Every finding on record at The Heights of Gonzales

Based on interviews and record reviews the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 3 residents reviewed for medical records. The facility nurses did not document accurately on Resident #1's Medication Administration Record on 07/15/2026 regarding the resident's [NAME] Hose (medical stockings used to help prevent blood clots in people who are not moving much). This failure could place residents at risk for records not accurately documented. Findings included:Record review of Resident #1's face sheet, dated 07/31/2026, revealed the resident was an 85-years-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnosis of dementia (loss of memory, language, problem-solving and other thinking abilities that ae severe enough to interfere with daily life), transient cerebral ischemic attack (temporary blockage of blood flow to the brain), and heart failure (the heart cannot pump enough oxygen-rich blood to meet the body's need). Record review of Resident #1's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident cognitive was intact, and in the Section GG (Functional Abilities), the resident was independent (Resident completes the activity by themself with no assistance from a helper) for most activities of daily living, such as sit to stand and chair to bed transfer. Record review of Resident #1's comprehensive care plan, dated 08/03/2026, revealed I have Heart Disease. I am at risk for associated cardiac complications such as chest pain, short of breath, fatigue, dizziness, poor endurance/activity intolerance and edema, Hypertension, and peripheral insufficiency venous. For intervention - Administer my medications as ordered by my physician. Record review of Resident #1's physician order, dated 10/09/2025, revealed the resident had an order for [NAME] Hose in am and Remove in pm - two times a day. Record review of Resident #1's Medication Administration Records from 07/01/2026 to 07/31/2026 revealed the resident received her [NAME] Hose as ordered and scheduled [NAME] Hose On at the morning time and [NAME] Hose Off at the bed time. Further record review of the resident's Medication Administration Records revealed there was blank (empty - no document) on 07/15/2026 at Morning time but documented at the bedtime as Off. Interview on 07/31/2026 at 3:29 p.m., LVN-A who worked on 07/15/2026 at morning time said that she applied the [NAME] Hose to Resident #1 at the morning time as ordered, but she forgot to document on the resident's Medication Administration Record because she was very busy. LVN-A stated it was her mistake and she should have documented on the resident's Medication Administration Record after applying the [NAME] Hose to the resident to provide accurate information to other nurses and inaccurate medical record might provide incorrect care to the resident. Interview on 07/31/2026 at 3:35 p.m., the ADON said the facility DON was on vacation, so she could interview with the surveyor, and the nurse who worked on 07/15/2026 at morning time applied the [NAME] Hose to Resident #1 as ordered because evening nurse took off the [NAME] Hose at bedtime. The ADON stated LVN-A should have documented accurately on Resident #1's Medication Administration Record regarding [NAME] Hose on 07/15/2026 because inaccurate medical records might provide incorrect care to the resident. Record review of the facility policy, titled Professional Standard of Care, dated 01/2023, revealed . F. Nurses should conduct assessments or evaluations and document nurses' notes in the following instances: 1) routine charting for residents should reflect the recipient's ability as assessed upon admission, re-admission and as clinically indicated; and 2) at the time of accidents, incidents or change in condition. All exceptions to stable, baseline or usual status should be recorded as exceptions and included in the clinical record.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (near Activities Area) of 2 kitchenettes reviewed, in that: The door to kitchenette #1 was open and unlocked; the steam table was on and hot to the touch, and the refrigerator held a gallon container of milk and three trays with approximately 40 glasses of liquid marked to be served at lunchtime. No staff were present in the kitchenette or within the surrounding area. This deficient practice could result in residents coming into contact with a hot surface, and/or consuming liquids of the incorrect texture for their diet, and/or contaminating the food and drinks in the refrigerator. The findings were: Observation on 03/24/2026 at 2:20 p.m. revealed the door to kitchenette #1 was open and unlocked; the steam table was on and hot to the touch, and the refrigerator held a gallon container of milk and three trays with approximately 40 glasses of liquid marked to be served at lunchtime. Further observation revealed no staff were present in the kitchenette or within the surrounding area. Further observation revealed there were staff and residents within approximately 30 feet of the kitchenette conducting a scheduled activity at the time. During an interview with the Activities Director on 03/24/2026 at 2:22 p.m., the Activities Director confirmed the door to kitchenette #1 was open, that no staff were present, the steam table was on and hot, and a refrigerator containing a gallon container of milk and glasses of liquid. During an interview with the Administrator on 03/27/2026 at 7:15 a.m., the Administrator stated he had directed new locks to be installed on the doors to both facility kitchenettes and directed staff to ensure the doors remain locked at all times. Record review of the facility policy, Physical Environment, revised January 2023, revealed, The community is designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public.

Number of residents sampled:Number of residents cited:The findings included: Record review of Resident #76's face sheet, dated 03/26/2026, reflected a [AGE] year old female who was originally admitted on [DATE] with current admission date 01/20/2026 with diagnoses including Low Vision Right Eye Category 2 (severe visual impairment), Tubulo-interstitial Nephritis (a type of inflammation that damages the tubules in the kidneys and the tissue that surrounds them), Spinal Stenosis (narrowing in the spine which puts pressure on nerves and spinal cord), Type 2 Diabetes Mellitus with Hyperglycemia (the body can't use insulin properly and/or doesn't make enough insulin resulting in high blood sugar levels), Essential Hypertension (high blood pressure), Uninhibited Neuropathic Bladder (a type of bladder dysfunction caused by brain or upper spinal cord damage), and Other Obstructive and Reflux Uropathy (a blockage in the urinary system that cause urine to back up into the kidneys). Record review of Resident #76's quarterly MDS assessment, dated 01/28/2026, revealed resident had a BIMS score of 15 which indicated intact cognitive status, resident has an indwelling urinary catheter with diagnosis of Neurogenic Bladder and Bowel Incontinence (always incontinent). Record review of Resident #76's comprehensive care plan, dated 02/10/2026, revealed Incontinence related to activity intolerance and impaired mobility. Intervention- incontinence care every shift and as needed. Comprehensive care plan also revealed I require a catheter: at risk for infection and catheter related injury/issues. Intervention- catheter care every shift and as indicated. Observation on 03/26/2026 at 09:45 a.m., of CNA A and CNA B providing incontinent care, CNA A cleaned resident #76 suprapubic area, left and right groin, separated labia wiping front to back, and cleaned catheter tubing using disposable wipes. Resident was turned to left side revealing resident had a bowel movement. CNA A cleaned resident's rectal area and buttocks but did not remove soiled brief. Resident rolled onto her back, with buttocks touching the soiled brief before being turned to right side. CNA B removed soiled brief but did not clean resident's buttocks before applying clean brief. Interview on 03/26/2026 at 10:00 a.m., CNA A stated she may have missed a step while performing care. CNA A and CNA B confirmed the soiled brief should have been removed before the resident rolled onto it and the resident's buttocks should have been cleaned again before applying the clean brief. Interview on 03/26/2026at 11:10 a.m., the DON stated CNA A and CNA B should have removed soiled brief before resident rolled onto it and her buttocks should have been cleaned again before applying new brief. Skills check-offs/training for CNA A and CNA B related to incontinence care was provided by DON as requested. Record review on 3/26/2026 of skills competency checkoffs Pericare/incontinence female and Foley catheter care female indicated CNA A and CNA B were provided training and checked off for competency. CNA A on 01/29/2026 and CNA B on 01/09/2026. Record Review on 3/26/2026 Procedural Guideline #20 Perineal Care/Incontinent Care- Female provided with skills check- off stated the following step after washing genital area, turn to side, then wash and rinse rectal area moving from front to back using a clean area of washcloth for each stroke, dry with towel.

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences in 1 (Resident #50) of 3 residents reviewed receiving supplemental oxygen via nasal cannula. The facility failed to ensure that Resident #50's oxygen tubing was stored properly to prevent contamination. Resident 50's oxygen tubing was on the floor in her room with nasal cannula resting on metal bed frame under headboard. This failure could put residents receiving supplemental oxygen via nasal cannula at risk for cross-contamination and respiratory infection.The findings included: Record review of Resident #50's face sheet, dated 03/25/2026, reflected a [AGE] year-old female with current admission date of 03/17/2026. Diagnosis include fracture of superior rim of right pubis (crack or break of pelvic bone), chronic respiratory failure with hypoxia (lungs cannot get enough oxygen into the blood), type 2 diabetes mellitus with diabetic neuropathy (high blood sugar damages nerves causing pain, tingling, or numbness in the feet and legs), chronic obstructive pulmonary disease (a group of lung diseases that make it hard to breathe) dependence on supplemental oxygen, heart failure (heart cannot pump enough blood to meet the body's needs), end stage renal disease (the final stage of chronic kidney disease) and essential hypertension (high blood pressure). Record review of Resident #50's 5-day MDS, dated [DATE] revealed resident BIMS score of 15 which indicated intact cognitive status. Record review of Resident #50's physician order dated 03/25/2026, indicated Oxygen 2-4 L/min prn as needed for shortness of breath. Record review of Resident #50's comprehensive care plan dated 03/25/2026 indicated Oxygen Therapy as needed r/t Ineffective gas exchange. Interventions included- encourage/cue/assist as needed with positioning in bed, intervention- monitor for s/sx of respiratory distress and report to MD, intervention- promote lung expansion and improve air exchange by positioning with proper body alignment (if tolerated, head of bed at 45 degrees). Observation on 03/25/2026 at 9:08 a.m. Resident #50 in bed with head of bed elevated approximately 45 degrees, oxygen concentrator was on opposite side of room with oxygen tubing noted on floor and nasal cannula resting on metal bed frame under the headboard of bed. No receptacle was observed in the room in which to store the tubing and nasal cannula. Interview with Resident #50 on 03/25/2026 at 9:08 a.m., Resident #50 stated she only wears her oxygen at night and I don't usually need it during the daytime when I am awake. Resident confirmed there was no receptacle to place her oxygen tubing into when she removed it and that she had not been offered a plastic bag or anything to place the tubing, stating I just lay it on the bed. Resident confirmed that she eats breakfast in bed every day and staff deliver her tray and that she requires transfer assistance to get from bed to wheelchair. Observation on 03/25/2026 at 10:07 a.m., oxygen tubing noted in same place under the bed. Resident was not in room. Interview on 03/25/2026 at 10:07 a.m., CNA C stated oxygen tubing and nasal cannula should not be on the floor and under resident's bed. CNA C stated, oxygen tubing should be placed in a plastic bag because the floor can be dirty. When asked what the potential outcome could be to contaminated tubing CNA C confirmed risk of infection. CNA C immediately removed tubing and nasal cannula to be replaced. Interview on 03/26/2026 at 11:10 a.m., the DON stated, the expectation is that oxygen tubing be placed in a plastic bag when not in use. and confirmed that placing in a bag was to avoid cross-contamination and potential respiratory infection. Record review of facility policy Oxygen-Respiratory Tubing/Equipment Management dated 03/12/2018, revised January 2022 with Compliance Guidelines: To maintain properly functioning equipment and decrease the potential for the spread of infection by maintaining clean equipment and tubing bottles and masks, listed 1. Change tubing weekly and provide storage receptacle for proper storage when not in use.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1's Zyrtec (Cetirizine) an allergy medication had a dosage ordered on MARS. This failure could place residents at risk of not receiving the therapeutic effects of their prescribed medications.The findings included: Record review of Resident #1's face sheet, dated 3.26.2026, reflected a [AGE] year-old female with an initial admission date of 1/22/26 and diagnoses including: hypertension (is a chronic condition defined as consistently high force of blood against artery walls), Heart failure (is a chronic, progressive condition where the heart muscle cannot pump blood efficiently enough to meet the body's needs for oxygen) and Epilepsy (is a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by sudden, excessive electrical discharges in the brain). Record review of Resident #1's Initial MDS assessment, dated 1/29/26, revealed Resident #1 had with a BIMS score of 12, which indicated moderate cognitive impairment Review of Resident #1's Physician orders for March 2026 revealed that Resident #1 was prescribed Zyrtec once daily in the morning, with no dosage specified. Record review of medication administration history for Resident #1, dated 3/26/26, revealed that Zyrtec was administered throughout March 2026 without a specified dosage. Observation on 3/26/26 at 8:20 a.m. revealed MA D pulling medication from the cart and reading the MAR, at which time she noted the order did not specify a dosage. Interview with on 3/26/26 at 8:25 am MA D said the Zyrtec order for Resident #1 did not list a dosage; therefore, she had the order clarified by DON prior to administering it to Resident #1. Interview with Resident #1 on 3/26/26 at 9:00 a.m. stated she did not recall how many pills she takes in the mornings or what they were for, but trusted nurses to administer the correct medications. During an interview on 03/26/2026 at 9:45 AM, the DON stated that certified medication assistants are expected to administer medications according to physician orders and notify the charge nurse of any deviations. She was unaware why the Zyrtec order for Resident #1 did not include a dose on the MARS, but clarified the order promptly once informed. The DON expects all MAs to verify orders before administering medication, confirming the correct patient, dose, time, and route, and to inform charge nurses of any discrepancies so orders can be clarified, especially since Zyrtec is available in 5 mg or 10 mg. She added that her ADON monitors this process at random and provides oversight. Record review of the facility's policy titled, Policy Medication Administration, dated March 2017, revised January 2023, revealed, Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly for 1 of 5 residents (Resident #23) reviewed for medication storage, in that: The facility failed to ensure medication Vick's (nasal decongestant) was not left on Resident #23's bedside table. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered.The findings were: Record review of Resident #23's face sheet, dated 3/25/26, revealed an [AGE] year-old female admitted to the facility on [DATE] with the diagnosis that included Chronic obstructive pulmonary disease, (refers to a group of diseases that cause airflow blockage and breathing-related problems), hypertension (is a chronic condition defined as consistently high force of blood against artery walls) and Diabetes mellitus (is a chronic metabolic disorder characterized by high blood sugar). Record review of Resident #23's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. Record review of Resident #23's physician orders for March 2026, reviewed on 3/25/26, did not reveal an order to self-administer medications. Further review revealed there was no order for the resident's use of Vicks. Observation on 03/25/2026 at 11:30 a.m. of Resident #23's room revealed there was a jar of Vicks on the nightstand. Interview with Resident #23 on 3/25/26 at 12:15 p.m., the Resident stated her family purchased Vicks for her and brought it sometime right before February 14th of 2026. The Resident further stated that no one had given her a self-medication assessment, and she had not used the Vick's. Interview with CNA F on 3/25/2026 verified she was assigned to Resident #23, and recalls assisting Resident #23 with morning care today; however, she does not recall seeing a jar of Vicks on the nightstand. Interview with LVN E on 3/25/26 at 12:30 p.m., LVN E confirmed she was assigned to Resident #23 and verified that a jar of Vicks was on the resident's bedside table. She stated Resident #23 had not received a self-medication assessment and should not have access to medication for self-administration, as this poses a risk of improper use by the Resident or accidental ingestion by others due to lack of secure storage and cognition. Interview with the DON on 03/24/26 at 9:35 a.m., the DON reported a jar of Vicks was found on Resident #23's bedside table. The DON explained that no medication should be left on a resident's bedside table without a self-medication assessment, as this may lead to the resident taking more than the prescribed dosage. Record review of the facility's policy titled, Medication Administration, March 2019, revised January 2023, revealed, Avoid leaving medications with the Resident to self-administer unless the Resident is approved for self - administration on the medicine.

Based on observation, interview, and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 8 of 35 days for the Fall/Winter 2025 menu. This facility failed to ensure their menu met the nutritional needs of residents in accordance with established national guidelines. This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake.The findings include:Record review of a complaint from an anonymous complainant reflected The complainant feels the facility does not serve a good variety of foods for residents .The food does not meet the nutritional guidelines for each resident.Observation on 01/27/26 at 06:17PM of the requested dinner sample tray for dinner did not include an option of fruit from a dessert cart and observation of residents during this dinner service did not reveal a dessert cart or anyone passing out fruits to residents.Interview on 01/28/26 at 09:46 AM, the CDM revealed she followed the menus and wondered sometimes why food items like fruit were missing, however, she followed the menus that had been approved by [food company] and the RD. Interview and record review on 01/28/26 at 12:39PM revealed the facility's Fall/Winter 2025 Menu reflected the Day 6 menu included for the day: choice of juice, cereal, eggs, meat, bread, margarine/jelly, chicken rice pilaf, sweet peas, ice cream, shrimp po' boy, French fries, pickle slices, and cake. The menu reflected 1 serving of vegetable (sweet peas) and 1 serving of fruit (juice). Interview with the RD revealed potatoes and cucumbers were considered vegetables on that day. She further revealed she was going to contact the CDM to further investigate the fruit and vegetable servings per day for the facility and call back. The RD revealed that for a balanced diet, they ensured there were 5 servings of fruits and vegetables per day. During the interview, this Surveyor shared that an email would be sent to the RD later about other days we could discuss about that did not have enough fruits and vegetables for the day. On 01/28/26 at 01:40 PM an email was sent to the RD expressing concerns about Days 12, 14, 16, 20, 22, 25, and 30 (in addition to Day 6) on the Fall/Winter 2025 menu of not having enough fruits and vegetables for the day. Record review of the facility's Fall/Winter 2025 Menu reflected the Day 12 menu included for the day: choice of juice, cereal, eggs, meat, bread, margarine/jelly, [Barbecue] pork, potato salad, cole slaw, cookie, ravioli, sliced zucchini, garlic bread, and poke cake. Record review of the facility's Fall/Winter 2025 Menu reflected the Day 14 menu included for the day: choice of juice, cereal, eggs, meat, bread, margarine/jelly, garlic pork cubes, herbed orzo, seasoned peas, fudge rounds, vegetable soup, deli sandwich, potato chips, and fresh fruit. Record review of the facility's Fall/Winter 2025 Menu reflected the Day 16 menu included for the day: choice of juice, cereal, eggs, meat, bread, margarine/jelly, crusted fish, cheesy broccoli rice, cornbread, ice cream, polish sausage, parsley new potatoes, sauerkraut, and cake. Record review of the facility's Fall/Winter 2025 Menu reflected the Day 20 menu included for the day: choice of juice, cereal, eggs, meat, bread, margarine/jelly, fried fish, baked potato wedges, buttered spinach, cookie, pasta bake, Italian vegetables, garlic [sticks], and cobbler. Record review of the facility's Fall/Winter 2025 Menu reflected the Day 22 menu included for the day: choice of juice, cereal, eggs, meat, bread, margarine/jelly, cheesy chicken pasta, herbed green beans, garlic [sticks], cookie, baked fish sandwich, macaroni salad, carrot sticks, and lemon cream pie. Record review of the facility's Fall/Winter 2025 Menu reflected the Day 25 menu included for the day: choice of juice, cereal, eggs, meat, bread, margarine/jelly, spaghetti with meat sauce, tossed salad, garlic bread, applesauce, deli sandwich, potato chips, lettuce and tomato, and pumpkin pie. Record review of the facility's Fall/Winter 2025 Menu reflected the Day 30 menu included for the day: choice of juice, cereal, eggs, meat, bread, margarine/jelly, chicken and dumplings, mixed green salad, cornbread, ice cream, goulash, wheat roll, mixed [vegetables], and cinnamon pears. Interview on 01/28/26 at 02:40PM, the ADM revealed his expectation was for the menus the facility provided to the residents were well-balanced. He revealed the facility got their menus from somewhere that made sure that the menu had all the proper nutrition for the residents. He further revealed that the RD signed off on the menus so he would expect the menus to be nutritionally adequate. Interview on 01/28/26 at 02:55 PM, the CDM asked if this surveyor had considered fruit juice being available all day as a part of the daily fruit intake. Interview on 01/28/26 at 02:58 PM, the RD revealed the fruit juice that was offered all day was counted towards the residents' fruit intake, there was a dessert cart of fruits offered at dinner, and there were snacks at the nurse's station that counted too. Record review on Fall/Winter 2025 Menu reflected no mention of fruit juice being available all day, fruit and vegetable snacks available at nurse's station, or dessert carts of fruits being offered at dinner. Record review of page 1-14 of the facility's Nutrition Care Manual, dated 2021, reflected the Individualized/Liberalized Diet for Older Adults included 2.5 cups or more of vegetables and 2 cups or more of fruits per day. Record review of page 1-8 of the facility's Nutrition Care Manual, dated 2021, reflected at least half of fruits should come from whole fruits rather than juice. Record review of the facility's policy Dietary Services, revised January 2023, reflected The community provides each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident and The community provides menus that meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences. Record review of the National Research Council's Recommended Dietary Allowances, 10th edition and last revised in 1989, did not reflect the fruits and vegetables needed for a healthy diet for older adults in a day.

Based on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy for 1 of 5 residents (Resident #3) reviewed for resident rights, in that: The facility failed to ensure CNA A and LVN B completely closed Resident #3's privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #3's face sheet, dated 12/12/2024, revealed an admitted [DATE] and, a readmitted [DATE], with diagnoses which included: Dementia (decline in cognitive abilities), Epilepsy (Neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions), Moderate intellectual disabilities, and Psychosis (Difficulties determining what is real and what is not real). Record review of Resident #3's Quarterly MDS assessment, dated 09/10/2024, revealed the resident had a BIMS score of 00, which indicated he was severely cognitively impaired. Resident #3 was always incontinent of bladder and bowel and, required total care with his ADLs. Record review of Resident #3's care plan, dated 02/09/2022, revealed a problem of I have bowel/bladder incontinence related to Disease Process and at risk for skin breakdown, with an intervention of INCONTINENT: provide incontinent care as needed for incontinent episodes. Observation on 12/12/24 at 10:25 a.m. revealed CNA A and LVN B did not completely close the privacy curtains while they provided incontinent care for Resident #3, exposing the resident who could be seen from the room's door. During an interview with CNA A and LVN B on 12/12/2024 at 10:40 a.m., they confirmed the privacy curtains was not completely closed while they provided care for Resident #3 but it should have been. They stated they received resident rights training within the year. During an interview with the DON on 12/12/2024 at 2:20 p.m., the DON confirmed privacy must be provided during nursing care and Resident #3's privacy curtains should have been closed completely. She stated the staff had received training on resident rights within the year and the training was provided by the ADONs and herself. They also checked the staff skills annually and as needed. Review of Facility's policy titled Certified Nurse Aide Standards of Clinical Practice dated January 2023, revealed we believe that each resident has the right to be treated with dignity and respect and that privacy be maintained during procedures.

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 5 residents (Resident #88) observed for nursing care and 3 of 19 (residents #10, #88 and #89) reviewed for infection control, in that: 1. The facility failed to ensure CNA E washed or sanitized her hands or changed her gloves, before touching the resident #88's clean brief and after touching the soiled resident's chuck and brief. 2. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented or used while staff provided high-contact resident activities, including: catheter care for Resident #88, wound care for Resident #10, and medication administration via G-tube for Resident #89. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1. Record review of Resident #88's face sheet, dated 12/12/2024, revealed an admitted [DATE], and a readmitted [DATE], with diagnoses which included: Hypertension (high blood pressure), Need for assistance with personal care, Injury of urethra (thin tube connected to the bladder that carries urine out of the body), Chronic osteomyelitis (bone infection) right ankle and foot, History of urinary tract infection (an infection in any part of the urinary system), Obstructive uropathy (urine cannot drain through the urinary tract). Record review of Resident #88's Significant change MDS assessment, dated 10/21/2024 revealed Resident #88 had a BIMS score of 3, indicating severe cognitive impairment. Resident #88 was coded as always incontinent of bowel and had an indwelling catheter. Resident #88 required total care with his ADLs. Review of Resident #88's care plan, dated 12/22/2023, revealed a problem of I require an Indwelling Catheter, with a goal of I will not experience any complications associated with my catheter to include trauma, infection or pain, dignity concerns through my next review date. Observation on 12/12/2024 at 9:40 a.m. revealed while providing incontinent care for Resident #88, CNA E removed soiled chucks and brief from Resident #88 and, without changing her gloves or sanitizing her hands, placed and fasten new clean brief on Resident #88. During an interview with CNA E on 12/12/2024 at 9:53 a.m., CNA E verbally confirmed she did not wash or sanitize her hands or change her gloves, before touching the clean brief and fastening the brief to the resident. CNA A stated she should have changed her gloves and wash or sanitize her hands prior to placing the new brief on Resident #88. She stated the staff received infection control training regularly. During an interview with the DON on 12/12/2024 at 2:20 p.m., the DON confirmed the CNA should have washed or sanitize her hands and changed her gloves, prior to placing the clean brief under the resident to prevent risk of cross contamination and prevent infection for the resident. She stated the staff received infection control training frequently and their skills were checked yearly. The DON revealed she and her ADONs were doing spot checks to check the skills of the staff. Review of facility's policy, titled Hand washing/hand hygiene, dated January 2023, revealed Use an alcohol-based hand rub [ .] for situations such as this [ .] before moving from a contaminated/soiled to clean care or procedures [ .] after contact with blood or bodily fluid; After handling use dressing, contaminated equipment, etc. 33866 2a. Record review of Resident #88's face sheet dated 12/13/2024 revealed he was an [AGE] year-old man, with an initial admitted [DATE] with re-admission on 06/01/2024, with diagnoses which included: Cerebral infarction (stroke), Obstructive and reflux uropathy (blockage in urinary tract), unspecified injury of urethra and retention of urine. Record review of Resident #88's Order Summary dated 12/13/2024 revealed orders for: Foley Catheter 14-16 Fr 5-30cc, change monthly and as needed with order date of 06/03/2024; and EBP (Enhanced Barrier Precautions): Practice EBP as indicated (foley care) every shift for foley care with order date of 12/13/2024. Observation by Health Surveyor-I on 12/12/2024 at 9:40 a.m. of catheter and incontinent care being provided to Resident #88 by LVN-B and CNA-E, revealed neither staff wore a gown, just gloves, while providing catheter care, and there was no sign for EBP posted on his door or PPE supply outside Resident #88's room. b. Record review of Resident #10's face sheet dated 12/13/2024 revealed a [AGE] year-old woman with an initial admitted [DATE] and a re-admitted [DATE] and diagnoses which included: Dementia (loss of cognitive functioning that interferes with daily life) and Type 2 Diabetes Mellitus (chronic condition leading to high blood sugar levels). Record review of Resident #10's order summary dated 12/13/2024 revealed an order for Right foot 5th: cleanse with wound cleanser apply skin prep and cover with dressing daily and PRN removal /soiling. Observation by Health Surveyor-I on 12/12/2024 at 1:27 p.m. of wound care being provided to Resident #10 by LVN-F revealed LVN-F did not wear a gown, just gloves while providing wound care to Resident #10, and there was no sign for EBP on the door and no PPE supply available outside her room. c. Record review of Resident #89's face sheet dated 12/13/2024 revealed she was an [AGE] year-old woman with an initial admitted [DATE] and re-admission on 12/06/2024, with diagnoses that included: Hemiplegia and hemiparesis (one-side paralysis or weakness) following cerebral infarction (stroke) affecting left non-dominant side, dysphagia (inability to swallow safely); and artificial opening status (feeding tube into small intestine to for medication administration and nutrition) Record review of Resident #89's Care Plan initiated 11/18/2024 revealed a focus area for feeding tube r/t [related to] dysphagia. Observation on 12/13/2024 at 7:11 a.m. revealed LVN-H did not wear a gown, just gloves while administering medications via a -tube to Resident #89. There was no EBP sign posted on Resident #89's door, and no PPE supply available outside her room. During an interview with LVN-H on 12/13/2024 at 7:39 a.m., LVN-H revealed she had never heard of or had been trained on EBP and did not know what these precautions entailed. LVN-H stated she had received training on medication administration and had passed a competency check done by the ADON on medication administration including via G-tube. This training did not include training on EBP. Record review of LVN-H's competency checklist dated 9/20/2024 revealed she had been checked off as meeting criteria on infection control, which included isolation techniques, and Medication Administration including by feeding tube. During an interview with ADON-G on 12/13/2024 at 7:45 a.m., ADON-G stated they had not yet implemented Enhanced Barrier Precautions at the facility, and stated she would immediately be getting EBP signs posted, and PPE supply units placed outside all residents room's who require EBP. Interview on 12/13/2024 at 10:40 a.m. with the DON revealed she confirmed that EBP was included in the facility Infection Control Policy to be used during high-contact activities for residents with wounds or in-dwelling devices. The DON also confirmed that there were no EBP signs or PPE supplies available outside resident's room who had wounds or in-dwelling devices, and that staff had not been trained on EBP, but had no answer other than it just fell through the cracks for why EBP precautions had not been implemented at the facility. Record review of the facility policy titled Infection Prevention and Control revised April 2024, Under Section II. Categories: Types of Isolation Precautions revealed EBP may be indicated as a recommendation by the CDC (when contact precautions do not otherwise apply) for residents with the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Further review revealed: Resident/Patients with the following clinical indication should be under EBP: Significant Wounds such as chronic wounds, ulcers, open PUI or complicated/non-healing surgical incisions or wounds, and/or open wounds requiring a dressing .and Indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. Record review of CMS Memorandum dated 3/20/2024 from Director, Quality, Safety and Oversight Group (QSOG), Subject: Enhanced Barrier Precautions in Nursing Home revealed that CMS was issuing new guidance for State Survey Agencies and LTC facilities on use of [NAME] to align with nationally accepted standards. The Memorandum included: EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact care activities regardless of their multidrug-resistant organism status. The new guidance related to EBP is being incorporated into F880 Infection Prevention and Control.

Based on interview and record review, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 18 residents (Residents #30 and #59) reviewed for care plans. 1. The facility failed to revise Resident #30's comprehensive care plan to reflect the resident's change in cognitive status. 2. The facility failed to revise Resident #59's comprehensive care plan to reflect the resident's discontinued use of anti-depressant medication. These deficient practices could cause confusion for staff members responsible for providing direct care for residents and medication administration and place residents at risk of receiving improper care. The findings were: 1. Record review of Resident #30's face sheet, accessed on 12/11/2024, revealed the resident was an [AGE] year old female admitted to the facility on [DATE] and again on 08/11/2024 with diagnoses including hypokalemia (a condition where the potassium levels in the blood are lower than normal), cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die), and type II diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin, leading to high blood sugar levels). Record review of Resident #30's quarterly MDS assessment dated [DATE] revealed a BIMS of 15, indicating the resident had full cognition. Record review of Resident #30's comprehensive care plan, last review completed 12/06/2024, revealed a focus area indicating: I have impaired cognitive function or impaired thought process r/t CVA. LOW BIMS SCORE 8. Date Initiated: 06/11/2024. Created on: 06/11/2024. Created by: ADON. Revision on: 06/27/2024. The goal was to maintain the current level of cognitive function, and interventions/tasks included keeping the resident's routine consistent and to provide consistent caregivers as much as possible to reduce confusion, administer medications as ordered, ask yes/no questions and break tasks into one step at a time. During an interview on 12/12/2024 at 12:45 PM, the ADON stated Resident #30's comprehensive care plan did not reflect her current cognitive status and should have been updated to indicate her improved cognition. The facility hired a new social worker within the past two months who completed the most recent assessment for this resident and did not make her aware there had been a change in the resident's cognition level. During an interview on 12/12/2024 at 1:30 PM, the DON stated Resident #30's cognition had been moderately impaired due to a stroke but it had improved since her last assessment and the resident's comprehensive care plan should have been updated by the ADON, who was responsible for updating care plans, to reflect the change. 2. Record review of Resident #59's face sheet, accessed on 12/12/2024, revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses including dementia (a brain disorder that causes a progressive decline in cognitive function, memory, thinking, and behavior), bipolar disorder (a mental health condition characterized by significant and persistent mood swings between periods of extreme elation and deep depression) and major depressive disorder (a serious mental illness that affects how people feel, think, and act). Record review of Resident #59's quarterly MDS assessment dated [DATE] revealed a BIMS of 15, indicating the resident had full cognition. Section I, Active Diagnoses, indicated I5800 Depression was checked, and Section N, Medications, N0415 High-Risk Drug Classes: Use and Indication, C - Antidepressant was not checked. Record review of Resident #59's comprehensive care plan, last review completed 11/27/2024, revealed a focus area indicating: I require anti-depressant medication r/t Dx: Depression. Date Initiated: 8/21/2023. Created on: 08/21/2023. Created by: ADON. The goal was the resident will have no complications related to anti-depressant medication, and interventions/tasks included administering medication per MD orders, educating the resident and/or family regarding all potential side effects and risk associated with psychotropic medications, and monitoring for target/behavior symptoms. Further review of this comprehensive care plan did not indicate a focus area indicating a diagnosis of depression. Record review of Resident #59's consolidated physician's orders for the month of December 2024 revealed there were no orders for any psychotropic medications. During an interview on 12/12/2024 at 12:45 PM, the ADON stated Resident #59's comprehensive care plan was incorrect. The resident was no longer taking any anti-depressant medications and this focus area should have been removed, and the diagnosis of depression should have its own focus area in the care plan to ensure interventions were in place for this diagnosis. During an interview on 12/12/2024 at 1:40 PM, the DON stated Resident #59's care plan should not have included the focus area of anti-depressant medication, which the resident was no longer taking, and instead should have included the diagnosis of depression as a focus area, with goals and interventions for this diagnosis. It was important to update comprehensive care plans to ensure proper care was provided for residents. Record review of facility policy Care Plans revised January 2023 revealed, The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk, outcome objective, and the resident's ability, needs, medical condition, preventive measures .the care plan should be initiated upon admission, continued to be developed during the initial 48-72 hours, throughout the completion of the admission comprehensive assessment. The care plan should be updated and reviewed at least quarterly thereafter, then annually and with significant changes in conditions as defined in the RAI manual. Additional updates to the care plan may be done as indicated. Record review of the CMS RAI Version 3.0 Manual dated October 2019 revealed .to evaluate the information gained through both the comprehensive assessment processes in order to identify problems, causes, contributing factors, and risk factors related to the problems .the IDT must evaluate the information gained to develop a care plan that addresses those findings in the context of the resident's goals, preferences, strengths and problems.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 5 residents (Resident #62) reviewed for incontinent care, in that: The facility failed to ensure CNA C thoroughly cleaned Resident #62 while providing incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #62's face sheet, dated 12/12/2024, revealed an admitted [DATE], and a readmitted [DATE] with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Severe obesity, Need for assistance with personal care, Hypothyroidism (under active thyroid), Hypertension (high blood pressure), History of urinary tract infection (an infection in any part of the urinary system). Record review of Resident #62's Quarterly MDS assessment, dated 09/18/2024, revealed Resident #62 has a BIMS score of 11, which indicated mild to moderate cognitive impairment. Further review revealed Resident #62 required extensive assistance to total care with ADLs and was indicated to occasionally be incontinent of bladder and frequently incontinent of bowel. Record review of Resident #62's care plan, dated 02/17/2022, revealed a problem of I have bladder incontinence related to overactive bladder at risk for skin breakdown, with a goal of I will remain free from skin breakdown due to incontinence and brief use through the review date. Observation on 12/12/24 at 1:35 p.m. revealed, while providing incontinent care for Resident #62, CNA C did not clean the rectal area of the resident and did not clean the groin areas and upper thighs of the resident. During an interview on 12/12/2024 at 1:47 p.m. CNA C stated she did not clean between the resident's buttocks' cheeks area or the groin area. CNA C stated she should have cleaned the rectal area and groins areas. CNA C stated she was nervous. CNA C stated she received training for infection control and incontinent care within the last year. During an interview with the DON on 12/12/2024 at 2:20 p.m., the DON stated the rectal and groins areas had to be cleaned. The DON stated the ADONs and herself were the one training the staff for infection control and incontinent care and that the ADONs and herself would check the staff skills annually and as needed if a problem was noted. During an interview with the DON on 12/13/2024 at 10 a.m., the DON stated they did not have a policy/procedure describing the steps the staff had to execute during incontinent care for a female. Review of Peri-care: What Every Caregiver Needs to Know By mmLearn.org on Fri, Jun 14, 2019 revealed Moving from front to back, use warm water and a clean washcloth (or disposable wipes) to clean the perineal area. For females, this involves cleaning the inner legs, labia, and groin area while for men it requires cleaning the tip and shaft of the penis, along with the scrotum. Both men and women require cleaning of the anal area, which will involve turning the patient on his/her side.

Based on observation, interview and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnnel to have access to the keys for 1 of 4 medication carts ([NAME] Unit Nurse's medication cart) reviewed for storage. The facility failed to ensure LVN-F secured Resident #62's Fiasp Insulin, when it was left unattended on top of the Nurses medication cart. This failure could place residents at risk for drug diversion and accidents and hazards. Findings include: Observation on 12/12/2024 at 11:03 a.m. revealed LVN-F prepared Resident # 62's medications, which included drawing up 16 units of Fiasp Insulin into a syringe, locked the medication cart, and left the vial of Fiasp insulin on top of the medication cart, and entered Resident #62's room to administer her medications. The medication cart was out of sight from LVN-F. During an interview with LVN-F on 12/12/2024 at 11:12 a.m., LVN-F stated the vial of insulin was left out unsecured on top of the medication cart, noting she had left it out for the State Surveyor to view, but then forgot to put it back inside the medication cart before locking it. LVN-F stated medications should always be kept locked up to prevent theft of drugs, and to keep it from being accidently pushed off the cart, breaking on the floor and causing a hazard with broken glass. Interview on 12/12/2024 at 3:23 p.m. with the DON revealed she was aware of the insulin vial being left out on top of medication cart unsecured during medication administration with Resident #62, and stated each Nurse was responsiible for ensuring all medications were secured inside the medication cart unless directly supervised by the Nurse. She stated not keeping medications locked and secured could result in theft of medications. Record review of the facility policy titled Medication Cart Use and Storage revised January 2023 revealed under Guidelines 1. Security- The medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use. During administration of medications avoid placing medications of top of the cart unless pulling medications from the cart. The only exception would be if the cart and medications are within the direct line of sight of the authorized personnel. Note: Best practice is to avoid leaving medication on top of the cart.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to properly store a 16-oz. bag of chips in the dry storage room. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 12/12/2024 at 10:10 AM revealed a 16-oz. bag of chips that had been opened, was rolled down, and stored inside a bag with a zip lock that was not closed. During an interview on 12/12/2024 at 10:11 AM, the DM stated the bag with the zip lock should have been sealed and failure to ensure it was sealed could lead to pests in the dry storage room and potential food borne illness. Record review of the facility's policy number 03.003, Food Storage, revised 06/01/2019, revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Code and HACCP guidelines. Procedure: 1. Dry storage rooms. d. to ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination.

Based on observation, interview and record review, the facility failed a to dispose of garbage and refuse properly for 1 of 2 Dumpsters (Dumpster #1) reviewed for disposal of garbage. The facility failed to ensure the sliding doors on both sides of the dumpster was completely closed. This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings were: Observation on 12/12/2024 at 10:19 AM revealed the sliding doors on both sides of Dumpster #1 were open, leaving an approximate 6 gap between the door and wall of the dumpster on both sides. During an interview on 12/12/2024 at 10:21 AM, the DM stated the doors on the sides of Dumpster #1 were both open and should not have been. It was important for the doors to be completely shut to prevent rodents from entering the dumpsters and potentially spreading foodborne illness. Record review of the facility's policy number 04.015 Garbage Receptacles, revised 06/01/2019, revealed, This facility will maintain garbage receptacles in a clean and sanitary manner to minimize the risk of food hazards. Outdoor receptacles: It shall be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insects and rodents with doors/lids kept closed and no waste outside of the receptacle. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (B) With tight-fitting lids or doors if kept outside the food establishment. 5-501.114 Using Drain Plugs. Drains in receptacles and waste handling units for refuse, recyclables, and returnables shall have drain plugs in place.

Based on observation, interview and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 3 of 5 residents (Resident #6, #7 and #8) reviewed for respiratory care. 1. The facility failed to ensure Resident #6's oxygen tubing was not on the floor. 2. The facility failed to ensure Resident #7's oxygen tubing was not on the floor. 3. The facility failed to ensure Resident #8's nasal canula was not on the floor. These deficient practices could place residents at risk of receiving incorrect or inadequate oxygen support, possible contamination/cross contamination/infection and could result in a decline in health. The findings were: 1. Record review of Resident #6's face sheet reflected she is a [AGE] year-old female with an original admitted [DATE] and a readmitted [DATE]. Resident #6 had diagnoses which included Chronic Obstructive Pulmonary Disease (a group of lung diseases causing constriction of the airways and difficulty breathing) and type II diabetes mellitus (causes high blood sugar due to the pancreas not producing enough insulin). Record review of Resident #6's consolidated physician orders for March 2024 reflected orders for Oxygen at 2-4 Liters per N/C PRN (order date 08/04/2021). Further review of the consolidated orders reflected an order to change O2 and /or nebulizer tubing Q week, every night shift every Sunday (order date 08/04/2021). Record review of Resident #6's care plan, revised 12/26/2023, reflected Resident #6 has oxygen therapy related to ineffective gas exchange related to COPD. The goal was will have no s/sx of poor oxygen absorption through the review date with a target review date of 05/01/2024. The interventions reflected administer oxygen per order. Record review of Resident #6's Quarterly MDS, dated [DATE], reflected a BIMS score of 12, indicating mild impaired cognition. Resident #6 was on oxygen therapy for COPD. Observation on 03/29/2024 at 11:48 am revealed Resident #6's oxygen tubing on the floor. Resident #6 was in the dining room seated at a table. Her oxygen concentrator was plugged into the wall and her concentrator was 6 feet away from the resident. Her oxygen tubing was stretched across the floor from the concentrator to the resident. During an interview on 03/29/2024 at 11:49 am with Resident #6, she stated the staff bring her oxygen into the dining room and set it up for her. She said she has asked them to not let the tubing touch the floor but they do not care. During an interview with CNA C on 3/29/24 at 11:55 am, CNA C acknowledged Resident #6's tubing on the floor. She stated the staff are responsible for setting up Resident #6's oxygen and stated the oxygen should not be touching the floor. CNA C stated this deficient practice could result in cross contamination or the tubing getting run over or bent, causing the resident to not get as much oxygen. CNA C stated she had received training regarding oxygen tubing not touch the floor. 2. Record review of Resident #7's face sheet reflected she is a [AGE] year-old female with an admitted [DATE]. Resident #7 has diagnoses which included Chronic Obstructive Pulmonary Disease (a group of lung diseases causing constriction of the airways and difficulty breathing) Dependence on Supplemental Oxygen and Dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #7's consolidated physician orders for March 2024 reflected oxygen at 2-3 liters per n/c PRN and change O2 and/nebulizer tubing Q week every night shift every Sunday (order date 11/28/2023). Record review of Resident #7's Quarterly MDS, dated [DATE], reflected a BIMS score of 5 indicating severe cognitive impairment and oxygen therapy with a diagnosis of COPD. Record review of Resident #7's care plan, revised 09/26/2023, reflected oxygen therapy related to CHF, ineffective gas exchange, COPD. The goal was to have no s/sx of poor oxygen absorption through the next review date of 04/18/2024. The interventions reflected monitor for s/sx of respiratory distress and report the MD PRN. Observation on 03/29/2024 at 11:47 am revealed Resident #7's oxygen tubing on the floor while Resident #7 was seated at the dining room table. Resident #7's oxygen tubing was connected to an oxygen cylinder attached to the back of Resident #7's wheelchair. During an interview with CNA C on 3/29/24 at 11:55 am, CNA C acknowledged Resident #7's oxygen tubing was on the floor. CNA C stated the staff are responsible for the placement of the oxygen and oxygen tubing and stated the oxygen tubing should not be touching the floor. 3. Record review of Resident #8's face sheet reflected she is an [AGE] year old female with an original admitted [DATE] and a readmitted [DATE]. Resident #8 has diagnoses which include Acute Respiratory Failure (caused by a disease or injury that effects breathing). Record review of Resident #8's consolidated physician orders for March 2024 reflected orders for continuous oxygen 2-4 liters per n/c every shift (order dated 03/01/2024). Record review of Resident #8's Quarterly MDS, dated [DATE], reflected a BIMS score of 08, indicating moderate cognitive impairment. Resident #7 is on oxygen therapy for respiratory failure. Record Review of Resident #8's care plan, revised 10/05/2023, reflected Resident #8 is on oxygen therapy r/t ineffective gas exchange, respiratory illness, resident wears CPAP at HS. The goal was she would have no s/sx of poor oxygen absorption through the review date of 04/01/2024. The interventions reflected monitor for s/sx of respiratory distress and report to MD PRN. Observation on 04/01/24 at 1:30 p.m. revealed Resident #8's oxygen nasal canula on the floor in the bathroom. Resident #8 was sitting in a recliner in her room. An oxygen cylinder was in the bathroom with the oxygen tubing nasal cannula lying on the floor in front of the toilet. During an interview with Resident #8 on 04/01/24 at 1:30 p.m., Resident #8 stated she was unaware of the nasal canula being on the floor in the bathroom. During an interview with LVN B on 04/01/2024 at 11:10 am she stated oxygen tubing should not touch the floor because it can get dirty and cause cross contamination. She stated it can cause a resident to get a respiratory infection or other sicknesses. Furthermore, LVN B stated she had received training on oxygen tubing placement. During an interview with LVN B on 04/01/2024 at 1:32 p.m. she acknowledged the oxygen nasal canula on the floor and stated, it should not be there, I am going to change it out right now. During an interview with the Administrator 04/01/2024 at 1:45 p.m. he stated nasal canula oxygen tubing should not touch the floor because it can become contaminated and introduce germ into the nose. For the oxygen tubing itself, it is going to touch the floor if the resident moves around. The tubing has to be long enough for them to move around the room. The Administrator stated staff have received training on oxygen and tubing. During an interview with the DON on 04/01/2024 at 2:00 p.m. the DON was asked why is it important that oxygen tubing not be on the floor in the dining room or a resident room, she stated if it is a long tubing and the resident is going to and from the bathroom, the tubing could be on the floor She also stated I do not think the tubing itself is an issue but the nasal cannula itself could introduce germs. Furthermore, the DON stated staff had received training on changing and labeling tubing and where to place tubing when not in use. Record review of the facility's policy on Oxygen-Respiratory Tubing/Equipment Management, revised 01/2022, states the guideline is to maintain properly functioning equipment and decrease the potential for the spread of infection by maintaining clean equipment and tubing bottles and mask. A procedure is to change tubing weekly and provide storage receptacle for proper storage when not in use.

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 10 residents (Residents #81, #93 and, #31) reviewed for infection control, in that: 1. Medication Aide F did not sanitize the blood pressure cuff between Resident #81 and Resident #93 2. While providing incontinent care for Resident #31, CNA G did not wash her hands after touching the trash can and, LVN H did not change her gloves or wash her hands before touching a pair of clean briefs These failures could place residents at-risk for infection due to improper care practices. The findings include: 1. Record review of Resident #81's face sheet, dated 10/18/2023, revealed an admitted [DATE], with diagnoses that included: Hemiplegia (Paralysis of one side of the body), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Cerebral infarction (Stroke). Record review of Resident #81's physician orders for October 2023 revealed an order for amlodipiine Besylate Tablet 5 MG Give 1 tablet by mouth in the morning related to HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE (I11.9) hold if sbp (Systolic blood pressure) under 100, or dbp (Diastolic blood pressure) under 60, or pulse under 60 Record review of Resident #93's face sheet, dated 10/19/2023, revealed an admitted [DATE] with diagnoses which included: Dementia (decline in cognitive abilities), Atrial fibrillation (Abnormal heart rhythm), Insomnia (Sleep disorder), Malignant neoplasm of female breast (Breast cancer) Record review of Resident #93's physician orders for October 2023 revealed an order for amlodipiine Besylate Tablet 5 MG Give 1 tablet by mouth in the morning related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) hold if sbp (Systolic blood pressure) under 100, or dbp (Diastolic blood pressure) under 60, or pulse under 60 Observation on 10/19/23 at 8:52 a.m revealed, while administering medications, Medication Aide F took the blood pressure and pulse of Resident #81. Further observation at 8:58 a.m. revealed, Medication Aide F took the blood pressure and pulse of Resident #93 with the same blood pressure/pulse cuff that was used for Resident #81. Medication aide F did not sanitize the blood pressure/pulse cuff between the two residents. During an interview with Medication aide F on 10/19/2023 at 9:15 a.m. the medication aide confirmed she forgot to use a wipe to clean the blood pressure/pulse cuff between use. She revealed it was causing a risk of cross contamination. She received infection control training within the year. During an interview on 10/19/2023 at 3:34 p.m., the DON confirmed the medication aide should have sanitized the blood pressure/pulse cuff in between resident to avoid cross contamination. She revealed infection control training was provided to the staff multiple times a year. She revealed the staff's skills were checked annually. She also stated the ADON and herself would do spot check of the staff for skills and infection control knowledge. Review of the facility's policy, titled Infection prevention and control program, dated 10/2022, revealed 10 Disinfecting multi-patient use equipment or supplies after each use and stored appropriately 2. Record review of Resident #31's face sheet, dated 10/19/2023, revealed an admitted [DATE] and, a readmitted [DATE], with diagnoses which included: Chronic atrial fibrillation (heart rhythm disorder), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Chronic kidney disease (gradual loss of kidney function), Hemiplegia (Paralysis of one side of the body) and, Urinary tract infection (an infection in any part of the urinary system). Record review of Resident #31's MDS quarterly assessment, dated 07/27/2023, revealed the resident had a BIMS score of 7, indicating moderate cognitive impairment. Resident #31 required extensive assistance and was always incontinent of bowel and bladder. Record review of Resident #31's care plan revealed a care plan revised 08/30/2023 with a problem of I am at risk for significant infections and/or recurrent infections r/t compromised medical condition: Actual Infections: UTI (urinary tract infection) and a goal of I will not experience any complications to include distress throughout the course of my treatment of infection until resolved and/or next revision Observation on 10/19/23 10:20 a.m., revealed while providing incontinent care for Resident # 31 CNA G, after washing her hands, touched the trash can with her gloved hands. She did not change her gloves or wash her hands, then, started providing care for Resident #31. LVN H touched the door and privacy curtain to close them and without changing her gloves or washing her hands, touched the resident to position her and the clean brief and fasten it on the resident, During an Interview on 10/19/2023 at 10:30 a.m., CNA G confirmed she touched the trash can after washing her hands and putting her gloves one. She did not realize the trash can was considered contaminated and that she should have changed her gloves and clean her hands. She confirmed receiving infection control training within the year. During an interview on 10/19/2023 at 10:30 a.m., LVN H confirmed not changing her gloves and cleaning her hands after touching the door and privacy curtain. She confirmed she needed to clean her hands and change gloves, but she forgot. She confirmed receiving infection control training within the year. During an interview with the DON on 10/19/2023 at 3:34 p.m., the DON confirmed the staff should change gloves and wash their hands after touching the environment directly around the resident She confirmed the staff was trained in infection control within the year. She revealed the staff's skills were checked annually by the ADON and they would spot check skills in case of concerns with infection control. Review of the facility's policy, titled Infection prevention and control program, dated 10/2022, revealed Educating staff and ensuring that they adhere to proper infection prevention and control practices when performing resident care activities

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 2 of 7 residents (Residents #2 and #56) reviewed for privacy, in that: 1. CNA A and CNA B did not close Resident #2's window curtain while providing incontinent care for the resident. 2 LVN M did not completely close Resident #56's privacy curtain while providing wound care for the resident. These failures could place residents at-risk of loss of dignity due to lack of privacy. The findings include: 1. Record review of Resident #2's face sheet, dated 10/19/2023, revealed an admitted [DATE], with diagnoses which included: Peripheral vascular disease (Abnormal narrowing of arteries), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Hypertension (High blood pressure) and, Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 3, indicating she was severely impaired. Resident #2 required extensive assistance and was always incontinent of bladder and frequently incontinent of bowel. Record review of Resident #2's care plan, dated 09/13/2023, revealed a problem of I have incontinence r/t (related to) Activity and a goal of I will remain free from skin breakdown due to incontinence and brief use through the review date. Observation on 10/19/23 at 1:24 p.m. revealed CNA A and CNA B did not close the window curtain while providing incontinent care for Resident #2. Anybody walking outside would have been to see the resident fully exposed. During an interview with CNA A and CNA B on 10/19/2023 at 1:30 p.m., CNA A and CNA B confirmed the window curtain was not closed while they provided care for Resident #2 but it should have been. They revealed they forgot to lose it. They confirmed receiving training for residents rights within the year. During an interview with the DON on 10/19/2023 at 3:34 p.m., the DON confirmed the window curtain should have been closed to protect the privacy of the resident. She confirmed the staff were trained in resident rights 2. Record review of Resident #56's face sheet, dated 10/23/2023, revealed an admitted [DATE] and, a readmitted [DATE], with diagnoses which included: Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypothyroidism (under active thyroid) and, Dementia (decline in cognitive abilities) Record review of Resident #56's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 0, indicating she was severely impaired. Resident #56 required extensive assistance to total care and was always incontinent of bladder and bowel. Record of Resident #56's care plan, dated 07/10/2023, revealed a problem of My skin is fragile and I am at risk for skin injury--new or worsening skin condition. 0/10/23 pressure ulcer to Sacrum. with an intervention of Apply treatment as ordered. Observation on 10/20/2023 at 9:03 a.m. revealed LVN M provided wound care for Resident #56, exposing the end of the resident's bed which could be seen from the door if someone had entered the room during care. Further observation revealed LVN M did not pull the curtains completely around Resident #56's bed to offer privacy to the resident during care because the privacy curtain was not long enough During an interview with LVN M on 10/20/2023 at 9:16 a.m., LVN M confirmed the privacy curtain was not completely closed while she provided care for Resident #56, but it should have been. She confirmed receiving training for residents' rights within the year. During an interview with the DON on 10/20/2023 at 12:52 p.m., the DON confirmed the privacy curtain should have been closed to protect the privacy of the residents. She confirmed the staff was trained in resident rights The DON revealed The ADON would annually check the skills and knowledge of the staff and sport check were done if a concern was noted. Review of facility policy, titled Standards for clinical procedures, dated January 2022, revealed [ .] g. Pull the privacy curtain between the residents, even if the roommate is not present. close windows blinds.

Based on interview and record review, the facility failed to report alleged violations related to neglect or abuse, including injuries of unknown source, are reported immediately, but not later than 24 hours after the allegation is made to the administrator of the facility and to other officials (including to the State Survey Agency), for 1 of 39 residents (Resident #9) reviewed for abuse and neglect, in that: The facility failed to report to the State Survey agency (HHSC) when Resident #9 alleged a dietary cook hit her on the arm on 08/16/2023. This failure could place residents at risk for abuse and neglect. The findings were: Record review of Resident #9's face sheet, dated 10/19/2023, revealed the resident was readmitted on [DATE] (original admission on 05/22/2015) with diagnoses that included: major depressive disorder, age-related physical debility, and muscle weakness. Record review of Resident #9's quarterly MDS assessment, dated 03/11/2023, revealed the resident had a BIMS score of 15, which indicated intact cognitive impairment. Record review of the Grievance/Concern Report - Residents and Families, dated 08/21/2023, revealed Room Name: Resident Council. [ .] Concern/Details: Resident #9 claimed [name of Dietary Cook C] from kitchen hit her on the arm. Resident did speak to [name of Administrator] about incident. [ .] Action Taken: on 8/16/23 resident approached this writer [Administrator] in hallway & stated [name of Dietary Cook C] in the kitchen hit her on the arm. Resident [#9] stated she got me my food & then hit me on the arm. I [Administrator] asked if she did it to be mean or like she was patting her to say here you go. She [Resident #9] stated she didn't know. I [Administrator] asked her [Resident #9] if she believed she [Dietary Cook C] was trying to hurt her, if so I [Administrator] would call the police & notify the state & her family. Resident [#9] started laughing & stated no she [Resident #9] just didn't want her [Dietary Cook C] to do that anymore. I [Administrator] assured resident [#9] that I [Administrator] would speak with [name of Dietary Cook C] & this wouldn't happen again. Conversation held with [name of Dietary Cook C] & documented. [name of Dietary Cook C] is aware that Resident [#9] does not want to be touched. Record review of Tulip, on 10/19/2023, revealed no incident report for Resident #9, during 08/2023, of Resident #9's alleged staff complaint. During an interview on 10/18/2023 at 2:25 p.m., Resident #9 stated she told an unknown staff member that she wanted cottage cheese and then Dietary Cook C came to her and hit her on her arm, while motioning to her upper left arm. She stated she believed it was last month. She stated she felt bad because all she did was ask for something and then was hit by staff. Resident #9 stated she told the Administrator and he had told her he would contact the police and correct it but she never saw anything done. Resident #9 stated that Dietary Cook C didn't even come apologize to her or anything. During an interview and record review, of written grievance dated 08/21/2023, on 10/20/2023 at 10:55 a.m., Activity Assistant stated she remembered the incident and that Resident #9 first brought up the incident during resident council on 08/16/2023. She stated that Resident #9 told her that she had asked someone for something (believed it was cottage cheese but couldn't remember) and that Dietary Cook C had swatted her on the arm. During an interview and record review, of written grievance dated 08/21/2023, on 10/20/2023 at 11:00 a.m., the Administrator stated he remembered the incident. He stated he contacted Resident #9's family about this incident and he said they laughed and stated Resident #9 was not a touchy feely person and did not like to be touched. The Administrator stated he believed it was not abuse and therefore was not reported because the resident stated she was not wanting it reported and that the resident stated she believed the staff was not being hurtful. During an interview and record review, of written grievance dated 08/21/2023, on 10/20/2023 at 11:21 a.m., Dietary Cook C stated Resident #9 asked for cottage cheese and she placed it on the table and then tapped the resident on the shoulder to say here you go. She stated Resident #9 had no response afterward. Dietary Cook C stated the Administrator spoke with her about the incident and asked her what happened and for her not to touch Resident #9 anymore. She stated that she was not aware of what should be reported but if a resident was claimed abuse, then maybe it should be reported. During an interview and record review, of written grievance dated 08/21/2023,on 10/20/2023 at 12:31 p.m., the DON stated she believed she was on PTO at the time and only recalled the incident upon her return to work. She stated she believed it was not a reportable because of the resident's statements and it was probably just a tap [instead of a hit]. Record review of facility's Abuse Guidance: Preventing, Identifying, and Reporting, dated 02/2017, revealed Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. [ .] Report any alleged or suspicions of abuse to HHSC by telephone reporting or via TULIP reporting with the designated time frames in accordance with HHSC's PL 19-17 (Replaces PL 17-18)[a] are reported immediately, [b] but not later than 2 hours after the allegation is made, if the events cause the allegation involve abuse or result in serious bodily injury; [c] or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, [ .].

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 27 residents (Resident #81) whose assessments were reviewed, in that: Resident #81's Annual MDS incorrectly documented the resident as receiving an insulin injection. This failure could place residents at-risk for inadequate care due to inaccurate assessments. The findings were: 1. Record review of Resident #81's face sheet, dated 10/18/2023, revealed an admitted [DATE], with diagnoses that included: Hemiplegia(Paralysis of one side of the body), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood) and, Cerebral infarction (Stroke). Record review of Resident #81's Physician orders and Medication administration record for August 2023 revealed orders for: Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous Solution Peninjector 2 MG/3ML (Semaglutide) Inject 1 milliliter subcutaneously one time a day every Mon related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) Wipe pen prior to applying needle Record review of Resident #81's Annual MDS, dated [DATE], revealed the assessment indicated Resident #81 received an injection of insulin. During an interview with MDS nurse D on 10/20/23 at 12:05 p.m., the MDS nurse confirmed she had completed the MDS. The MDS nurse confirmed Resident #81's Annual MDS was coded as the resident having received an insulin injection when Resident #81 had only received Ozempic (medication used for the treatment of type 2 diabetes in combination with diet and exercise) . The MDS nurse revealed she did not know why she had coded Ozempic as an insulin. She confirmed Ozempic was a non-insulin injection pen and should not have been coded as an insulin injection. The MDS nurse revealed the RAI was used as reference for the MDS and she had access electronically to the RAI on her computer. Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, October 2019, revealed, Enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received.

Based on interview and record review, the facility failed to revise the comprehensive person-centered care plan to reflect the current condition for 1 of 20 residents (Resident #86) reviewed for care plan revisions The facility failed to update Resident #86's care plan to reflect his risk for elopement This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: Record review of Resident #86's face sheet, dated 10/20/2023, revealed he was admitted to the facility on [DATE] with diagnoses which included: Dementia (decline in cognitive abilities), Heart disease, Insomnia (Sleep disorder), Dysarthria (Speech sound disorder) and, Ataxic gait (lack of voluntary coordination of muscle movement) Review of Resident's 86 quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 8 which indicated moderate cognitive impairement. Resident #86 was coded as no behavior for the look back period. Record review of Resident #86's care plan with a review date of 09/14/2023 revealed there was no risk for elopement care plan. Review of Resident #86's nurse's progress note, dated 08/09/2023, revealed Resident ambulating again by pushing his wheelchair towards middle of building -and trying to go outside again-- voicing he was going outside to sit down-- three staff members redirecting him back to his room and he did. Review of Residnet #86's nurse's progress note, dated 09/28/2023, revealed Resident has been redirected back to room from nearest exit doors X 3 by CNA. Resident is having hallucinations. States someone is coming to pick him up. Offered snack and a drink. Redirected resident back to room. No questions or concerns at this time During an interview on 10/20/23 at 12:52 p.m., the DON confirmed Resident #86 was trying to exit the building and confirmed that no care plan for elopement or exit seeking had been created. The DON Confirmed a care plan should have been created and that they had apparently forgotten to create a care plan. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, Version 1.18.11, October 2023 revealed Therefore, facilities are responsible for assessing and addressing all care issues that are relevant to individual residents, regardless of whether or not they are covered by the RAI (42 CFR 483.20(b)), including monitoring each resident ' s condition and responding with appropriate intervention