field, and he was not a nurse. He stated the facility routinely covered nursing and resident care issues during their monthly QAPI (Quality Assurance and Performance Improvement) meetings. He continued to state he and the DON disseminated the information to floor/line staff via either group in-services, one-on-one in-services and memos posted at the time clock and employee break room. The Administrator stated each Performance Improvement Project identified would have approaches implemented, then evaluated and continued or re-assessed and re-implemented. 13) An interview with the Medical Director on 09/27/13 at 3:50 PM revealed he had been informed of the IJ being called, but was unaware that there was a problem with PICC lines and the care of them. 14) The facility's Plan of Removal was accepted on 09/28/13, and reflected the following: LVN B was suspended pending evaluation of his skills on 09/26/13, and would be reinstated to active status on 09/27/13. LVN C would receive disciplinary action in regard to her performance failures. Both nurses would be attending the IV certification class on 09/30/13 and 10/01/13. They would not be allowed to administer IV medication, change IV dressings, or provide any care related to IV sites until completion of the class and IV medication administration, maintenance and dressing care competency check offs including hand washing and further re-education by the DON. All residents with IVs, including Residents #3 and #12, were assessed by RN CC (the facility's Clinical Coordinator) and the DON on 09/25/13, and no problems were identified. Resident #3's physician was notified of the problems with infection control related to the resident's IV care on 09/25/13 at approximately 4:30 PM. No new orders were given at that time. Resident #12's physician, who was also the facility's Medical Director, was informed of the problems related to the resident's IV care and the IJ on 09/26/13 at approximately 8:58 AM. Thirteen LVNs were identified without IV certification and would be completing one of the two IV certification classes, which were scheduled for 09/30/13 at 8:30 AM [MEDICATION NAME] for two days, and 10/03/13 at 8:30 AM [MEDICATION NAME] two days. All attendees would have their IV skills competency check offs completed by the pharmacy nurse at the conclusion of their class. The IV education would include assessing patency, flushing of the line using a 10 cc syringe before and after IV medication administration and dressing change/reinforcement with return demonstration. Newly-hired licensed nurses would be requested to provide documentation of IV certification before conclusion of their four-day orientation period. If unable to provide IV certification, the licensed nurse will be prohibited from administering IV medications/providing care for residents with IVs until IV certification class was completed and IV skills/infection control competency was completed. This would be required within 30 days of their start date at the facility. The DON, RN CC (the facility's Clinical Coordinator) or RN designee would conduct competency evaluations for newly-hired nurses during the orientation period once IV certification was received. All Licensed/Registered Nurses and LVNs certified in IV care will have a competency evaluation completed prior to being allowed to administer IV medications. The DON, RN CC (the facility's Clinical Coordinator) and Corporate RN will observe each nurse administering IV medication at least once per week for four weeks; once every two weeks for two mon

Based on observation, interview and record review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest physical well-being of each resident for four (Residents #3, #4, #12, and #15) of four residents reviewed with IV access. The DON failed to check the RNs and LVNs competency to care for residents with IV access. An Immediate Jeopardy (IJ) was identified on 09/25/13 at 5:15 PM. While the IJ was removed on 09/28/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm that is not immediate jeopardy," because the facility was still ensuring licensed nurses were receiving IV certification with an IV performance check-off and monitoring the Plan of Removal. These failures could affect Residents #3, #4, #12, and #15, the residents identified with IV access, by placing them at risk for worsening infections, increased debility due to infection and possible death from improper procedures. Findings included: 1) Resident #3's undated Face Sheet reflected the resident, an [AGE] year-old female, was admitted on [DATE]. Resident #3's admission physician's orders [REDACTED]. Resident #3's [DIAGNOSES REDACTED]. Resident #3's Physician's Telephone Order, dated 09/16/13, reflected to change the PICC line dressing every week and PRN. LVN B was observed on 09/25/13 from 7:46 AM through 8:15 AM, administering medication to Resident #3. LVN B performed hand hygiene and donned gloves. LVN B checked Resident #3's legs and feet and repositioned the oxygen tubing. LVN B removed his gloves and regloved without performing hand hygiene. LVN B activated/mixed the Ceftaroline 600 mg medication with 100 ml of NS, shaking it well. LVN B pushed back Resident #3's left sleeve exposing the PICC line site. The dressing, which was supposed to cover the PICC line site was coming off, and the PICC line insertion site was exposed. The PICC line had a length of catheter with an independent loop between the insertion site and the catheter hub anchor site. The catheter was not marked to indicate the original insertion length, making it impossible to determine if the PICC line had become dislodged with the dressing. LVN B stated at that time he would secure the dressing with an ace wrap until the dressing could be changed. LVN B connected the blue port/lumen of the double port/lumen PICC line with a 10 cc syringe of NS. LVN B unclamped the line and flushed the line without aspirating for blood backflow (obtaining a backflow of blood ensures the line was still in place and patent) and re-clamped the line. LVN B prepared the IVPB (containing the antibiotic) by spiking the bag with the tubing and then realized there was no "dial-a-flow" device (used to infuse the medication at a certain rate of speed using gravity) available. LVN B de-gloved, performed hand hygiene and left the room to gather the needed supplies. LVN B returned to Resident #3's room with a dial-a-flow. He performed hand hygiene and put on gloves. LVN B connected a 10 cc syringe of NS to the blue port/lumen of the PICC line, unclamped the line and again flushed the PICC line port/lumen with 10 cc of NS without aspirating for blood backflow first to ensure the PICC line was patent. LVN B re-clamped the PICC line tubing, connected the IVPB, unclamped the line and began the infusion. Observation on 09/25/13 at 10:00 AM with LVN B, after the IVPB antibiotic had infused, revealed Resident #3's PICC line site had not been secured with the ace bandage as the LVN had said he was going to do. LVN B performed hand hygiene and left Resident #3's room to retrieve gloves. LVN B returned to Resident #3's room and donned the gloves without performing hand hygiene. LVN B disconnected the IVPB tubing without clamping closed the blue port/lumen of the PICC line. LVN B connected the syringe and flushed the blue port/lumen (line the IVPB had infused into) with 5 cc of NS without aspirating for blood backflow prior to flushing. LVN B did not clamp the blue port/lumen line closed. LVN B then cleaned the red port/lumen with an alcohol wipe and disconnected the syringe from the blue port/lumen and, using the same syringe he had just used to flush the blue port/lumen line, connected the syringe to the red port/lumen line. LVN B flushed the red port/lumen with 5 cc of NS without aspirating for blood backflow prior to flushing. When finished, LVN B did not clamp the red port/lumen line closed. LVN B disconnected the NS flush syringe from the red port/lumen and then connected a syringe containing [MEDICATION NAME] for the [MEDICATION NAME] flush. LVN B flushed the red port/lumen with 2.5 cc of [MEDICATION NAME] without aspirating for blood backflow prior to the flush. LVN B then clamped the red port/lumen line closed. LVN B then disconnected the [MEDICATION NAME] flush syringe and, using the same syringe containing [MEDICATION NAME], connected the syringe to the blue port/lumen line. Without aspirating for blood backflow, LVN B flushed the blue port/lumen with 2.5 cc of [MEDICATION NAME]. LVN B clamped the blue port/lumen line closed. LVN B wiped the overbed table with a Sani-cloth wipe and then opened the sterile Central Venous Catheter (CVC) dressing change kit, placing it on Resident #3's overbed table. LVN B applied a face mask and applied sterile gloves. LVN B set up the sterile work field utilizing the drape in the kit. LVN B continued the set up by placing the [MEDICATION NAME] swab, alcohol wipe and transparent dressing onto the sterile drape. LVN B stated he forgot something, reached over Resident #3 and pressed the call light button located on the wall at 10:15 AM. At 10:20 AM, LVN B left Resident #3's room, leaving the sterile set-up on the overbed table uncovered and unattended, thereby breaking sterility. LVN B returned with another unopened CVC dressing change kit and applied non-sterile gloves after performing hand hygiene. LVN B did not reapply a face mask. LVN B removed the previous PICC line dressing from Resident #3's left upper arm. LVN B removed the non-sterile gloves. LVN B did not perform any hand hygiene. LVN B picked up the (new) sterile CVC dressing change kit, opened it and took out the sterile gloves. LVN B threw the rest of the just-opened CVC sterile dressing change kit onto the floor. LVN B donned the sterile gloves, without performing any hand hygiene. LVN B picked up the Chloroprep wipe from the previously set-up sterile field and began to wipe the peri-wound of the PICC site, without cleaning the actual insertion site of the PICC line. LVN B then applied a transparent dressing over the PICC line insertion site and the independent loop in the catheter. When asked by the surveyor, LVN B measured the independent loop, which had a length of 14 cm from insertion site to catheter hub. LVN B, while wearing his soiled/contaminated gloves, gathered the contaminated supplies, including those thrown to the floor, lowered the bed, positioned the overbed table in a lower position, picked up the container of Sani-cloths, offered Resident #3 the water pitcher (picked the pitcher up), gave Resident #3 a pen and piece of paper, repositioned a second overbed table, repositioned the linens at the foot of the bed, pulled the covers back to feel Resident #3's upper, inner thighs (resident had complained of leg pain), left the room and disposed of the bag of soiled/used items in the container located in the hallway. LVN B then removed the now-contaminated sterile gloves worn during the sterile dressing change. LVN B did not perform any hand hygiene after removing the soiled gloves. Interview with LVN B on 09/25/13 at 10:30 AM, revealed he had not received any IV training nor had a competency skills checks conducted since he began his employment at the facility in early August 2013. LVN B stated he had had previous IV training, just not at this facility. An interview with the DON on 09/25/13 at 3:00 PM, revealed when asked regarding LVN B's IV training and competency, a nurse was out on maternity leave and LVN B, when asked, told her (the DON) he had IV experience. When asked by the surveyor about his IV certification, the DON stated she had not required LVN B to bring a copy of his IV training certificate, which would have included peripheral, PICC and CVC line training. The DON further stated she and facility nursing administrative staff had not conducted any IV competency skills checks prior to assigning LVN B to provide care for residents with an IV, administer IV medications, provide site care and/or dressing changes. She continued to state no competency skills check had been completed for LVN B until today (09/25/13), after the surveyor informed her of the issues she (the surveyor) had observed. The DON then said she should have conducted a skills check for LVN B's IV skills (before assigning him to a hall with residents who had IVs). On 09/25/13 at 3:00 PM, when the surveyor requested certification of LVN B's IV training, the Corporate RN was unable to provide evidence of the LVN's certification. The Corporate RN stated LVN B did not have an IV training certificate on file with the facility, that he was going home to retrieve a copy for the facility. On 09/25/13 at 4:00 PM, the Corporate RN provided copies of IV training certification for LVN B, with copies of a Peripheral Vascular Competency, dated 12/06/12, and a Central Vascular Competency, dated 12/07/12, both performed at another facility. 2) The Face Sheet, dated 09/25/13, reflected Resident #12, a [AGE] year-old male, was admitted to the facility on [DATE] at 6:00 PM. Resident #12's admission physician's orders [REDACTED]. Resident #12's admission physician's orders [REDACTED]. An observation on 09/25/13 at 2:10 PM, revealed LVN C was administering Resident #12's [MEDICATION NAME] via a peripheral IV (saline lock) located on the right hand. LVN C flushed the saline lock line with 5 cc of NS prior to connecting and infusing the [MEDICATION NAME]. LVN C did not aspirate the saline lock for blood return prior to flushing with NS (to ensure patency). An observation on 09/26/13 at 1:15 PM, revealed LVN C was about to administer Resident #12's [MEDICATION NAME]. LVN C did not prime (remove the air bubbles) from the NS-filled syringe before connecting it to the peripheral saline lock. LVN C was not able to aspirate any blood backflow. LVN C began talking to RN CC (the facility's Clinical Coordinator), who was in the resident's room, about what to do since she could not get any blood backflow. Resident #12 was looking between LVN C and RN CC with a curious look, but no explanation was given to the resident. RN CC left the room and retrieved another NS-filled syringe, and LVN C again connected the syringe without priming it first. LVN C was still unable to obtain any blood backflow. 3) During an interview with the DON on 09/25/13 at 3:00 PM, she was queried what her expectations were for nursing staff when flushing IV lines. The DON responded she expected the nurses to aspirate for blood return prior to flushing the site (to determine patency). When queried about the procedure she expected nursing staff to use when changing the dressing on the PICC line insertion site, she stated she expected the nurses to use aseptic or sterile technique without breaks in sterility. She added dressing changes were scheduled weekly (for PICC lines) but should be done as needed when coming loose and/or were soiled. 4) On 09/25/13 at 3:00 PM, following a request from the surveyor for proof of the facility's LVNs' IV training, the Corporate RN provided a IV training certificate for LVN C. 5) An IJ was identified on 09/25/13. The Administrator, the DON, and Corporate RN (Clinical Services Director) were notified of the IJ on 09/25/13 at 5:15 PM, and a Plan of Removal was requested at that time. 6) Resident #4's undated Face Sheet reflected the resident, an [AGE] year-old male, was admitted on [DATE]. During an interview on 09/24/13 at 11:02 AM, LVN G stated Resident #4 had a Port-a-Cath (Central Line) in his right chest wall and received IV antibiotics through the port for a UTI. Resident #4's admission physician's orders [REDACTED]. An observation was made on 09/26/13 at 2:15 PM, for Resident #4's [MEDICATION NAME] IV antibiotic with RN F. The sterile transparent dressing, which was supposed to cover the insertion site of the Huber needle (a needle that is bent at a 90-degree angle), into Resident #4's Port-a-Cath, was not completely adhered to the skin and was not providing a sterile, occlusive barrier. The dressing had not been pinched around needle/tubing accessing the Port-a-cath and left a finger-sized gap/tunnel from the open edge of the dressing through to the needle insertion site. RN F did not secure the transparent dressing. RN F cleaned the port and while priming the NS-filled syringe, touched the tip of the port with her unsterile gloves. RN F did not reclean the port prior to connecting the NS-filled syringe. Once she finished starting the IV antibiotic, RN F threw the contaminated syringes, which contained NS and blood obtained during aspiration, into Resident #4's trash can instead of a biohazard sharps container. An observation of RN CC, the facility's Clinical Coordinator, on 09/26/13 at 3:05 PM in Resident #4's room, after the IVPB antibiotic had infused, revealed she clamped the IV infusion tubing, primed a NS-filled syringe, disconnected the IV tubing, connected the NS-filled syringe and flushed the port/line with 5 cc of NS. RN CC clamped the port/line and disconnected the NS syringe. She then connected the [MEDICATION NAME]-filled syringe, released the clamp on the port/line and flushed with the [MEDICATION NAME]. RN CC did not clean the port prior to flushing the port/line with the NS or [MEDICATION NAME] or aspirate for blood backflow to ensure patency before flushing. RN CC stated she would get some tape and secure the transparent dressing. An observation by the surveyor on 09/26/13 at 4:35 PM of Resident #4's transparent dressing, revealed additional tape had been applied to the dressing, but the dressing was still not completely adhered to the skin to form an impermeable barrier against possible cross-contamination and possible infection. The surveyor requested the DON to view the site and upon observing Resident #4's Port-a-Cath site on 09/26/13 at 4:45 PM, she stated it was a hard angle to get it done right, but it needed to be done. She stated she would figure it out and get it taken care of. 7) Resident #15's admission physician's orders [REDACTED]. Resident #15, a [AGE] year-old female, had the following [DIAGNOSES REDACTED]. Resident #15's admission physician's orders [REDACTED]. Resident #15's Physician's Telephone Order, dated 09/25/13, reflected a clarification order to flush the PICC line with 5 cc of NS before medication and after medication, followed by 5 cc of [MEDICATION NAME] 10 units/ml and to change the dressing for the PICC line site every week and PRN. An observation on 09/26/13 at 1:00 PM, revealed RN F was administering Resident #15's IV antibiotic, [MEDICATION NAME] 2 mg. RN F exposed Resident #15's right upper, inner arm at the PICC line site. The dressing covering the site was dated 09/17/13 (nine days since it was changed). RN F released the clamp on the port/lumen, cleaned the port/lumen with alcohol wipes and connected the NS flush-filled syringe without first priming the syringe. RN F threw the contaminated syringes into Resident #15's trash can as they were used, instead of disposing of them in the biohazard sharps container. An observation on 09/26/13 at 1:43 PM, revealed RN F was flushing Resident #15's PICC line after the IV antibiotic infusion. RN F did not prime the NS-filled syringe before connecting it to the PICC line port/lumen and flushing the port/lumen. RN F did not prime the [MEDICATION NAME]-filled syringe before connecting it to the PICC line port/lumen and flushing the port/lumen. Again, RN F threw the contaminated syringes into Resident #15's trash can as they were used, instead of disposing of them in the biohazard sharps container. Observation on 09/28/13 at 9:40 AM revealed RN F disconnected Resident #15's IV antibiotic Cefapime 2 mg infusion tubing without first clamping the PICC line port/lumen. RN F then cleaned the port/lumen, aspirated for blood backflow and flushed the port/lumen with NS. RN F left the port/lumen laying on Resident #15's right arm while she retrieved the syringe of [MEDICATION NAME]. RN F attached the syringe of [MEDICATION NAME], released the clamp on the port/lumen and flushed the port/lumen with the [MEDICATION NAME]. RN F did not wipe/clean the port/lumen with an alcohol wipe prior to attaching the [MEDICATION NAME]-filled syringe. RN F did not aspirate for blood backflow before flushing with the [MEDICATION NAME]. 8) During an interview on 09/27/13 at 4:45 PM, the Administrator stated he knew better than to have the issues with hand washing and breaks in the sterile field, and he was not a nurse. He stated the facility routinely covered nursing and resident care issues during their monthly QAPI (Quality Assurance and Performance Improvement) meetings. He continued to state he and the DON disseminated the information to floor/line staff via either group in-services, one-on-one in-services and memos posted at the time clock and employee break room. The Administrator stated each Performance Improvement Project identified would have approaches implemented, then evaluated and continued or re-assessed and re-implemeted. 9) An interview with the Medical Director on 09/27/13 at 3:50 PM revealed he had been informed of the IJ being called, but was unaware that there was a problem with PICC lines and the care of them. 10) The facility's Plan of Removal was accepted on 09/28/13, and reflected the following: LVN B was suspended pending evaluation of his skills on 09/26/13, and would be reinstated to active status on 09/27/13. LVN C would receive disciplinary action in regard to her performance failures. Both nurses would be attending the IV certification class on 09/30/13 and 10/01/13. They would not be allowed to administer IV medication, change IV dressings, or provide any care related to IV sites until completion of the class and IV medication administration, maintenance and dressing care competency check offs including hand washing and further re-education by the DON. All residents with IVs, including Residents #3 and #12, were assessed by RN CC (the facility's Clinical Coordinator) and the DON on 09/25/13, and no problems were identified. Resident #3's physician was notified of the problems with infection control related to the resident's IV care on 09/25/13 at approximately 4:30 PM. No new orders were given at that time. Resident #12's physician, who was also the facility's Medical Director, was informed of the problems related to the resident's IV care and the IJ on 09/26/13 at approximately 8:58 AM. Thirteen LVNs were identified without IV certification and would be completing one of the two IV certification classes, which were scheduled for 09/30/13 at 8:30 AM [MEDICATION NAME] for two days, and 10/03/13 at 8:30 AM [MEDICATION NAME] two days. All attendees would have their IV skills competency check offs completed by the pharmacy nurse at the conclusion of their class. The IV education would include assessing patency, flushing of the line using a 10 cc syringe before and after IV medication administration and dressing change/reinforcement with return demonstration. Newly-hired licensed nurses would be requested to provide documentation of IV certification before conclusion of their four-day orientation period. If unable to provide IV certification, the licensed nurse will be prohibited from administering IV medications/providing care for residents with IVs until IV certification class was completed and IV skills/infection control competency was completed. This would be required within 30 days of their start date at the facility. The DON, RN CC (the facility's Clinical Coordinator) or RN designee would conduct competency evaluations for newly-hired nurses during the orientation period once IV certification was received. All Licensed/Registered Nurses and LVNs certified in IV care will have a competency evaluation completed prior to being allowed to administer IV medications. The DON, RN CC (the facility's Clinical Coordinator) and Corporate RN will observe each nurse administering IV medication at least once per week for four weeks; once every two weeks for two months; once monthly for three months; once quarterly for six months and once every six months thereafter. Observation will include: IV medication administration to include care of the IV site including infection control, assessing patency, priming syringe and tubing, cleaning port, flushing before and after medication administration with a 10 cc syringe and performing dressing changes without an infection control break and properly securing sterile IV dressing site. All identified deficient practices will be corrected immediately and reported to the Administrator as part of the Quality Assurance Performance Improvement process. Results will be reported to the facility's Medical Director and actions approved during the monthly QAPI meetings. Additional in-service meetings will be held as needed to address deficient practices or concerns. IV medication administration, maintenance and dressing care competency check offs and re-education were completed by the Corporate RN on 09/26/13 from approximately 8:30 PM to 9:00 PM, for RN CC (the facility's Clinical Coordinator) and RN Z, a Charge Nurse. 11) The facility's list of employees, supplied on entry on 09/24/13, and identified as current, included the following licensed nurses: LVNs A, B, C, E, G, H, I, J, L, M, N, O, P, Q, R, S, T, U, V, W, X, and Y, and RNs D, F, K, Z, AA, and BB. On 09/25/13 at 7:30 PM, the Corporate RN supplied facility competency skills check for three of seven RNs providing IV care, including RNs D, K, and Z. On 09/26/13 at 9:35 AM, the Corporate RN provided IV training certificates including PICC and Central lines for LVNs I and J. On 09/26/13 at 9:35 AM, the Corporate RN provided a copy of the Omnicare 4.3 Peripheral Catheter Dressing Change Policy, Skills Checklist 7: Midline/CVC Dressing Change, 4.2 Peripheral Catheter Flushing, Skills Checklist: IV Medication Administration, Skills Checklist 18: Accessing and De-accessing an Implanted Port. The Corporate RN said this would be the policy and procedures used for both peripheral and central line access. On 09/26/13 at 11:00 AM, the Corporate RN provided IV training certificates including PICC and Central lines for LVN L. On 09/27/13 at 8:20 PM, a nursing skills checklist for LVN L for Peripheral Catheter Removal, Setting up a Secondary Infusion, Flushing a Vascular Access Device, Midline/Central Line Dressing Change and Inserting a Peripheral IV Catheter, all dated 05/24/10, were also received from the Corporate RN Copies of the curriculum and an IV Competency for LVN I, dated 07/11/07 (more than four years old), both from another facility were received from the Corporate RN on 09/26/13 at 1:30 PM. On 09/26/13 at 4:30 PM, the Corporate RN provided IV Training Certificates for LVNs A and M with curriculum information attached. On 09/27/13 at 2:50 PM, the Corporate RN provided IV competency skills checks, including medication administration and CVC dressing changes for RN F (three checks, but only one dated and timed for 09/27/13 at 12:15 PM), RN CC (the Clinical Coordinator) (dressing change check, dated 09/26/13, and medication administration was undated), RN Z (dressing change check dated 09/26/13, and medication administration was undated), RN AA (dressing change check dated 09/27/13, and medication administration was undated), LVN H (dressing change check dated 09/27/13 and medication administration was undated), and the facility DON (dated 09/27/13). On 09/27/13 at 8:30 PM, the Corporate RN provided IV competency skills checks, including medication administration and CVC dressing changes for LVN J (dated 09/27/13), LVN I (dressing change check dated 09/26/13 and medication administration was undated), LVN M (dated 09/27/13), RN D (dressing change check dated 09/27/13 and medication administration was undated), and RN K (dated 09/27/13). 12) Observation of Resident #15's sterile dressing change to the PICC line site was performed by LVN H on 09/27/13 at 7:25 PM. No breaks in sterility or infection control procedures were observed. LVN H then retrieved the [MEDICATION NAME] 2 gm IV antibiotic for infusion. LVN H cleaned, aspirated for blood backflow and flushed the port/lumen without infection control breaks or IV procedural breaks. Observation on 09/27/13 at 9:30 PM, after the IVPB antibiotic had infused, revealed LVN H disconnected the empty Cefapime bag and cleaned, connected a flush syringe, aspirated for blood backflow and flushed with NS, per physician's orders [REDACTED]. LVN H then repeated the process for the [MEDICATION NAME] flush without breaks in procedure and infection control procedures. 13) Observation of Resident #12's [MEDICATION NAME] 1 gm IVPB administration by LVN I on 09/27/13 at 8:00 PM revealed LVN I cleaned, aspirated for blood backflow and flushed the port/lumen without infection control breaks or IV procedural breaks prior to connecting the IVPB. 14) Observation on 09/28/13 at 8:30 AM with RN F for Resident #15's Cefapime 2 mg IV antibiotic, revealed RN F cleaned, aspirated for blood backflow and flushed the port/lumen without infection control breaks or IV procedural breaks. 15) The IJ was removed on 09/28/13 at 2:20 PM. The Administrator, the DON, and the Corporate RN (Clinical Services Director) were notified at that time the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern"and a severity level of "potential for more than minimal harm that is not immediate jeopardy," because the facility was still ensuring licensed nurses were receiving IV certification with an IV performance check-off and monitoring the Plan of Removal. 16) The facility's 672 dated 09/26/13 revealed a census of 95. These failures could affect the four residents with PICC (Residents #1 and #3) and/or central lines (Residents #2 and #4), identified upon entry to the facility on [DATE], including Resident #3, and two residents who were admitted with a PICC line (Resident #15) and a peripheral line (Resident #12) on 09/24/13, by placing them at risk for worsening infections, increased debility due to infection and possible death from improper procedures.