Every finding on record at The Villages of Dallas

Based on observation, interview and record review, the facility failed to maintain an effective pest control program for the facility's 1 of 1 kitchen reviewed for pest control.The facility failed to keep an effective pest control program to ensure the facility's 1 of 1 kitchen was free of mice or rat feces.This failure could place residents at risk for food-borne illness, cross contamination, poor sanitary environment, and infection.During an observation of the facility's only kitchen on 07/28/2026 at 10:00 a.m., the following was revealed: small uniform black to gray pellets approximately 1 to two mm in size inside the kitchen cleaning closet along the left wall under the metal shelving.small uniform black to gray pellets approximately 1 to two mm in size on the kitchen baking room floor between the stove and the industrial mixer, as well as inside the large mixing bowl resting on the mixer.small uniform black to gray pellets approximately 1 to two mm in size inside the dry storage area along the left and right walls under the metal shelving.During an interview on 07/28/2026 at 10:27 a.m., [NAME] D said she had not seen any live mice for about a month, but she noticed fresh mouse or rat feces every day even after cleaning them up. She said that a mouse ran across her foot in the kitchen a month ago and that she never received training on what to do when she sees mice in the kitchen. She said she had not seen pest control in the kitchen for about two months and that mice or rats tracking bacteria across countertops could contaminate the kitchen and endanger residents' health.During an interview on 07/28/2026 at 10:33 a.m., [NAME] E said he observed a mouse running across the kitchen floor approximately two weeks prior but had not seen any mouse or rat feces since that time. He said he received in-service training on pest control protocols, which instructed staff to log any mice or rat sightings or feces into TELS and immediately report the findings to the DM.During an interview on 07/28/2026 at 10:38 a.m., the Assistant DM said approximately three weeks had passed since his last mouse sighting and noted that the kitchen underwent daily mopping and cleaning. He said he received in-service training on pest protocols, which directed staff to report any mouse or rat activity or feces to the DM. He said that the presence of mouse or rat feces in the kitchen posed no health or safety risks to the residents.During an interview on 07/28/2026 at 10:45 a.m., the DM said the industrial mixer located in the baking room had remained unused during her seven-years at the facility, she said that while the room itself underwent daily cleaning, staff only cleaned the specific equipment they used. She said she received in-service training regarding pest reporting protocols both last week and the prior month, she was instructed to either notify the maintenance department directly or submit a work order through TELS. She said she saw a live mouse in the kitchen last week and stated that she promptly notified the maintenance department. She said that her staff members understood the protocol to report any mouse or rat sightings or feces directly to her or to the front desk personnel for logging into the TELS database. She said the facility's contracted pest control service visited the building weekly, resulting in a noticeable decrease in rodent activity. She said that the presence of mouse or rat feces in the kitchen posed a significant health risk that could cause widespread illness among the residents.During an interview on 07/28/2026 at 10:45 a.m., the facility's Pest Control Operator (owner of the third party pesticide company hired by the facility) said the facility was experiencing a mouse infestation that would take time to resolve. After seeing the small uniform black to gray pellets in the kitchen he agreed they were mouse feces. He said he was working directly with the Administrator to fix the issue, which included visiting the facility twice a week for regular maintenance. He said during these visits, he applied targeted treatments to any areas with reported mouse activity and checked the building for holes where they could get inside. He said he reported any openings he found to the Administrator, and that he fixed small holes on his own, but bigger holes required help from the maintenance department. He said that once the droppings were cleaned up, he set out traps for the mice. He said if later checks showed feces, he used chemical treatments and set out even more traps. He said he had heard mice could spread diseases, but he did not know the specific illnesses they carried. During an interview on 07/28/2026 at 3:13 p.m., the Administrator said the facility experienced an uptick in rodent activity during the month of May, which led to the termination of the maintenance director, who had failed to keep up with the structural repairs needed to keep pests out. He said that the facility had since focused on sealing open gaps throughout the building and ensuring an adequate number of traps were in place. He said that staff members received in-service training instructing them to log the exact location of any rodent or dropping sightings into the TELS database so the pest control service could address the area. He said the contracted pest control company visited the building twice a week to treat the property. He said the presence of mouse or rat feces in the kitchen posed a significant health risk that could cause widespread illness among the residents.In a record review on 07/28/2026 of the facility's Pest Control Service Inspection Report dated 06/02/2026 to 07/28/2026 revealed on 06/02/2026 the pest control company treated kitchen for mice activity., on 06/10/2026 the pest control company treated for rodents.installed mechanical traps in the ceiling also rebaited exterior., and on 06/16/2026 the pest control company treated for rodent also have traps set in the ceiling. Further record review revealed no other Service Inspection Reports for rodents after 06/16/2026.In a record review of the facility's Pest Control, policy revised July 2018, revealed Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program for insects and rodents

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 2 (200 Hall and 3000 Hall) of 2 hallways reviewed for accidents and hazards.1. The facility failed to ensure that 3 mechanical lifts were locked and secured when not in use on the 200 Hall. There was 1 mechanical lift and 1 wheelchair that blocked entry to the Fire Exit door on the 200 Hall.2. The facility failed to ensure that 3 mechanical lifts were locked and secured when not in use on the 3000 Hall.This failure could place residents, visitors and staff at risk of falls and/or injuries. Findings Included:Observation of the 200 Hall on 07/14/26 at 10:23 PM revealed 1 unlocked and unsecured mechanical lift parked on the hallway in between 2 resident rooms.Observation of the 200 Hall on 07/14/26 at 11:13 AM revealed 2 unlocked and unsecured mechanical lifts parked at the end of the hallway.Observation of the 3000 Hall on 07/14/26 at 12:19 PM revealed 3 unlocked and unsecured mechanical lifts parked on 2 hallways outside of resident rooms.Observation of the 200 Hall on 07/14/26 at 12:24 PM revealed 3 unlocked and unsecured mechanical lifts and 2 wheelchairs parked at the end of the hall. There were 1 Hoyer Lift and 1 wheelchair that blocked the entrance to the Fire Exit Door. During an interview on 07/14/26 at 1:03 PM with CNA A, she stated that she had been employed at the facility for 7 years. CNA A stated that she was assigned to the 200 Hall on 07/14/26. CNA A stated that she was unaware that the 3 mechanical lifts parked on the 200 Hall were unlocked and unsecured that day. CNA A stated she was unaware that 1 unlocked mechanical lift and 1 wheelchair were parked in front on the Fire Exit Door on the 200 Hall on 07/14/26. CNA A stated she was unaware that the 3 mechanical lifts parked on the 3000 Hall were unlocked and unsecured on 07/14/26. CNA A stated that she had taken in-service trainings on mechanical lift safety and storage, and fire safety. CNA A stated that she did not remember when she had previously taken in-service trainings on mechanical lift usage, safety, storage and fire safety. CNA A stated that mechanical lifts should be locked and secure when they were not in use. She stated she would check the mechanical lifts every time she passed them to ensure that they were secure and always locked. CNA stated there should never be anything including unlocked and unsecured mechanical lifts and wheelchairs parked in front of any Fire Exit Doors in the facility. CNA A stated that if she observed a staff member store the mechanical lift, she would ask them if they ensured that the parked mechanical lifts were always locked when they were parked. CNA A stated if a mechanical lift was unlocked, there was a risk of it being moved by someone, which would cause the mechanical lift to roll. She stated another risk of having an unlocked and unsecured mechanical lift and wheelchair blocking the Emergency Exit Door, was it could cause people to have no access to exit the building through the Fire Exit Door. She stated the Fire Exit Doors throughout the facility should be always cleared including unlocked and unsecured mechanical lifts and wheelchairs. CNA A stated that someone could be harmed by an unlocked mechanical lift and may fall and receive broken bones, fractures, and bust their head, which can cause a serious injury or possible death.During an interview on 7/14/26 at 2:01 PM with LVN B, she stated that she had been employed at the facility for 10 months. LVN B stated that she was Full Time Nurse assigned to the 200 Hall on 07/14/26. LVN B stated that she was unaware that the 3 mechanical lifts parked on the 200 Hall were unlocked and unsecured on 07/14/26. LVN B stated she was unaware that 1 unlocked mechanical lift and 1 wheelchair were parked in front on the Fire Exit Door on the 200 Hall on 07/14/26. LVN B stated she was unaware that the 3 mechanical lifts parked on the 3000 Hall were unlocked and unsecured on 07/14/26. LVN B stated that she had taken in-service trainings on mechanical lift safety and storage, and fire safety. LVN B stated that she could not recall when she had previously taken in-service trainings on mechanical lift usage and safety and fire safety. LVN B stated she thought that the last In-Service Training she had taken was about 30 days ago. LVN B stated all mechanical lifts were to be always locked and secured when they were not in use. LVN B stated she did not work on the 3000 Hall, but the mechanical lifts on each hall should always be locked at secured. LVN B stated if she observed an unlocked mechanical lift, she would immediately park the mechanical lift and ensure it was in a safe area away from any hazards. LVN B stated mechanical lifts and wheelchairs or anything should never be placed in front of the Fire Exit Door to prevent hazards and access to the Fire Exit Door in case of an emergency. LVN B stated that she would ensure and tell other staff members that the mechanical lifts on the hallway adjacent to the 3000 Hall were always locked and secured when parked and not in use. LVN B stated that mechanical lifts should always be locked and secure, such as the hallways when they were not being used. LVN B stated that harm could be caused to anyone when a mechanical lift was unlocked, which included accidents and falls due to the unlocked and unsecured mechanical lift being moved and rolled. She stated that someone could be harmed by having a serious fall with injuries, such as someone's foot getting caught in the mechanical lift, and someone falling face and landing on the floor. LVN B stated harm such as cuts, bruises and fractures, which has potential for someone to be hospitalized due to a mechanical lift being on the hallway unlocked and unsecured.During an interview on 07/14/26 at 2:34 PM with the DON, she stated that she had been employed at the facility for 9 years. The DON stated that she was unaware that the 3 mechanical lifts parked on the 200 Hall were unlocked and unsecured on 07/14/26. The DON stated she was unaware that 1 unlocked mechanical lift and 1 wheelchair were parked in front on the Fire Exit Door on the 200 Hall on 07/14/26. The DON stated she was unaware that the 3 mechanical lifts parked on the 3000 Hall were unlocked and unsecured on 07/14/26. The DON stated that her expectation for all staff at the facility was to ensure that all mechanical lifts in the facility were to be locked and secured when they were parked and not in use. The DON stated that all staff have been educated and trained on the proper usage and safety of mechanical lifts, which included always locking at always securing them. The DON stated that all staff have been educated on Fire Safety, which included ensuring that the Fire Exit Doors were always cleared and free of any debris in case of an emergency. The DON stated that she could not recall when all staff received their last in-service training on mechanical lifts, safety, accidents and hazards and fire safety. The DON stated that she will reeducate staff with in-service training on mechanical lifts safety and storage and fire safety. The DON stated that the in-service training for staff would also include education on performing routine checks of the mechanical lifts in the building to ensure they were always locked. The DON stated the facility did not have a designated area for storage for the mechanical lifts in the building. She stated she would have to meet with management to locate designated areas for mechanical lift storage throughout the facility. The DON stated there was a risk to anyone in the facility to be injured due to an unlocked and unsecured mechanical lift. She stated the risk was the resident and/or staff could bump against the unlocked mechanical lift and cause an accident. The DON stated the risk of the Fire Exit Door being inaccessible in the event of an accident could prevent anyone from exiting the floor through that door during an emergency. The DON stated she felt that there was no harm caused to anyone in the facility due to the unlocked and unsecured mechanical lifts and blocked Fire Exit Door because there had not been any reported accidents or incidents at the facility. The DON stated that the facility did not have any policies regarding accidents and hazards.During an interview with the Administrator on 07/14/26 at 2:55 PM, he stated that the facility did not have a policy for accidents and hazards relating to mechanical lift safety and storage.The policies received on 07/14/26 were encrypted. So, an email was sent to the Administrator on 07/21/26 at 11:31 AM, requesting the facility's policy, Fire Safety relating to accidents and hazards The surveyor did not receive a response from the Administrator on 07/21/26.Record Review of facility's policy revised May 2007 for Incident Accident Reporting, did not provide any information regarding accidents and hazards relating to mechanical lift safety and storage.Record Review of facility's policy revised July 2018, for Equipment Inspection and Maintenance, did not provide any information regarding accidents and hazards relating to mechanical lift safety and storage.

Based on observation, interview, and record review, the facility failed to provide maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable for 2 of 2 areas (Shower Room and Utility Room) on the 200 Hall reviewed for safe, and clean environment.1. The facility failed to ensure the bed liner in the Shower Room on the 200 Hall was cleared from standing water on 07/14/26.2. The facility failed to ensure the sink in the Soiled Utility Room the 200 Hall was cleared from standing water and working properly on 07/14/26.These failures place residents at risk for a diminished quality of life, infection, and clean environment.Findings included:During an observation of the facility's 200 Hall Shower Room on 07/14/26 at 11:17 AM, the Shower Bed Liner underneath the Shower Bed had 4 puddles of standing water. The standing water appeared light brown in color. The Shower Bed Liner appeared to be white in color with areas that appeared to be brown and black in color. During an observation of the facility's 200 Hall Utility Room on 07/14/26 at 11:25 AM, the sink was filled with standing water. The standing water appeared light brown in color. There was a glove, plastic clear cup, and 2 other unknown items that were floating inside the standing water in the sink. The sink appeared to be white in color with dirt, which appeared to be brown in color. During an observation of the facility's 200 Hall Shower Room on 07/14/26 at 12:27 PM, the Shower Bed Liner underneath the Shower Bed had 4 puddles of standing water. The standing water appeared light brown in color. The Shower Bed Liner appeared to be white in color with areas that appeared to be brown and black in color. During an observation of the facility's 200 Hall Utility Room on 07/14/26 at 12:31 PM, the sink was filled with standing water. The standing water appeared light brown in color. There was a glove, plastic clear cup, and 2 other unknown items that were floating inside the standing water in the sink. The sink appeared to be white in color with dirt, which appeared to be brown in color. During an observation on 07/14/26 at 12:57 PM, a confidential resident was observed exiting her room on the 200 Hall with an empty soda can box. The confidential resident opened the door to the Utility Room and threw the empty soda can box into the trash can in the Utility Room on the 200 Hall. During a telephone interview with Resident #1's RP on 07/13/26 at 3:58 PM, she stated Resident #1 was admitted to the facility for 6 years. The RP stated she had washed her FM's hair on several occasions in the Shower Room on the 200 Hall. The RP stated on 07/12/2026, she provided her FM with a hair shampoo in the Shower Room on the 200 Hall. The RP stated on 07/12/26, the Shower Room on the 200 Hall had the same Shower Bed Liner with the puddles of brown water. The RP stated she mentioned her concerns to the facility staff regarding the standing water in the Shower Room and there had not been any changes. The RP stated she had not filed any Grievances with the facility regarding her concerns about the standing water in the Shower Bed Liner in the Shower Room on the 200 Hall. During a confidential interview with a resident at an undisclosed date at time, they stated she had been at the facility for an unknown timeframe. The resident stated she utilized the Shower Room on the 200 Hall to bathe, which was three times per week. The residents stated she was in a wheelchair but was independent and able to take showers independently. The resident stated the Shower Bed Liner in the Shower Room on the 200 Hall had, some yucky water puddles, which were brown with some kind of unknown substance in the water, and the was dirty and gross. The resident stated the puddles of water in the Shower Bed Liner had been there for an unknown period, but they have been there for some time. The resident stated she reported to staff about the Shower Bed Liner being dirty, but it did not make a difference. The resident stated she had not filed any Grievances with the facility regarding her concerns with the Shower Bed Liner in the Shower Room on the 200 Hall. The resident stated the water in the sink in the Utility Room on the 200 Hall had been there for an unknown time frame. The resident stated she did not file any Grievances with the facility regarding her concerns with the water in the sink in the Utility Room on the 200 Hall. During an interview on 07/14/26 at 1:03 PM with CNA A, she stated she had been employed at the facility for 7 years. CNA A stated that she was assigned to the 200 Hall on 07/14/26. CNA A stated she was unaware that the Shower Bed Liner in the Shower Room and the Utility Room the 200 Hall had standing water in both areas. CNA A stated she had not observed standing water in both areas at any time. CNA A stated there should not be any standing water in the Shower Room and the Utility Room areas on the 200 Hall. CNA A stated if there was an issue with the shower drains or the sink being clogged up, she would notify someone in the Maintenance Department and submit a Maintenance Repair Request to fix the problem. CNA A stated the sink in the Utility Room was used to rinse out the soiled or stained items, such as undergarments, clothing and linen prior to placing them in the soiled containers in the Utility Room. CNA A stated if a resident had a bowel movement, the sink in the Utility Room would be used to rinse and clean the bowel movement from the garment, so the item would not be sent to the Laundry Department with the bowel movement on the items. CNA A stated she previously received In-Service Trainings on Infection Control and Maintenance Repair Requests. CNA A stated the risk of standing water being in the Shower Room and Utility Room areas on the 200 Hall was that an incoherent resident could ingest the standing water. CNA A stated if an incoherent resident ingested the standing water, they could be harmed by having stomach issues. CNA A stated if the standing water was spilt from both areas, someone could slip and fall due to the water being on the floor. CNA A stated a fall from water being on the floor could cause a busted head and/or broken bones. During an interview on 07/14/26 at 2:34 PM with the DON, she stated that she had been employed at the facility for 9 years. The DON stated she was unaware that the Shower Bed Liner in the Shower Room and the Utility Room of the 200 Hall had standing water in both areas on 07/14/26. The DON stated all staff had taken In-Service Trainings on Infection Control and Maintenance Repair Requests. The DON stated, on 07/14/26, she observed the Shower Bed Liner on the Shower Bed in the Shower Room on the 200 Hall. The DON stated she observed the puddles of water in the Shower Bed Liner. The DON stated the Shower Bed Liner was removed from underneath the Shower Bed in the Shower Room in the 200 Hall. The DON stated the Shower Bed Liner was not needed on the Shower Bed due to there being a drain on the floor in the shower. The DON stated on 07/14/26, the standing water was observed in sink in the Utility Room on the 200 Hall. The DON stated she notified the Maintenance Department to have the sink repaired, if needed. The DON stated she would have staff perform daily Routine Rounds/Checks on each hall in the Utility Room and Shower Rooms to ensure that there was no standing water or repairs needed in both areas. The DON stated the staff would be re-educated via In-Service Trainings. The DON stated the In-Service Trainings would include entering all Maintenance Repair Requests in the facility's electronic maintenance tracking system, and discuss any findings regarding Maintenance Requests in the daily morning meetings. The DON stated there was no risk of harm to a resident with the standing water being in the Shower Room and Utility Room areas due to there being no incidents reported at the facility. During an interview on 07/14/26 at 3:31 PM with the Maintenance Staff C, he stated that he had been employed at the facility for 12 years. Maintenance Staff C stated the Shower Bed Liner in the Shower Room on the 200 Hall was removed by staff on 07/14/26 and he was unable to view the puddles of water that were in the Shower Bed Liner due to the Shower Bed Liner being removed by staff. Maintenance Staff C stated he observed the water in the sink in the Utility Room on the 200 Hall. He stated he observed the sink filled with water, and there was a glove, plastic cup and some other items from the sink. He stated he threw all the items from the sink into the trash can. He stated the sink in the Utility Room was not clogged due to needing to be repaired but was clogged because the items in the sink covered the sink drain, which caused the water and items in the sink to remain in the sink. Maintenance Staff C stated he reviewed the Maintenance Requests for the 200 Hall, and there had not been any relating to the Shower Bed Liner in the Shower Room and the sink in Utility Room on the 200 Hall. He stated that he would have an In-Service Training with the staff to ensure that all staff were on the same page with completing a Maintenance Request in TELS. Maintenance Staff C stated the facility did not have Maintenance Repair or Request Logs and the staff utilized TELS for maintenance repairs. He stated that the risk of standing water being in the sink and bathroom areas for 1-2 days had a potential of odors and breathing issues. Maintenance Staff C stated there was a potential of harm to anyone who encountered the standing water, which may cause skin irritations. Maintenance Staff C stated there was a potential of harm to anyone who ingested the standing water to have a bacterial infection due to germs. Record Review of the facility's Grievance Logs for April 2026 - July 2026 revealed no concerns regarding the Shower Bed Liner in the Shower Room and the Utility Room areas having standing water. An email was sent to the Administrator on 07/21/26 at 11:31 AM, requested the facility's policy, Fire Safety relating to accidents and hazards due to the policy's received on 07/14/26 being encrypted. The surveyor did not receive a response from the Administrator on 07/21/26. Record Review of the facility's policy revised 07/2022, for Quality Care - ADL, Services to Carry Out, revealed:Policy:It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. Procedures:1. Maintenance and restorative provided to residents in accordance with he resident's comprehensive assessment.2. If a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene will be provided by qualified staff. Record Review of facility's policy revised 07/2018, for Equipment Inspection and Maintenance, did not provide any information regarding, and ensuring a safe, clean environment.

Based on observation, interview and record review, the facility failed to ensure an effective pest control program so the facility was free of pest and rodents two (Residents #1 and #2) of five residents reviewed for pest control.The facility failed to keep an effective pest control program to ensure the resident's rooms were free of rodents.This failure could place residents at risk for reduced quality of life and poor sanitary environment.Findings included:Record review of Resident #1's face sheet dated 06/10/26 revealed that she was a [AGE] year-old female with an initial admission date of 02/04/2026. Her diagnoses included: Pressure Ulcer Stage 2, Need for Assistance with Personal Care, and Cellulitis of Right Lower Limb.Record review of Resident#1's Quarterly MDS dated [DATE] revealed that Resident #1 had a BIMS score of 15 (Cognitively Intact) and required the help of at least one helper for toileting, showers, dressing, and personal hygiene. Record review of Resident #1's Comprehensive Care Plan dated 02/09/2026 revealed Resident #1 had a Focus: ADL Self Care Deficit related to chronic lower extremity weakness, swelling chronic back pain, lymphedema chronic with elephantiasis, generalized osteoarthritis. Goal: Will safely perform Bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene through the review date. Interventions: Transfer (chair/bed to bed to chair transfer, toilet transfer): Requires one to two staff participation with transfers.Record Review of Resident #2's face sheet, dated 06/10/26 revealed that she was a [AGE] year-old female with an initial admission date of 04/29/2022. Her diagnoses included: Mild Cognitive Impairment of uncertain or Unknown Etiology, Type 2 Diabetes Mellitus with Unspecified Complications and Respiratory Disorders.Record Review of Resident #2's Nursing Home Comprehensive MDS dated [DATE] revealed Resident #2 had a BIMS score of 15 (Cognitively Intact) and required partial/moderate assistance for sit to lying, lying to sitting on side of bed, and toilet transfer.Record review of Resident #2's Comprehensive Care Plan dated 03/21/26 revealed that Resident #2 had a Focus: Has altered respiratory status/Difficulty Breathing related to Chronic Respiratory Failure with Hypoxia. Goal: Will have no signs or symptoms of poor oxygen through the review date. Interventions: Administer medications/puffers as ordered. Monitor for effectiveness and side effects.Record Review of the facility Grievance Logs from 03/01/2026 to 05/30/2026 found a grievance from Resident #4, Date Reported: 4/1/26 (Room Number Redacted), Summary of Concern Resident stated that she saw a rodent in her room Resolution: Pest Control Services sprayed her room and building. Date Resolved: 4/2/26.Record Review of the Pest Control Sighting Log/Log Book Check-In Dated from 04/22/26 to 06/05/2026 revealed Rats or Rodents sighted on the following dates: 4/22/26, 4/27/2026, 4/30/2026, 5/7/2026, 5/12/2026, and 6/2/2026. A service inspection Report dated 05/29/2026, Order # 102236 noted that Inspected Traps in kitchen for mice activity and Inspected Traps in [NAME] [Building Residents # 1and #3 reside in] for mice activity.In an observation and interview on 6/10/2026 at 11:05 AM Resident #1 revealed that she had lived in her room for around 5 months. She stated that she had seen mice in her room several times and that two of her friends from church were visiting and they all saw the mice in her room. She stated that one of the rehabilitation therapists had been giving her a treatment in her room when they both saw a mouse run across the room and into her closet. She stated she had reported it to the facility staff and they had offered to move her to another room but she had refused to move because another unnamed facility staff had told her that the whole building was infested with mice. She stated that having mice in her room made her very uncomfortable. Observation on the floor of Resident #1's closet revealed around 20 small oblong, tapered at both ends black objects around 1/8th of an inch long, scattered on the floor. A visiting Administrator (ADM #2) from a sister building was in the room at the time of the observation and he stated that it could be mouse droppings.In an observation and interview on 6/10/2026 at 11:25 AM with Resident #2 and Maintenance Director. Resident #2 stated that she had seen mice several times coming in from under her room door and into her closet. She stated that she had mentioned it to some of the staff but could not recount who. She stated that she had been seeing the mice for a few months, she stated she was not interested in changing rooms. While observing the floor of Resident #2's closet and closet shelves the Maintenance Director entered the room and he also observed around 50 small oblong, tapered at both ends black objects around 1/8th of an inch long, scattered on the floor, similar fresher looking 1/8th inch long were found on a pillow in Resident #2's closet and also on the top shelf of her closet. The Maintenance director stated that the objects appeared to be mouse droppings.In an interview on 6/10/2026 at 11:48 AM the Maintenance Manager stated that he had received some complaints about mice in the building and that he had set out some glue traps in a few rooms and that he had caught a few mice. He stated that he had seen a live rodent in a resident's room around 10 days ago. He stated that he receives reports for maintenance through texts and through an electronic computer based system. He stated that Pest Control comes out to the facility twice a week lately but the campus was 27 acres and they treat different areas at different times.In an observation on 6/10/2026 at 12:00 PM of the outside perimeter of the building it was noted that a few of the screen coverings for the individual room air conditioners were not affixed securely to the wall. In an interview on 6/10/2026 at 1:23 PM Resident #5 stated that she had not seen a mouse in her room but that she had heard from several other residents that they had mice in their rooms and that she would be scared to death to see one.In an interview on 6/10/2026 at 1:52 PM Pesticide Operator (owner of the third party pesticide company hired by the facility) stated that he had been the provider of pesticide services for the entire 26 acre campus for over 5 years. He stated he was familiar with rodent droppings and after viewing pictures of the rodent droppings in Resident #1's and Resident #2's room he agreed that that the black oblong objects were definitely mouse droppings. He stated that he had been aware of rodent sightings in the facility for the last 6 months or so, and he had caught a few mice a couple of weeks ago and he had placed traps inside of the facility. He stated the snap traps were in non-residential areas of the facility, and glue traps in resident accessible areas. He stated that when it rains it drives rats and mice into the facility from the creek on the property. He stated it was possible for mice to nest inside of buildings but he did not think mice were nesting in the facility building. He stated that he had heard mice could spread diseases but he did not know which diseases and that residents could be disturbed by having mice in their rooms.In an interview on 6/10/2026 at 2:14 PM the ST stated that she had been in Resident #1's room performing some therapy with Resident #1 when she and Resident #1 both saw a mouse in Resident #1's room. She stated that she had reported it to her Director of Rehabilitation. She stated that residents could be embarrassed or scared to have mice in their rooms.In an interview on 6/10/2026 at 2:22 PM LVN A stated that she had not seen any mice herself but she had heard from Resident #1 that she had mice in her room. She stated she had reported it to maintenance and that mice could spread disease and upset residents if there were mice in their rooms or anywhere in the facility.In an interview on 6/10/2026 at 2:32 PM CNA B revealed that Residents #1 and #3 had complained to her that they had mice in their room. She stated that she had not reported it and she was unable to describe how to report it. She stated that she had not seen any mice herself but that she could definitely understand that residents would be upset by having mice in their rooms. In an interview on 6/10/2026 at 2:36 PM Resident #4 stated that she had seen mice in the last two months. She stated that she had seen mice run from her closet and into the bathroom and under her chair. She stated she had filed a grievance about it and the exterminator had come up into her room. She stated that mice scared her, and she was glad she had not seen any recently.In an interview on 6/10/2026 at 3:06 PM the DON revealed that she had not had any staff alert her about mice in the building. She stated that residents could be emotionally upset about having mice in their rooms. She stated that mice could spread disease and possibly could injure residents through bites. She stated that the facility would be looking into possibly hiring another exterminator company to assist with getting rid of all the mice. She stated that she was sure that there were no injuries or diseases that could be attributed to rodents in the facility.Record review of the facility's policy revised July 2018 and titled Pest Control reflected Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program for insects and rodents

Based on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for five of five residents in a confidential group of residents. The facility failed to provide palatable food served at an appetizing temperature to residents. This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction with the meals served and weight loss.The findings included: During a confidential interview five residents stated that they had received cold food. Residents stated it was not dietary's fault as the dietary staff gets the food out, but the carts have sat on the hall for five to ten minutes before staff pass the trays Observation of food cart on 04/15/2026 at 12:25 PM, revealed an insulated food cart on hall 1-[NAME] with 10 food trays. Two staff members observed passing trays. During an interview on 04/16/2026 at 9:51 AM, CNA D stated that she had received one or two cold food complaints. CNA D stated that when she received a cold food complaint that she would take the tray and rewarm the tray in the microwave. During interview on 04/16/2026 at 10:50 AM, CNA E stated she had received complaints from residents stating that the food was cold, but it had been about two months. CNA E stated that the facility ordered new carts that were enclosed which helped with keeping the temperature of the food. CNA E stated that they asked the residents if they would like their tray to be reheated and residents were usually fine once the tray was reheated. Observation of test tray on 04/16/2026 revealed it left the facility kitchen at 12:49 PM, arrived on hall at 12:52 PM, and the last tray was served at 12:58 PM. State surveyor tested test tray at 1:03 PM which revealed mashed potatoes that were cold, chicken fried steak was room temp, and green beans that were room temperature. Record review of January, February and March 2026 grievance log reflected no complaints of cold food. Record review of January, February and March 2026 resident council minutes reflected no complaints of cold food. Record review of seven resident's weights reflected no significant weight loss noted. During interview on 04/16/2026 at 2:06 PM, DM stated that she had received complaints about cold food. The DM stated that dinner was the primary meal, because she originally had ordered one set of plate warmers, but they did not go into the dishwasher until 3PM and dinner meal service started at 5PM and they would not be ready. The DM stated that they ordered another set and covered the plates, utilized plate warmers and had enclosed carts. The DM stated that all the equipment was ordered two months ago and had not had a complaint since. The DM confirmed the test tray was not provided with a plate warmer. She stated that it contributed to the plate not being hot. The DM stated that her or the cook should monitor their trays to ensure they had the plate warmer. The DM stated that the risk to the residents for food being cold was loss of appetite and weight loss. During interview on 04/16/2026 at 3:02 PM, the ADM stated that his expectation of his staff was that food be served to residents at a safe and appetizing temperature. The ADM stated that cold food was a major topic from the residents last year, so he decided to spend about $30,000 on insulated meal carts, custom lids to fit on top of plates, and plate heaters. Additionally, he opened a steam table on floor two to assist with food temperatures as this facility had a heavy census and multiple floors.The ADM stated if food was not served at an appetizing temperature, it could have caused residents to not want to eat their food which could have led to weight loss but was not aware of any residents who had weight concerns. Record review of invoices dated 3/12/2026 reflected four meal delivery carts, 10 sets of electric heat plates, 10 sets of plate covers for total of $31, 778. Requested meal service/preferred temperature policy via email on 04/16/2026 at 2:28 PM. Did not receive it prior to exit.

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 in the facility's only kitchen reviewed for food safety.The facility failed to discard spoiled items stored in the walk-in refrigerator.These failures could place residents at risk for food-borne illness, cross contamination, and infection.During an observation of the walk-in refrigerator on 04/14/2026 at 10:20 a.m., the following was revealed: 1 large clear bin of what appeared to be 29 yellow onions. The bin had no item description or expiration date and was marked with a delivery date of 02/25/2026. Seven items displayed black, fuzzy soot-like spots covering more than half of the surface, two had long green shoots extending from the ends, and six were soft, mushy, and slimy to the touch.1 large clear bin of what appeared to be several dozen lemons. The bin had no item description or expiration date and was marked with a delivery date of 03/30/2026. Two were soft, spongy, and mushy to the touch and two were wrinkled, bumpy, shriveled, and hard to the touch.During an interview on 04/14/2026 at 10:24 a.m., the DM stated that fresh fruits and vegetables were not labeled with expiration or discard dates. The DM indicated that staff determined whether produce was no longer safe for consumption by physically looking at it and would not use the item if it was bad. The DM further stated that, if a resident were to be served spoiled produce, they might get sick. During an interview on 04/16/2026 at 11:52 a.m., [NAME] A stated she would not use produce that looked spoiled and it could make the residents sick.In a record review of the facility's Infection Control Policy Food Service, dated 10/2025, revealed there was nothing about storing or identifying spoiled fruits or vegetables. Review of the U.S. FDA Food Code 2022 reflected: . Section 6-404.11 Products which are damaged, spoiled, or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods.To preclude this, separate and segregated areas must be designated for storing unsalable goods.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 6%, based on 31 opportunities and 2 errors, which involved 2 of 4 residents (Residents #49 and #35) and one of two staff (MA A) observed during medication administration for medication error. 1. MA A failed to administer Resident #49's MiraLAX Oral powder 17grm (for constipation) with the appropriate amount of fluid. MA A left the cup of medication with Resident #49. 2. MA A failed to administer Resident #35's MiraLAX Oral powder 17grm (for constipation) with the appropriate amount of fluid. These failures could place residents at risk for not receiving the therapeutic dosages of their medications as ordered by the physician and a decreased health status. Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 5%, based on 31 opportunities, which involved 2 of 4 residents (Residents #49 and #35) and one of two staff (MA A) observed during medication administration for medication error.1. MA A failed to administer Resident #49's MiraLAX Oral powder 17grm (for constipation) with the appropriate amount of fluid. MA A left the cup of medication with Resident #49. 2. MA A failed to administer Resident #35's MiraLAX Oral powder 17grm (for constipation) with the appropriate amount of fluid. These failures could place residents at risk for not receiving the therapeutic dosages of their medications as ordered by the physician and a decreased health status. Findings include: Record review of Resident #49's quarterly MDS assessment dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #49 had diagnoses which include: Hypertension (high blood pressure), cerebral vascular accident (stroke), and constipation (hard stool). Resident #49 was alert and oriented and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #49's physician's order, dated 04/13/2026, reflected MiraLAX Oral Powder 17 gm/scoop give one scoop every 24 hours as needed for constipation mix with four to eight ounces of fluid. Record review of the plan of care for Resident #49 dated 01/02/2026 reflected no goals related to self-administration of medications. Further review revealed no assessments related to self-administration of medicines for Resident #49. Observation on 04/14/2026 at 9:48 a.m., revealed MA A administered the following medication to Resident #49: MiraLAX 17 gm. was administered to Resident #49 by MA A with an undetermined amount of fluid. During the administration of the medication MA A did not stay in the room to observe Resident #49 finish drinking the fluid with medication provided in the cup. MA A did not follow up to assure Resident #49 had completed the medication. Record review of Resident #35's quarterly MDS assessment dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #35 had diagnoses which include: Hypertension (high blood pressure), cerebral vascular accident (stroke), non-Alzheimer's dementia (confusion) and constipation (hard stool). Resident #35 had moderate cognitive impairment and was unable to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #35's physician's order, dated 04/02/2026, reflected MiraLAX Oral Powder 17 gm/scoop give one scoop every 24 hours as needed for constipation mix with four to eight ounces of fluid. Observation on 04/14/2026 at 9:58 a.m., revealed MA A administered the following medication to Resident #35: MiraLAX 17 gm. was administered to Resident #35 by MA A with an undetermined (did not measure the fluid, just filled up the unmarked cup) amount of fluid. In an interview on 04/14/2026 at 10:15 a.m., MA A stated she knew better than to give the medications without measuring out the appropriate amount of fluid. MA A stated she thought the cups offered 4 ounces of fluid, but was not sure, she had never measured the fluid, she just filled the unmarked cup up and gave it to Resident #49 and Resident #35 to drink. MA A stated she would have to slow down and be more thorough and stay with the residents while they take their medication. In an interview on 04/16/2026 at 9:33 a.m., the DON revealed the staff should be reading the medication administration record prior to and after giving the medication to be assured they were giving the correct medicines at the right time. The DON stated the medication administration record gave the staff all the information for type of medication, how much to give, and if it was by mouth, topical, or eye drops or nose spray. The MiraLAX was to be given with 4 to 6 ounces of fluid and if the cups were not marked, they should be measuring the amount the cup would hold to make sure the resident was getting the correct amount of fluid. The DON stated the staff should never leave the residents with their medications; part of the medication pass was to ensure the residents received the correct medication and assured they were taking it. Record review of the facility's policy and procedure Medication Administration, dated July 2020, reflected, It is the policy of this facility that medications shall be administered as prescribed by the attending physician., procedures: 2. Medications must be administered in accordance with the written orders for the attending physician. the seven rights of medications administration are as follows in order to ensure safety and accuracy of administration. 4. Right Dose-Medications are administered according to the dose prescribed.

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 3 of 3 (MA A, CNA B, and CNA C) staff members and 3 of 5 residents (Residents #49, #35, and #15) reviewed for infection control procedures. MA A failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #49 and #35. CNA B and CNA C failed to change their soiled gloves and perform hand hygiene during incontinent care on Resident #15. These failures could place residents at risk for cross contamination and infections.Findings included: Record review of Resident #49's quarterly MDS assessment dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #49 had diagnoses which include: Hypertension (high blood pressure), cerebral vascular accident (stroke), and constipation (hard stool). Resident #49 was alert and oriented and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #49's physician orders dated 04/13/2026 (open ended) reflected, amlodipine (high blood pressure) 50mg give one tab by mouth once a day, and amlodipine Besylate (high blood pressure) 5mg give one tab by mouth two times a day and obtain blood pressure one time a day on each shift. Record review of Resident #35's quarterly MDS assessment dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #35 had diagnoses which include: Hypertension (high blood pressure), cerebral vascular accident (stroke), non-Alzheimer's dementia (confusion) and constipation (hard stool). Resident #35 had moderate cognitive impairment and was unable to make decisions and required assistance of one staff foractivities of daily living. Record review of Resident #35's physician orders dated 04/02/25 (open ended) reflected, metoprolol (high blood pressure) 75 mg give one tab by mouth two times a day. Obtain blood pressure one time a day on each shift. Record review of Resident #15's quarterly MDS Assessment, dated 01/13/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #15 had diagnoses which included: hypertension (increased blood pressure), and cerebrovascular accident (stroke). Resident #15 was severely cognitively impaired and unable to make decisions for herself and required two staff for assistance with activities of daily living. She was incontinent of bowel and bladder. Observation on 04/14/2026 at 9:48 a.m., revealed MA A performing morning medication pass, during which time she checked the blood pressure on Resident #49. MA A failed to sanitize the blood pressure cuff before or after using it on Resident #49. Observation on 04/14/2026 at 9:58 a.m., revealed MA A performing morning medication pass, during which time she checked the blood pressure, on Resident #35, using the same blood pressure cuff used on Resident #49. MA A failed to sanitize the blood pressure cuff before or after using it on Resident #35. An interview on 04/14/2026 at 10:15 a.m., MA A stated she did not think about cleaning the blood pressure cuff between usage, she did not know she needed to. MA A stated she had used hand sanitizer on her hands between each usage when she took the blood pressure. MA A stated if the cuff was on the residents and then not cleaned it could spread germs to others. MA A stated she had in-service in the past three months concerning infection control and cleaning of equipment and handwashing. MA A stated, I guess I just forgot. Observation on 04/14/2026 at 1:53 p.m. CNA B and CNA C entered the room to transfer Resident #15 back to bed and perform incontinent care and activities of daily living with Resident #15. CNA B and CNA C did not use hand gel in the hallway or wash their hands and donned clean gloves. Resident #15 was transferred from the wheelchair to the bed and was lying on her back in bed. CNA B explained to the resident what she was going to do, and the resident agreed. CNA B removed Resident # 15's pants, leaving on her top. CNA C unfastened the brief tabs and CNA B wiped the pubic area with a disposable wipe, discarded the wipe, in the trashcan, while CNA C held the trashcan over the bed, with no trashcan liner in it. CNA B used another wipe on the peri area and discarded it. CNA B repositioned Resident #15 to her right side while pulling the clean brief under the resident. CNA B then used another wipe on the left buttocks, pulling the urine soiled brief off and placing in the trashcan. CNA B repositioned Resident #15 to her left side while pulling the clean brief under the resident. CNA B and CNA C without changing their soiled gloves or washing their hands fastened the tabs of the clean brief, pulled down her shirt, repositioning her on the bed. CNA C and CNA B pulled up Resident #15 in the bed, pulled up the top sheet and blanket, after placing a pillow between the resident's legs. CNA B and CNA C placed their gloves in the trashcan and washed their hands removing the trashcan from the room. An interview on 04/14/2026 at 2:30 p.m. with CNA B and CNA C revealed the CNAs stated, they were supposed to cleanse their hands with hand sanitizer or wash them in between dirty and clean glove changes, but they (CNAs) always have to change this resident at the end of their shift and it gets frustrating for them, they get into a hurry, so they did not change their gloves or clean their hands. Both CNAs stated they had both had in-service in the past three months concerning infection control for handwashing and incontinent care. CNA C stated she was new to the facility and had the training when she was first hired, but she had been a CNA for a long time and just thought the other CNA knew what she was doing so she followed her. An interview with the DON, who was the infection control preventionist on 04/16/26 at 9:33 a.m., revealed the DON stated that all direct care staff must clean equipment, including blood pressure cuffs after having contact with each resident. The DON stated, the staff has available the disinfectant wipes that will kill all germs. The DON stated the staff when performing incontinent care should be changing gloves from dirty to clean and washing their hands or using the available hand sanitizer. The DON stated she and her ADON had just had an in-service on 03/25/2026 concerning all of this, presenting step by step the cleaning of equipment and incontinent care. The DON stated that some of the CNAs had spent extra time with them, to make sure they understood. The DON stated during the in-service the staff did not ask any questions and appeared to understand and indicated they knew everything. The DON stated if they do not clean the blood pressure cuffs appropriately and change gloves and clean their hands when they should, they could spread germs to themselves and the residents. Record review of an in-service log dated 03/25/2026 revealed MA A and CNA B, and CNA C (she had received at hiring) had received cleaning and properly storing equipment after each use and how to perform correct incontinent care. Record review of the Facility's Policy titled Infection Prevention and Control program dated revised October 2022, reflected: Policy: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection control prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotics stewardship, outbreak management, prevention of infection, and employee health and safety. The program will be carried out by the facility infection preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers. Goals: decrease the risk of infection to residents and personnel. recognize infection control practices while providing care. Reporting Mechanisms for infection control. 6. c. Effective cleaning and disinfecting equipment as needed .between each residents use. Record review of the Facility's Policy titled Infection control Prevention and Control program-Hand Hygiene undated reflected: This facility considers hand hygiene the primary means to prevent the spread of infections . 4. Use an alcohol-based hand rub or alternative soap and water following. h. before moving from a contaminated body site to a clean body site during resident care: i. after contact with a resident's intact skin. 6. The use of gloves does not replace hand washing/hand hygiene. Record review of the Facility's Policy titled Perineal/Incontinent Care dated December 2024 reflected: Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident to prevent infections and skin irritations, and to observe the resident's skin condition . Steps to procedure 1. Place equipment on bedside . 2. Wash and dry your hands thoroughly . 7. Put on gloves . [steps to perform incontinent care for male/female] . 12. Remove gloves and discard into designated container. Wash and dry hands thoroughly. 13. Replace the bed covers. Make the resident comfortable . 17. Wash and dry hands thoroughly

Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for three of five residents (Resident #1, #2, and #3) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1, #2, and #3's rooms was in a position that was accessible to the residents on 09/09/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: Record review of Resident #1's Face Sheet, dated 09/09/25, reflected she was an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Acute Respiratory Failure (lack of oxygen) and unsteadiness on feet. Record review of Resident #1's Quarterly MDS assessment, dated 08/26/25, reflected he had a BIMS score of 9 (moderate cognitive impairment). For ADL care, it reflected the resident required total assistance. Record review of Resident #1's Comprehensive Care Plan, dated 08/26/2025, reflected the resident was a fall risk and one of the interventions was to ensure call light was within reach of the resident and to encourage the resident to use it. In an observation on 09/09/25 at 8:30 AM, Resident #1 was observed lying in bed and his call light was located under his bed, out of reach from the resident. Record review of Resident #2's Face Sheet, dated 09/09/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and unsteadiness on feet. Record review of Resident #2's Quarterly MDS assessment, dated 09/01/25, reflected she had a BIMS score of 5 (severe cognitive impairment). For ADL care, it reflected the resident required total assistance. Record review of Resident #2's Comprehensive Care Plan, dated 09/04/25, reflected the resident was a fall risk and one of the interventions was to ensure call light was within reach of the resident and to encourage the resident to use it. In an observation on 09/09/25 at 8:31 AM, Resident #2 was observed lying in bed and his call light was located approximately 3 feet away from his bed, out of reach from the resident. In an interview and observation on 09/09/25 at 8:33 AM, CNA Q was shown the call lights location for Resident #1 and Resident #2. She located the call lights and placed them alongside the residents. She stated the call light needed to be placed within reach of the resident so they could contact someone if they neededassistance. In an interview on 09/09/25 at 8:35 AM, LVN C was advised of the call lights for Resident #1 and Resident #2 not being within reach of the residents. She stated staff checked the resident rooms at least every 2 hours to ensure call lights were within reach of the resident. She stated if the resident's call light was not within reach, they could not contact anyone if they needed help. She stated Resident #1 and Resident #2 were fall risk. Record review of Resident #3's Face Sheet, dated 09/09/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and unsteadiness on feet. Record review of Resident #3's Quarterly MDS assessment, dated 07/12/25, reflected she had a BIMS score of 12 (moderate cognitive impairment). For ADL care, it reflected the resident required total assistance. Record review of Resident #3's Comprehensive Care Plan, dated 07/22/25, reflected the resident was a fall risk and one of the interventions was to ensure call light was within reach of the resident and to encourage the resident to use it. In an interview and observation on 09/09/25 at 8:33 AM, LVN P was shown the call light for Resident #3 hanging behind the back of the resident bed frame and out of reach of the resident. Resident #3 stated she had been looking for her call light all night. LVN P placed the call light within reach of the resident and stated the call light needed to be placed within reach of the resident so she could contact staff if she required assistance or had an emergency. In an interview on 09/09/25 at 9:00 AM, the DON was advised of Resident #1, Resident #2, and Resident #3 not having their call light within their reach. She stated the nursing staff checked room at least every hour and checked for call lights being within reach. She stated they had placed clips on the call light to ensure they stayed in placed. She stated the call lights needed to be within reach of the resident so they could contact staff if they needed any assistance. Record review of the facility's policy on Call Light/Bell (08/03/21), revealed It is the policy of this facility to provide the resident the means of communication with nursing staff. Leave the resident comfortable. Place the call device within reach resident's reach before leaving room.

Based on observation, interview and record review the facility failed to ensure the resident was free from physical restraints not required to treat the residents' medical symptoms as was possible for one of five residents (Resident #4) reviewed for physical restraints. The facility failed to ensure Resident #4 had physician orders for the bolster mattress on her bed. This failure could place residents at risk of not having an environment that was free of restraints which could result in injury. Findings include: Record review of Resident #4's face sheet, dated 09/09/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4's relevant diagnoses included unsteadiness on feet and repeated falls. Record review of Resident #4's Quarterly MDS assessment, dated 08/18/25, reflected she had a BIMS score of 99 (unable to complete the interview). For ADL care, it reflected the resident required extensive assistance. Record review of Resident #4's Comprehensive Care Plan, dated 05/22/25, reflected the resident was a fall risk and an intervention included the use of a bolster mattress for safety. Record review of Resident #4's physician orders, dated 09/09/25, reflected no physician orders for the bolster mattress. Record review of the facility's incident report for May 2025, June 2025, July 2025, and August 2025, revealed no falls or unknown injuries for Resident #4. In an observation on 08/12/25 at 10:10 AM, Resident #4 was observed lying in bed. The resident's bed had padding on the sides of the bed that measured approximately six inches in height and six inches in thickness. In an interview on 09/09/25 at 11:19 AM, the DON was advised that Resident #4 was observed with a bolster mattress and no physician orders was observed on file. She stated the resident was provided the equipment because she was a fall risk. She stated she had shown the bolster mattress to Resident #4's Responsible Party and they agreed that it would be a good device for the resident. She stated she added it to the resident's care plan, but she forgot to get the physician orders for it. She stated it was her sole responsibility. She stated the resident required physician orders for the equipment because it was needed. The facility's policy RESTRAINTS (06/17) reflected It is the policy of the facility to refuse to restrain residents for any cause. Should a resident have cause for need of a restraint, the physician will be notified immediately, and Texas state regulations will be followed

Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan was updated to reflect the resident's recent fall on 03/08/2025. This failure could place residents at risk of not receiving appropriate care to meet their current needs. Findings included: Record review of a facility undated face sheet for Resident #1, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included: vascular dementia (a condition caused by problems with blood flow to the brain, damaging blood vessels, leading to memory, thinking, and behavioral difficulties), other lack of coordination (jerky, unsteady movements and difficulty with balance and coordination), and muscle weakness (decreased ability of muscles to contract and generate force). Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected the resident had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #1's Quarterly MDS reflected she was dependent in the following areas: eating, oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene. Resident #1's MDS Section J1800 reflected that Resident #1 has had falls since admission/entry or reentry or the prior assessment with no injuries. Record review of Resident #1's undated Care Plan revealed Resident #1 was care planned for risks of falls, dx of dementia and had impaired cognition. Resident #1's care plan did not reflect she had a fall on 3/8/2025. Record review of Resident #1's progress notes did not reveal an entry by RN A related to Resident #1 being found on the floor on 03/08/2025. Record review of Resident #1's progress notes dated 03/08/2025 (LATE ENTRY) entered by the ADON not until 03/13/2025 revealed, Received report from the CNA of this resident being on the floor, laying on her fall mat after falling out of bed. Bed in low position with floor mat in place. Per the resident roommate, this resident crawled out of bed and no injury or complaints of pain voiced. Intervention: place a scoop mattress on resident bed. MD notified of this incident. Record review of the facility's incident log, dated 03/13/2025, reflected [Resident #1] had a fall on 3/08/2025. Record review of Resident #1's EMR revealed RN A failed to complete a Fall Assessment on 03/08/2025. Record review of Resident #1's EMR revealed the ADON completed a Fall Evaluation (with an effective date of 03/08/2025) five days later on 03/13/2025. Attempted to interview Resident #1 on 03/13/2025 at 1:45pm but was not successful due to her being hospitalized and diagnosed with acute metabolic encephalopathy (a change in how your brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness) and a suspected UTI (an infection in any part of the urinary system). Attempted to interview Resident #1's FM on 03/14/2025 at 11:05 am. Unable to leave a message as the voicemail was full. During an interview with RN B on 03/14/2025 at 10:35 am, she stated you are required to document no matter if the resident was observed on the mat, or if a fall was witnessed. RN B stated the staff member that assessed the resident was the one that needed to enter documentation into the EMR and complete any assessments and reports. During an interview with the ADON on 03/14/2025 at 11:40 am, he stated Resident #1's care plan should had been updated to reflect her most recent fall. The ADON stated the incident occurred on Saturday (3/8/2025) but he did not learn of it until Monday (3/10/2025). The ADON stated himself and the DON reached out to RN A on Tuesday (3/11/2025). The ADON stated he entered a Progress Note and created an Incident Report on Wednesday (3/13/2025) because RN A had not completed these tasks. The ADON stated if a resident's care plan was not updated then the resident may have not received the most efficient care. During an interview with the ADM on 03/14/2025 at 12:10 pm, he stated staff must make notifications and enter documentation. The ADM stated the assessment and documentation should had been completed timely. The ADM stated a resident's care plan should be updated after each fall. The ADM stated if a resident's care was not updated after a fall the resident would potentially not be receiving the highest level of care. A record review of the facility's Care Planning policy, with a reviewed date of July 2020, reflected Procedures: . 9. The resident's plan of care - focus, goals, and interventions - are communicated and implemented by the members of the health care continuum accordingly. 10. The resident's plan of care is reviewed and revised on an ongoing basis, quarterly at a minimum and/or as needed with changes in condition. A record review of the facility's Fall Management System policy, with a revision/reviewed date of January 2022, reflected Policy: It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. 3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record. 6. Resident's care plan will be updated.

Based on interview and record review the facility failed to ensure residents' environment remained as free of accident hazards as is possible; and residents received adequate supervision and assistance devices to prevent accidents, for one 1 of 5 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure Resident #1's fall mat was on the floor, next to her bed on 03/08/2025. This was evident by the photo taken on 03/08/2025 and submitted by FM B which showed Resident #1 laying on the bare floor away from her bed with her fall mat observed underneath her bed. This failure could place the resident at risk of injuries from falls and a decreased quality of care. Findings included: Record review of a facility undated face sheet for Resident #1, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included: vascular dementia (a condition caused by problems with blood flow to the brain, damaging blood vessels, leading to memory, thinking, and behavioral difficulties), other lack of coordination (jerky, unsteady movements and difficulty with balance and coordination), and muscle weakness (decreased ability of muscles to contract and generate force). Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected the resident had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #1's Quarterly MDS reflected she was dependent in the following areas: eating, oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene. Resident #1's MDS Section J1800 reflected that Resident #1 has had falls since admission/entry or reentry or the prior assessment with no injuries. Record review of Resident #1's undated Care Plan revealed the following: Focus: At risk for falls r/t decreased mobility, impaired cognition. Goal: Will not sustain serious injury through the review date. Interventions: Anticipate and meet needs. Be sure the call light is within reach and encourage to use it to call for assistance as needed. Keep needed items, water, etc., in reach. Focus: Has had an actual fall no injury r/t: Poor balance & Poor cognition. 01/14/25 Fall, no injury. 02/27/25 Fall, no injury. Goal: Will resume usual activities without further incident through the review date. Interventions: 1/14/25 Bed in lowest position. 2/27/25 Fall mat on floor. Continue interventions on the at-risk plan. Staff will make frequent bed checks. Record review of Resident #1's progress notes did not reveal an entry by RN A related to Resident #1 being found on the floor on 03/08/2025. Record review of Resident #1's Order Summary dated 03/13/2025, reflected [Resident #1] was to have a floor mat on both sides of her bed with the bed set at its lowest setting was ordered on 12/20/2024 and no start or end date noted. Record review of the facility's incident log, dated 03/13/2025, reflected [Resident #1] had a fall on 3/08/2025. Record review of the facility's incident report, dated 3/13/2025, under Nursing Description reflected, Received report from the CNA of this [Resident #1] resident being on the floor, laying on her fall mat after falling out of bed. Bed in low position with floor mat in place. Record review of the photo provided by FM B showed Resident #1 lying on the hardwood floor with her fall mat underneath her bed. During an interview on 03/13/2025 at 9:01 am, FM B stated she arrived at the facility on Saturday (03/08/2025) at 9:35 am. FM B stated as she walked past Resident #1's room, she saw her lying on the floor. FM B stated Resident #1 was positioned on her right side away from her bed and her fall mat was underneath her bed. FM B stated she walked to the dining room and informed a CNA that Resident #1 was on the floor. FM B stated she then walked back to visit her own family member. During an interview with CNA A on 03/13/2025 at 1:55 pm, she stated RN A requested her help to transfer Resident #1 from the floor. CNA A stated after RN A assessed Resident #1, they placed her in bed and changed her. CNA A stated she could not remember the exact time they picked Resident #1 up off the floor, but it could not have been more than 15 minutes that she had been on the floor. CNA A stated Resident #1 wiggled herself out of the bed. CNA A stated 10 minutes later, Resident #1 had wiggled out of the bed again. CNA A stated the first time, Resident #1 was on the floormat. CNA A stated the second time Resident #1 was halfway off the fall mat. CNA A stated due to not being able to use restraints, they brought Resident #1 to the nurse's station. CNA A stated Resident #1 had a fall mat on both sides of the bed. CNA A stated when Resident #1 was not in bed, they folded the fall mats up and placed them in the corner. CNA A stated when Resident #1 was in the bed, the fall mats were placed on the floor. CNA A stated Resident #1 was unable to walk nor transfer herself. During an interview with the ADON on 03/13/2025 at 2:25 pm, he stated himself and the DON called RN A and asked her if she knew how long Resident #1 had been on the floor and RN A stated, No, but it was not a long time because she had taken the roommate's vital signs around 9:20 am and then went to chart. The ADON stated RN A said she returned to the room around 9:30 am to see if the roommate was dressed for dialysis and that was when she observed Resident #1 laying on her fall mat. The ADON stated the incident was categorized as a fall with no injuries. During an interview with RN A on 03/14/2025 at 11:10 am, she stated she saw Resident #1 on the fall mat and immediately reached out to CNA A for assistance. RN A stated each time she went to check on Resident #1, she was back on the fall mat again. RN A stated she and CNA A assisted Resident #1 back in bed each time. RN A stated she changed Resident #1's diaper herself to make sure that was not why Resident #1 kept having the behavior. Resident #1 stated she continued to check on Resident #1 and administered her medications. RN A stated to the best of her knowledge that was what happened. RN A stated Resident #1 had not sustained any injuries. RN A stated Resident #1 was on the fall mat both times. RN A stated she assessed Resident #1 each time but failed to complete any assessments or enter any documentation into the EMR due to there being no injuries. RN A stated when she saw Resident #1 on the floor again she was confused as to why Resident #1 kept doing it. RN A stated per policy, whenever a resident was found on the floor, they would be assessed. RN A stated the nurse was required to complete all appropriate assessments that needed to be done. RN A stated she did not do any of these things because Resident #1 was on the fall mat with no injuries. During an interview with the ADON on 03/14/2025 at 11:40 am, he stated due to Resident #1 not being in her bed and observed on her fall mat, the incident would be categorized as an unwitnessed fall. The ADON stated RN A had not charted anything. The ADON stated RN A informed him and the DON that she had not believed it was a fall because Resident #1 was on the fall mat. The ADON stated regardless, if it was a fall or not, the DON informed RN A even if she thought it was a behavior, the least she could had done was documented it as a behavior. The ADON stated the incident occurred on Saturday (3/8/2025) but he did not learn of it until Monday (3/10/2025). The ADON stated he entered a Progress Note and created an Incident Report on Wednesday (3/13/2025) because RN A had not completed these tasks. The ADON stated the Care Plan should be updated to reflect all falls to ensure residents received the most effective care. The ADON stated the Charge Nurse said she completed an assessment including a pain assessment but failed to document anything. During an interview with the ADM on 03/14/2025 at 12:10 pm, he stated Resident #1 had not sustained any injuries and was okay. The ADM stated Resident #1 used a wheelchair and was unable to get up on her own. The ADM stated they preferred fall mats to be off the floor if the resident was not in bed to prevent a tripping hazard. The ADM stated no one was perfect, and they try their best to find the best fit for each resident. The ADM stated staff should assess to ensure it was safe to transfer the resident to bed from the floor pending the nurse's discretion. The ADM stated an assessment and documentation should had been completed timely. The ADM stated he expected all staff to follow the facility's policies. A record review of the facility's Fall Management System policy, with a revision/reviewed date of January 2022, reflected Policy: It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. 3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record. c. A Fall Risk Evaluation will be completed post fall incident. A record review of the facility's Significant Change of Condition, Response policy, with a revision/reviewed date of December 2023, reflected It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. Procedure 1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): . -Change in behavior or increased problems that may cause injuries or incidents to self or others . -Fall or other related incident

Based 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 three (Resident #42, Resident #45, and Resident #58) of eight residents reviewed for Infection Control. 1. The facility failed to ensure CNA B performed hand hygiene, changed her gloves, and did not put the gloves on her pocket while providing incontinent care to Resident #58 on 02/04/2025. 2. The facility failed to ensure CNA B and CNA C changed their gloves and performed hand hygiene while providing incontinent care to Resident #45 on 02/04/2025. 3. The facility failed to ensure CNA D changed her gloves and performed hand hygiene while providing incontinent care to Resident #42 on 02/05/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Record review of Resident #58's Face Sheet, dated 02/05/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with urinary tract infection. Record review of Resident #58's Quarterly MDS Assessment, dated 10/28/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated the resident was always incontinent for bowel and bladder. Record review of Resident #58's Comprehensive Care Plan, dated 01/29/2025, reflected the resident had bowel/bladder incontinence and one of the interventions was to provide pericare after each incontinent episode. Observation on 02/04/2025 at 9:46 AM revealed CNA B was about to do Resident #58's incontinent care. CNA B washed her hands and put on a pair of gloves. She prepared some wipes, a brief, and a plastic bag and put them on the resident's overbed table. She lowered the head of the bed and raised the bed. She unfastened the brief and pushed it between the resident's thighs. She removed her gloves, threw them on the plastic bag placed on the overbed table, and put on a new pair of gloves that she took from the left pocket of her scrub suit's top. She did not sanitize her hands before pulling the gloves from her pocket. She pulled some wipes and cleaned the resident perineal area (area between the thighs) using the front to back technique. She did it three times. After cleaning the perineal area, she assisted the resident to roll towards the left side and cleaned the resident's bottom. After cleaning the resident's bottom, CNA B took the new brief from the overbed table, put it under the resident, and fixed it. She did not change her gloves after cleaning the bottom of the resident and before touching the new brief. After fixing the brief, CNA B assisted the resident to roll back and fastened the brief on both sides. CNA B took off her gloves, threw them in the trash bag, and washed her hands. 2. Record review of Resident #45's Face Sheet, dated 02/05/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and need for assistance with personal care. Record review of Resident #45's Comprehensive MDS Assessment, dated 11/01/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 02. Comprehensive MDS Assessment indicated the resident was always incontinent for bowel and bladder. Record review of Resident #45's Comprehensive Care Plan, dated 01/13/2025, reflected the resident had bowel/bladder incontinence and one of the interventions was provide pericare (cleaning the private areas of the resident) after each incontinent episode. Observation on 02/04/2025 at 1:22 PM revealed CNA B and CNA C were about to do Resident #45's incontinent care. Both staff washed their hands and put on a pair of gloves. CNA B went to the resident's left side, while CNA C went to the resident's right side. CNA B unfastened the brief and pushed it between the resident's thighs. CNA B removed her gloves, pulled some gloves from her scrub suits' left pocket, and put on the gloves. CNA B pulled some wipes placed on the resident's side and cleaned the resident's perineal area. CNA B removed her gloves, pulled some gloves from her left pocket, and put on the gloves. After CNA B cleaned the perineal area, both CNAs assisted the resident to roll to his right side and CNA B cleaned the resident's bottom. After cleaning the resident's bottom, CNA B pulled the brief and threw it on the trash can. After CNA B threw the soiled brief, it was observed that the resident was still having a bowel movement. CNA B continued to clean the resident's bottom and placed the used wipes on the padding. After cleaning the resident's bottom, again, CNA B removed her gloves, went to the bathroom, took a box of gloves, placed some gloves in her pocket, and put on a pair of gloves. CNA B instructed CNA C to get the resident's brief on top of the resident's drawer. CNA C gave the brief to CNA B. CNA B placed a new padding on top of the rolled soiled padding, put the new brief on top of the new padding, and fixed them. Both CNAs rolled the resident to the other side. CNA C took the soiled padding with soiled wipes in it, put it on a plastic bag, and helped in fixing the brief. They rolled back the resident and fastened the brief. CNA C did not change her gloves after putting the soiled padding on a plastic bag. In an interview with CNA B on 02/04/2025 at 1:42 PM, CNA B stated she did change her gloves when she did Resident #58 and Resident # 45's incontinent care but did not sanitize in between changing of gloves. She said hand hygiene should be done after removing the gloves to make sure the hands were not soiled before touching the new gloves. She said gloves should also be changed before touching the new brief to prevent the new brief from being soiled. She said gloves should not be placed in the pockets because she used her pockets for something else, like for her cellphone, her car keys, and others. She said she would be mindful next time not to put the gloves in her pocket, to change gloves after cleaning the residents' bottom, and to do hand hygiene when she changed her gloves. She said not sanitizing the hands when the gloves were changed and not changing the gloves could cause infection. She said putting the gloves in the packet could also indirectly cause infection. In an interview with CNA C on 02/06/2025 at 9:47 AM, CNA C stated she realized she did not change her gloves after pulling the soiled padding that had soiled wipes in it. She said she should have changed her gloves, sanitized her hands, and put on a new pair of gloves. She said her gloves were basically soiled when she assisted in fixing the brief. She said not changing the gloves could cause infection like urinary tract infection. 3. Review of Resident #42's Face Sheet, dated 02/05/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with acute kidney failure. Review of Resident #42's Comprehensive MDS Assessment, dated 01/22/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated Resident #42 was always incontinent for bladder and bowel. Review of Resident #42's Comprehensive Care Plan, dated 01/27/2025, reflected the resident had bowel/bladder incontinence r/t: impaired mobility and one of the interventions was check as required for incontinence, wash, rinse, and dry perineum. Observation on 02/05/2025 at 9:02 AM revealed CNA D was about to transfer Resident #42's to her wheelchair through sit-to-stand. She said before she transfered the resident to her wheelchair, the resident would go to the restroom first for a bowel movement. She assisted the resident to a sitting position at the side of the resident's bed, put the sit-to-stand sling around the resident's torso, secured the sling to the sit-to-stand machine, and raised the resident to a standing position. CNA D rolled the resident to the restroom, pulled down the brief, and lowered the resident to the toilet seat. CNA D removed the sling and said she would wait for the resident. While she was waiting for the resident to be done, she removed her gloves, washed her hands, and put on a pair gloves. She put some paper towel on the sink and put some wipes and a brief on the paper towels. When the resident was done with the bowel movement, CNA D put back the sling around the resident, hooked it to the sit-to-stand machine, and raised the resident. She cleaned the bottom of the resident first. After cleaning the resident's bottom, she removed her gloves and put on a new pair of gloves. She did not sanitize her hands when she changed her gloves. CNA D then cleaned the perineal area. After cleaning the perineal area, she pulled the resident's brief and pants back up, rolled the sit-to-stand machine out of the restroom, and lowered the resident to her wheelchair. She did not change her gloves after cleaning the resident's perineal area and before pulling up the brief. In an interview with CNA D on 02/05/2025 at 9:29 AM revealed CNA D stated hands should be washed or sanitized when changing the gloves. She said gloves should be clean when touching the brief to prevent infection. She said the gloves should be changed after she cleaned the resident's perineal area and before touching the brief because the gloves that she used to clean the resident's perineal area were already soiled. She said she would be mindful the next time she does incontinent care to wash her hands and change her gloves during incontinent care. She said she had trainings for pericare but did not know why she forgot to wash her hands and change her gloves. In an interview with the DON on 02/06/2025 at 8:07 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and any kind of infection. She said the expectation was for the staff to sanitize their hands in between changing of gloves and change their gloves after touching anything soiled. She said, another expectation was for the staff to get their gloves from the boxes and not put them in their pockets. She said the pockets might be dirty that would render the gloves also dirty. She said she would do and in-service about hand hygiene, incontinent care, and not putting the gloves in their pockets. She said she would personally monitor the staff doing direct care. In an interview with the ADON on 02/06/2025 at 9:41 AM, the ADON stated putting the gloves in the pocket was a bad habit. He said the gloves, when placed in the pockets, could be considered soiled because the dirt from the pockets might cling to the gloves. He said hands should be sanitized every time the gloves were removed, and gloves should be changed after touching something soiled to prevent cross contamination and development of infection. He said they would he would remind the staff to change their gloves from dirty to clen, sanitize in between changing of gloves, and not to put their gloves in their pockets. He said they would also do an in-service about hand hygiene, pericare, and not to put the gloves in the pockets of their scrub suits. In an interview with the Administrator on 02/026/2025 at 10:07 AM, the Administrator stated the staff should change their gloves and sanitize their hands to prevent infection. He said they should not put the gloves in their pockets. He said the expectation was for the staff to follow the policy and procedures pertaining to incontinent care and infection control. He said he would coordinate with the DON on how to handle the issue about infection control and hand hygiene. Record review of facility policy, Perineal Care Policy/Procedure - Nursing Clinical revised 07/2021 revealed Policy . 3. Prevent irritation or infection. Record review of facility policy, Hand Hygiene Infection Prevention and Control Program 2009 revealed Policy: This facility considers hand hygiene the primary means to prevent the spread of infections . 4. Use an alcohol-based hand rub . f. Before donning sterile gloves . h. Before moving from a contaminated body site to a clean body site during resident care . j. After contact with blood or bodily fluids . k. After handling used dressings, contaminated equipment, etc. m. After removing gloves . Applying and removing gloves . 1. Perform hand hygiene before and after applying non-sterile gloves.

Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown and infection for one (Resident #45) of four residents reviewed for pressure ulcers (open wound on the skin caused by prolonged pressure to bony prominences). The facility failed to ensure that LVN A cleaned Resident #45's wound to right 5th toe from inside to outside on 02/05/2025. This failure could place the residents with pressure ulcers at risk for worsening of existing pressure ulcers and infection. Findings included: Record review of Resident #45's Face Sheet, dated 02/05/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with sepsis (infection of the blood stream) and muscle weakness. Record review of Resident #45's Comprehensive MDS Assessment, dated 11/01/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 02. Comprehensive MDS Assessment indicated the resident had a pressure ulcer over a bony prominence. Record review of Resident #45's Comprehensive Care Plan, dated 01/13/2025, reflected the resident had a pressure ulcer to right foot related to decreased mobility and one of the interventions was administer treatments as ordered. Record review of Resident #45's Physician Order, dated 01/17/2025, reflected Right foot (5th toe)- cleanse with NS/wound cleanser, pat dry, apply collagen (wound care product that support the wound's healing process) and cover with a dry dressing. Observation on 02/05/2025 at 9:59 AM revealed LVN A and the ADON were about to do Resident #45's wound care to the fifth toe of the right foot. LVN A sanitized her hand, put on a pair of gloves, and prepared the things needed for wound care. She prepared some gauze, some normal saline bullets, collagen wound dressing, a 2 by 2 dressing, and a plastic bag. While LVN A was preparing the things needed for wound care, the ADON washed his hands, put on a pair of gloves, and sanitized the resident's table. After the ADON sanitized the overbed table, LVN A placed the things to be used for wound care on the resident's overbed table. Both staff removed their gloves, washed their hands, and put on gowns and gloves. The ADON positioned and stabilized the resident's right leg under a blanket to raise it. LVN A removed the old dressing and threw it on the plastic bag. It was observed that the resident's wound was covered by a small piece of collagen dressing and the skin surrounding the wound was dry and scaly. LVN A removed her gloves, washed her hands, and put on a new pair of gloves. She took some gauzes and poured normal saline on them. She started to clean the skin surrounding skin of the wound by wiping it in circular motion. She did it two times. With the same gauze used to clean the surrounding skin, she cleaned the wound, and at the same time tried to remove the collagen that was on the wound. She removed her gloves, washed her hands, and put on a pair of gloves. She dried the wound with some gauze from outside to inside. After drying the wound, she put the collagen dressing, and covered the wound with a 2 by 2 dressing. The ADON removed the blanket from under the resident's right leg and lowered it to the bed. Both staff removed their gowns and gloves and washed their hands. In an interview with LVN A on 02/05/2025 at 10:20 AM, LVN A stated Resident #45's wound had a small opening that was why the collagen was sticking on the wound. She said she cleaned around the wound first before cleaning the wound. When asked again, she replied again that she started cleaning the surrounding skin of the wound and then moved to the wound. She said her understanding was that the wound must be cleaned from clean to dirty and for her the surrounding skin was cleaner than the wound. When asked if it was possible that whatever germs the gauze got from the surrounding skin were introduced to the wound, she replied yes. When asked if she was supposed to change the gauze when cleaning the wound, she said yes. In an interview with the DON on 02/06/2025 at 8:07 AM, the DON stated she was made aware by LVN A about the findings during wound care. She said she told LVN A that wound should be cleaned from the least contaminated area, meaning the wound itself to the most contaminated area, which was the surrounding skin. She said the wound could be infected if the contaminants from the surrounding skin were introduced to the wound bed. She said in cleaning the wound, the gauze should be discarded after every stroke. She said the expectation was for the wound to be cleaned the right way. She said she already did a one-on-one in-service with LVN A about wound care, and she was enrolled to a wound care training the following month. In an interview with the ADON on 02/06/2025 at 9:41 AM, the ADON stated the purpose of wound care was to remove debris, bacteria, and exudate in the wound to reduce the risk of infection. He said in wound cleaning, the staff start at the center of the wound going outward, ensuring not to spread the bacteria from the outer area back into the wound. He said a new piece of gauze must be used for each stroke to avoid contamination. He said the expectation was the wound would be cleaned from inside to outside and the gauze be changed with every stroke. He said they would conduct an in-service about wound care. In an interview with the Administrator on 02/06/2025 at 10:07 AM, the Administrator stated the expectation was for the staff do the right procedure in cleaning the wound to prevent infection. He said he would collaborate with the DON on how to deal with the issue. Record review of facility policy Wound Care Policy/Procedure - Nursing Clinical revised 05/2007 revealed Procedure for Clean Dressing Technique . Wash from the center of the wound to the periphery. Always wash from the area of least contamination to the area of most contamination.

Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #59) of five residents was provided medications and pharmaceutical services, including the accurate administering of all drugs, to meet their needs. The facility failed to ensure MA did not leave Resident #59's medications inside the resident's room and failed to monitor the administration of the medications on 02/04/2025. This failure could place the residents at risk of chocking or not receiving medications as ordered by the physician. Findings included: Record review of Resident #59's Face Sheet, dated 02/05/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure), gastro-esophageal reflux disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach), cerebral infarction (insufficient oxygen in the brain causing stroke). Record review of Resident #59's Quarterly MDS Assessment, dated 12/16/2024, reflected resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment also indicated the resident had cerebral infarction, hypertension, and gastro-esophageal reflux disease. Record review of Resident #59's Comprehensive Care Plan, dated 11/07/2024, reflected the resident had gastro-esophageal reflux disease, cerebral vascular disease, and hypertension and the interventions for the three medical issues were to give medications as ordered. Review of Resident #59's Clinical Assessment on 02/04/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage her own medications. Review of Resident #59's Physician Order, dated 04/04/2023, reflected Aspirin EC Tablet Delayed Release 81 MG (Aspirin). Give 1 tablet by mouth one time a day for CVA (cerebrovascular accident: stroke). Review of Resident #59's Physician Order, dated 04/04/2023, reflected Famotidine Oral Tablet 20 MG (Famotidine) Give 1 tablet by Mouth one time a day for GERD (gastro-esophageal reflux disease: stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Review of Resident #59's Physician Order, dated 04/04/2023, reflected Nifedipine ER Oral Tablet Extended Release 24 Hour 30 MG (Nifedipine) Give 1 tablet by mouth one time a day for HTN DO NOT CRUSH Hold for SBP<110 DBP<60 HR<60, Observation on 02/04/2025 at 10:38 AM revealed MA was observed exiting Resident #59's room and closing the door. Observation and interview with Resident #59 on 02/04/2025 at 10:40 AM revealed the resident was sitting on a chair beside her bed. In front of the resident was her overbed table with a small plastic cup on top of it. Inside the plastic cup was a white, round pill. The resident she was going to take the medication in a minute. She said she already taken two out of three pills that was left by the staff. She said the staff would leave her medications with her and she would take. She said she told her what the medications were, but she could not remember them and all she could remember was how many. In an interview with the MA on 02/04/2025 at 10:48 AM, the MA stated she did leave Resident #59's medication with her because the resident wanted to take the medication every five minutes. She said should have returned to the room and checked on the resident or stayed with the resident until the resident had taken all the medications. She said the pills should not be left with the resident because the resident might not take them, throw them, or choke while taking them and no one would know. She said she left three pills with the resident, her aspirin, famotidine, and her blood pressure medication. In an interview with the DON on 02/06/2025 at 8:07 AM, the DON stated staff should never leave the medications with the resident for the residents to take later. She said the staff must wait for the residents to be done with their medications before leaving the room. She said the resident might choke while taking the medications and no one would know. She said the resident might not take the medications or hide the pills to avoid taking them. She said the residents could also hoard the medications and take them altogether that could cause an overdose. The DON said the expectation was for the staff not to leave the room until the residents were done taking the medications or if the residents were still not ready to take the medication, just take the medications with them and come back later. She said she would do an in-service pertaining to not leaving the medications with a resident. In an interview with the ADON on 02/06/2025 at 9:41 AM, the ADON stated medications were not left with the residents. He said the staff administering the medications should stay with the resident until the resident was done taking the medications. He said the resident might not take them or someone else might, like another resident or a visitor. He said the resident might aspirate while taking the medications and nobody was with him. He said he would coordinate with the DON to do an in-service about not leaving the medications with the residents. In an interview with the Administrator on 02/026/2025 at 10:07 AM, the Administrator stated staff should not leave medications unattended because of the risk of the resident not taking them or the pills not taken on time. He said he would coordinate with the DON on how to go forward to prevent untoward outcomes of leaving the medications with a resident. Record review of facility policy, Medication Administration Policy/Procedure - Nursing Services revised 07/2020 revealed POLICY: It is the policy of this facility that medications shall be administered as prescribed by the attending physician . PROCEDURES . 4. Identification of the resident must be made prior to administering medication to the resident . 5. Medications may not be set up in advance and scheduled medications must be administered within facility time frame.

Based observations, interviews, and record review, the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #42) of three residents observed for Incontinent Care. The facility failed to ensure that CNA D did not wipe Resident #42's perineal (area between the legs) area from back to front while providing incontinent care on 02/05/2025. This failure could place the residents at risk of cross-contamination and development of urinary tract infections. Findings included: Review of Resident #42's Face Sheet, dated 02/05/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with acute kidney failure. Review of Resident #42's Comprehensive MDS Assessment, dated 01/22/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated Resident #42 was always incontinent for bladder and bowel. Review of Resident #42's Comprehensive Care Plan, dated 01/27/2025, reflected the resident had bowel/bladder incontinence r/t: impaired mobility and one of the interventions was check as required for incontinence, wash, rinse, and dry perineum. Observation on 02/05/2025 at 9:02 AM revealed CNA D was about to transfer Resident #42 to her wheelchair through sit-to-stand. She said before she transfered the resident to her wheelchair, the resident would go to the restroom first for a bowel movement. She assisted the resident to a sitting position at the side of the resident's bed, put the sit-to-stand sling around the resident's torso, secured the sling to the sit-to-stand machine, and raised the resident to a standing position. CNA D rolled the resident to the restroom, pulled down the brief, and lowered the resident to the toilet seat. CNA D removed the sling and said she would wait for the resident. While she was waiting for the resident to be done, she removed her gloves, washed her hands, pulled a pair of gloves from the left pocket of her scrub top, and put on the gloves. She prepared some wipes on the sink covered with paper towels. When the resident was done with the bowel movement, CNA D put back the sling and raised the resident. She cleaned the bottom of the resident. After cleaning the resident's bottom, she removed her gloves, and put on a new pair of gloves. CNA D then cleaned the perineal area from back to front. She did it three times. After cleaning the perineal area, she pulled the resident's brief and pants back up, rolled the sit-to-stand machine out of the restroom, and lowered the resident to her wheelchair. Observation and interview with CNA D on 02/05/2025 at 9:29 AM revealed CNA D demonstrated the manner she cleaned Resident #42's perineal area. She said she started on the sides and then the middle. When asked how she cleaned the middle of the perineal area, she demonstrated wiping the middle from back to front. She said it was because of the position of the resident that was why she cleaned the resident's perineal area that way. She said she still should had cleaned the resident's front part from front to back regardless of the position of the resident. She said the wiping should always be from front to back to prevent urinary tract infection. She said she should be mindful of how she does incontinent care because the resident would be at risk for infection. In an interview with the DON on 02/06/2025 at 8:07 AM, the DON stated the cleaning the perineal area should be from front to back to prevent cross contamination and probable infection. She said the procedure did not change with regards to the position of the resident. She said cleaning the perineal area was front to back whether the resident was in the bed, sitting in the toilet seat, sitting in a commode, or standing up. She said the gloves should not be placed in their pockets because, basically, we did not know how dirty their pockets were and then they would use the gloves from the pockets to clean the residents. She said the expectation was for the staff to focus on the prevention of infection and not their convenience. She said she would do an in-service about incontinent care and said the expectation was for them to practice the right procedure of incontinent care. In an interview with the ADON on 02/06/2025 at 9:41 AM, the ADON stated the proper way of cleaning the resident's perineal area would be always front to back to avoid transfer of germs from the bottom to the front part of the resident. He said the purpose of which was to prevent infection. He said the expectation was for the staff to do incontinent care the right way which was cleaning the front part from front to back. He said they would do an in-service pertaining to incontinent care focusing on proper cleaning of the front part of the residents. In an interview with the Administrator on 02/06/2025 at 10:07 AM, the Administrator stated improper incontinent care could cause infection and the expectation was for the staff to do the right procedure. He said he would collaborate with the DON on how to deal with the issue. Record review of facility policy, Perineal Care Policy/Procedure - Nursing Clinical revised 07/2021 revealed Policy . 3. Prevent irritation or infection . Procedures . NOTE: The basic infection control-concept for pericare is to wash from the cleanest area to the dirtiest area.

Based on interview and record review, the facility failed to ensure residents in facility received adequate supervision and assistance devices to prevent accidents 1 of 5 residents (Resident #10) reviewed for accidents and supervision. The facility staff member failed to follow the facility's No Lift policy, which indicated the total mechanical lift will be used for individuals who can bear weight on their legs and can only offer minimal assistance with their transfers/lifts. The facility failed to provide assistive devices (mechanical lift) during transfers as required per their No Lift policy and after requested by Resident #10 and her POA on 04/04/24. After the inappropriate transfer, Resident #10 had uncontrolled pain (even after administration of opioid analgesic), was sent to the hospital via 911 and was diagnosed with a fracture. The facility failed to obtain accurate transfer status information from the referring facility prior to admission. On 4/04/24 Resident #10 was inappropriately transferred resulting in a right distal tibial spiral fracture. An Immediate Jeopardy (IJ) was identified and presented to the Administrator on 10/01/2024 at 1:36 PM. The IJ was lifted at 10/02/2024 at 7:00 PM. the facility remained out of compliance at a severity level of actual harm and scope of isolated, due to the facility's continued monitoring of the effectiveness of their plan of removal. This failure could place residents at risk of serious injury resulting from improper transfer technique. Findings Included: Record Review of Resident #10's Face Sheet dated 03/29/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included osteoarthritis, hemiplegia and hemiparesis affecting her left side resulting from a stroke (unknown date, but not recent). She had a surgical history of knee replacement to her right knee [AGE] years prior. Record review of referral information from previous facility indicated that resident #10 was a moderate assist of 1 or 2 persons and that she was only able to provide minimal assistance due to left sided hemiplegia (weakness to left side). No incident report was completed by the facility staff for this incident per the DON due to the resident's transfer to the hospital for evaluation, and no incident report was completed after the incident. Record review of Resident #10's Admission Minimum Data Set (MDS) dated [DATE] revealed her cognition was intact with a Brief Interview of Mental Status (BIMS) score of 15. She was impaired of upper and lower extremities on one side. She was dependent for total assistance for sit to stand and transfer from chair/bed transfers to bed. She was wheelchair bound and required total assistance with shower/bathing and personal hygiene. Resident #10 was always continent of bladder and bowel. Record review of Resident #10's Care Plan Review, dated 04/03/2024, revealed she had limited mobility, hemiplegia, musculoskeletal impairment, impaired balance, pain, limited range of motion, stroke, she was at risk for falls related to gait balance problems, she had acute/chronic pain related to arthritis, and persistent right knee pain with a history of total knee arthroplasty (a surgical procedure that replaces a damaged knee joint with prosthetic components. ) which was over twenty years ago. Physical examination by the facility medical director 0on 04/04/24 noted that she may have been experiencing excessive wear of hardware, and possible loosening of hardware. It was recommended she follows up with orthopedic provider a to formally evaluate right knee with imaging and full evaluation. Other recommendations included Patient will continue Norco (hydrocodone) regimen per facility attending (physician). Record review of Resident #10's Progress Note by LVN F, dated 04/03/2024 at 6:13 PM, revealed: Resident transferred via WC with attendant from a transport service. with belongings. Vitals at this time is T-98.3, P-78, R-17, BP-145/76. O2 @ 96% on room air. Meds verified with the AP (Attending Physician) to see resident tomorrow. no complaints of pain at this time, head to toe done skin intact, clean, and dry, resident is incontinent of bowl [sic] and bladder. alert and oriented x 2. resident oriented to facility at this time. bed in lowest possible call light within reach. Record review of Resident #10's Progress Note by LVN F, dated 04/04/2024 at 9:26 PM, revealed: Change in Condition: Symptoms or signs noted of Condition change: Pain (uncontrolled) Vital Signs: BP 151/66 - 4/4/2024 11:23 Position: Lying r/arm, P 79 - 4/4/2024 11:23 Pulse Type: Regular, R 17.0 - 4/3/2024 18:43, T 98.3 - 4/3/2024 18:43 Route: Forehead (non-contact), O2 96.0 % - 4/3/2024 18:43 Method: Room Air Notifications: Reported to primary care clinician: Physician's Assistant (PA), Date and time of clinician notification: 04/04/2024 4:09 PM, Name of family member or resident representative notified: Power of Attorney (POA) (at bedside), Date and time family or representative notified: 04/04/2024 4:00 PM. Record review of Resident #10's Progress Note by LVN F, dated 04/05/2024 at 11:19 AM, revealed the resident was hospitalized . Review of Resident #10's clinical records from 09/30//24 to 10/02/24 revealed there was no assessment completed PT/OT to determine her weight bearing status during her stay at the facility nor prior to her discharge to the hospital . Record Review of page 1 of the Discharge Summary Brief Overview from the hospital dated 04/16/24, revealed the resident was admitted on [DATE] and discharged on [DATE]. Primary Discharge Diagnosis was Fracture of right tibia. Record Review of page 14 of the Discharge Summary Brief Overview from the hospital dated 04/16/24, revealed the report from Radiology: X-ray Ankle 3+, Result Date: 4/6/26 IMPRESSION: 1. Spiral fracture of the distal shaft of the tibia Finalized by MD on 04/06/2024 4:03 X-ray Tibia Fibula 2 View Right, Right, Result Date: 4/6/2024, Result Date: 4/6/2024, IMPRESSION: 1. Spiral fracture of the distal shaft of the tibia. Record review of Details of Hospital Stay dated 04/16/24 revealed Resident #10 had an elevated risk for surgery due to Cardiac disease. As a result of her cardiac risk, the orthopedic specialist opted to pursue nonoperative management of her fracture and placed a brace on her right leg and ordered non-weight bearing status for 6- 8 weeks. In an interview on 09/27/24 at 3:08 PM with Resident #10's Family Member, she stated on 04/04/24, Resident #10 was complaining about the mattress on her bed. Then a short, dark skinned African guy brought in another mattress, and he began to try to pick her up by lifting her up under her arms. She stated when she saw how he was going to try to get her up, she told him that he could not do it like that, because it was not safe, and he needed to get someone to help him or get a lift and the resident agreed with her. She stated he said, I'll do it, I can do it. She stated he continued to get her up by lifting her under her arms and when he got her up, he almost dropped her. She stated he hurried up and twisted her around to get her in the chair and he basically dropped her into the chair. She stated right then, she hollered out and said she felt something pop and she was screaming and crying really bad. She stated it made her cry. She stated a middle-aged woman was present in the room and she was attending to another resident who was in the room. She stated a little white or Hispanic man was standing in the doorway. She stated once he got her in the chair, he left the room. She stated he did not try to see about Resident #10, he just walked out of the room. She stated neither the female staff nor the guy in the doorway came to see about Resident #10. She stated a little bit later, the man who was in the doorway came back with a pain pill and gave it to the resident. She stated he then went and called 9-1-1 and the paramedics came to take the resident to the hospital. She stated she arrived at the facility to visit Resident #10 around 2:30 PM. She stated the transfer happened close to 4:00 PM. In a follow-up interview on 09/27/24 at 3:45 PM with Resident #10's Family Member, she stated she called the next day and spoke to a lady, but she did not remember the name or title. She stated she told the lady that Resident #10 was in the hospital and the lady told her that someone would call her back the next day, but no one ever did, and she did not try to call the facility back. In an interview on 09/30/24 at 1:50 PM with Resident #10, she stated she did not know why the guy was bringing another mattress to her. She stated she just knew that it was a dark, heavy-set guy. She stated he was a big guy. She stated he was tall to her. She stated he came in with a mattress and he said she would have to get out of the bed, so he could change out the mattresses. She stated he then started pulling her up with his hands. She stated he was pulling her up by holding her under her arms. She stated he was moving too fast, and she was telling him that he needed to get a slip for her and use the lift. She stated her family member also told him the same thing. She stated he did not listen to her either. She stated she kept telling him not to bend her leg, but he did it anyway and that was when she felt the pop. She stated she could not remember what time of day it was. She stated after thinking about it, she believed it happened during the middle of the day, around 2:00 PM. She stated she knew for sure that she was lying in bed and her family member was sitting near the bed. She stated she was not in pain prior to man getting her out of bed. She stated she and her family member were just sitting there talking prior to the guy coming in the room. In an interview on 09/30/24 at 9:38 AM with the Central Supply Clerk, she stated if a resident needed something like a mattress switched out, it would go through her. She stated the nurse would verbally communicate that request to her and then she would locate another mattress and bring it to the floor and change it out. She stated if the mattress was somewhere further away from the room which it needed to go to, then one of the maintenance staff would assist by retrieving the mattress and bringing it to the floor of the room and then she would be the one to take it to the room and change it out. She stated only herself would be the one to change the mattresses. She stated that was her sole responsibility. She stated there have been times when she has instructed the maintenance staff to meet her at the room and then they might bring the mattress into the room, and she would still be the one to remove the current mattress and then replace it with the one which was brought to the room. Then they would take the old mattress out and store it. She stated she remembered Resident #10 and she stated the maintenance staff, who did not match the description of the person who transferred Resident #10, did bring it to the room and she was the one who placed it on the bed frame. She stated when she entered the room, the resident was sitting in a wheelchair and so she went ahead and took the air mattress off the bed frame and when the replacement mattress was brought in, she was the one who put it on the bed frame. She stated she removed the air mattress from the room. An interview with the Administrator on 09/25/24 at 12:05 PM, he stated when they have a new admission, the care information was obtained by the nurses. He stated they are responsible for communicating with the previous facility or hospital from which the resident was coming from. He stated information was shared with the aides. He stated they have been doing it this way for a very long time and there had not been any incidents. He stated the information was placed where any of the staff could access it and know how to care for the new resident. He stated the Progress Notes which they received from the previous facility stated the resident was moderate assist x1, which meant the resident only needed one person. He stated C.N.A. G had never had an incident while transferring residents. He stated they go by what was done at the previous facility or hospital, until facility staff can complete their own assessments. Then that information was entered into the system and shared with other staff. He stated they did not have a policy for this process, because there has not been a need to have one for this issue. He stated based on the information which they received from the previous facility, he believed C.N.A. G did what he was supposed to do. An interview with the DON on 09/25/2024 at 12:09 PM, she stated she was not familiar with Resident #10, and she needed to see the resident's records. She stated LVN F was the floor nurse who entered the assessments for the resident. She stated LVN F was no longer at this facility but was working at a sister facility. She stated he did not report anything to her about the resident's injury. She stated had the resident been injured, it would have been documented in Progress Notes and it would have been reported to Health and Human Services Commission (HHSC). She stated the records from the hospital or facility, which the resident transferred from, would have gone to the nursing department. She stated the Social Workers (SW) would have done initial assessments with the resident, upon admission. She stated when a resident comes from a hospital or another facility, they would refer to those records for indications on the resident's care, until they could complete their own assessments. She stated transfer needs would be included in what they would reference from the hospital or former facility's records. She stated that the resident's transfer information would be in LVN F's notes and/or could probably be obtained from the Director of Rehabilitation. An interview with the SW on 09/25/2024 at 12:33 PM, she stated she did not remember the resident. She stated she would have to look at her notes. She then stated the SW would conduct an initial assessment by speaking with the resident or their representative. She stated the assessment is a collection of information which they get during that interview. She stated those notes are taken and translated into a Social Services Progress Note. She stated any transfer needs would be provided by the Director of Rehabilitation. An interview with the PA on 09/25/2025 at 3:55 PM, She stated she did not remember the incident. She stated by looking at the Progress Notes, she was notified, but she did not remember it. She stated she was not familiar with Resident #10 because she never got the chance to see her. She reviewed the resident's chart and stated given her being hemiplegic and her size, and the fact that she had not ambulated for a number of years, she would imagine that the resident would require adequate assistance for transfers and mobility. She stated staff should have referred to the transfer notes from the resident's previous facility. She looked through the notes from the previous facility and could not find anything referencing transfers. She stated staff should have at least listened to the resident, given that her cognition was intact, and she was able to communicate to the staff who was assisting her, that he should have help with assisting her with her transfer to the wheelchair. She stated, especially since there was no documented reference as to how to transfer her, CNA G should have listened to the resident. She stated with Resident #10 being overweight, paralyzed on the left side and the right knee was problematic and the notes under Functional Performance, dated 04/03/2024 revealed, the resident was non-weight bearing on her right leg, she should have at least had a two-person assist with transfers. In a follow-up interview on 09/26/2024 at 11:12 AM with the DON, she stated the floor nurse was supposed to ask for specifics, such as ADL care, including transfers when considering new admissions. She stated if they have someone new come in, they should 1.) use information from where the new admit came from, and 2.) use clinical decision making. She stated depending on the resident's cognition level, the resident could also tell them how they have received care previously. She stated if staff do not use informed methods to transfer a resident, injury could occur. In an interview on 09/26/24 at 12:32 PM with the ADON, he stated when a new resident is coming in, they take a verbal report from the facility that they are coming from. He stated they have a temporary report sheet which they write the information on. He stated this template was only used for their initial assessment and getting information that they need to know about the in-coming patient. He stated it includes everything about the patient, including when they had their bowel movement, are they mobile, do they used some type of device, or do they ambulate independently. He stated whatever they need to relate to the Certified Nurse Aides (C.N.A.) and the rest of the staff, was then shared from that report sheet. He stated the report was usually done prior to the resident coming to the facility. He stated once the resident comes to the facility, they also use that report sheet to do their head-to-toe assessment. He stated the assessment includes if they can stand, ambulate, how far can they ambulate, and do they require a device to ambulate. He stated if he does not know anything about the person, when he walks into the room, and if that person cannot tell him how they need to be transferred, he is going to assume they are a two-person assist or a two-person lift. He stated a two-person lift means they are going to use a mechanical lift. He stated if he saw a sling underneath the resident, that would tell him that the resident requires a two-person lift and he would go get the mechanical lift and call for a co-worker. He stated if he did not see a sling under the resident, he would assume they are a one-person assist and could stand or give some type of assistance with pivoting. He stated when he went to the room to introduce himself, Resident #10's family member was present. He stated he thought she had an immobilizer on her right leg; however, he could not be sure. He stated the resident's family member told him that even though she had an immobilizer on her right leg (unsure if it was right or left leg) the resident could stand a little bit and bear weight. He stated the family member told him that she was having some pain and that the previous facility had had an X-ray on the resident's right knee done just a few prior to her coming to this facility. He stated the resident's family member told him that the resident could stand a little bit, by standing on her right side, but not for long. He stated he was assuming that maybe that was what CNA. G used, to determine how to transfer Resident #10, however, he was not sure if that was true. He stated when he met Resident #10, he did not see CNA G. He stated LVN F may have relayed that information from the resident's family member to CNA G. He stated when he met her, she was not complaining of pain to him. He stated he knew she was taking was taking Norco and was taking it routine and prn. He stated if nursing staff did not have the information on the resident prior to them arriving to the facility, or if no one told him how to transfer a newly admitted resident, and they had not received the report from the previous facility, he stated he would go by what the resident told him. He stated he would ask if the resident was able to stand and/or walk, if the resident was alert and oriented, he would ask them. He stated the questions staff could ask a new resident are, Can you stand? Will you be able to help me, get you over there or to the wheelchair? He stated if the resident were to say, No, then staff would need to ask the resident to wait and then the staff should go get a co-worker to assist. He stated if Resident #10's family member did tell C.N.A. G that the resident could help him transfer her and he was unsure, he could have asked the resident some clarification on her abilities and requirements before trying to transfer her alone. In an interview on 09/26/24 at 2:02 PM with the Attending Physician, he stated he referred to the Progress Notes from the previous nursing facility and stated the notes read that Resident #10 was mod assist x1 with functional transfers. He also stated that the notes read that Resident #10's legs would swell when she tries to stand, so they (facility) knew that she could put weight on her legs. He stated Resident #10 told him that she could not walk, which made sense, but as far as transfers are concerned. He stated she complained of right knee pain and the notes spoke of multiple negative X-rays of the right knee; however, the X-rays were only of the knee. There were also notes from the doctor, which read that she needed to be seen by an Orthopedist for possible hardware loosening. He stated when he saw her, she did not say anything about that, as bothering her, in particular. He stated she was pleasant and interactive. He stated she had chronic pains, but she did not focus on that leg during their interview. He stated she did tell him about her shoulder and knee pains and that she could not push on a wheelchair. She stated her shoulder limited her from self-propelling in a wheelchair. He stated she did not say anything about how she usually transfers. He stated he specifically asked her when the last time was that she walked, (because that tells him a lot about how functional a person was going to be. He stated it told him whether they will be wheelchair dependent.) He stated she told him that she had not ambulated, meaning walking, in years. He stated he did not see an immobilizer on her leg when he talked to her. He stated she was sitting in a couch-like chair, watching tv. He stated if there was no other information to go by, it was reasonable to believe that a one-person transfer was feasible. He stated the notes reflected that she was standing at the other facility, and she was moderate assist x1. He stated he did not see why she could not transfer her with one person. He stated there was no trauma reported, meaning just because there was a fracture, it did not mean it came from being plopped down into a chair. He stated given that only the knee was X-ray at the previous facility, while she had been complaining about knee and leg pain, who is to say that the fracture did not happen at the previous facility. He stated, it's the chicken vs the egg kind of thing because he did not know if the fracture was already there or not. He stated given the location of the fracture (distal tibia); it would not have been seen on a knee X-ray. He stated they (facility) did not get very clear information from the previous nursing facility, about activity in terms of whether she needed assistance, or whether she needed a Hoyer. He stated what was provided revealed she was doing standing with therapy, because the notes indicated that her legs got swollen while she was standing. He stated also, the notes stated she was moderate assist x1; which tells us that she was able to bear weight on both her legs. He stated if the resident was able to bear weight and was transferred incorrectly it could have prompted a new fracture, a refracture, or exacerbated an existing fracture that anyone was even aware of. He stated she was not at the facility long enough (facility) to decipher what was going on with her. He stated there are multiple dependent to factors when a new patient was admitted to the facility. He stated what does the paperwork say, was the patient oriented, can they tell what was necessary and what is not. He stated days before Resident #10 arrived at the facility, the notes provided from Occupational Therapy (OT) stated she was moderate assist x1 with transfers. He stated in worst case scenario, you do not know if there was hesitancy for anything then yes, wait until therapy can evaluate. He stated he has had patients who can just get up and go with a walker, but they are obviously demented. He stated there are a lot of factors that come into play when you are making a decision. He stated he could not be more help because he only saw her once. He stated if she had been there longer, who is to say that while she was at the facility, they would not have X-rayed her leg. He stated he did not know why the former facility did not X-ray more than just the knee. He stated you can have radiating pain. He stated you can have hip pain radiating to the knee, you can have ankle pain radiating to the knee. He stated he did not know why they only focused on the knee and not anywhere else, especially since the pain was persistent. He stated the notes indicated that the resident's activity had decreased. He stated the physician made note that he had referred her to an Orthopedist, but she never got to go because she left the facility. He stated the Orthopedist probably would have X-rayed her leg. In an interview on 09/26/24 at 2:59 PM with C.N.A. G, he stated he started his shift at 2:00 PM. He stated about 2:30 PM, a female C.N.A. was standing at the door of Resident #10's room and called for him to come help her. He stated when he came to the room, the female aide left to get something, but he was not sure what. He stated the family member told him the resident could help him get her into bed. He stated Resident #10 then said she could stand a little and could help him. He stated when he entered the room, Resident #10 was sitting in the wheelchair and it was near the bed, but not right next to the bed. He stated her family member was standing next to her, kind of between the chair and the bed. He stated the family member told him that the resident wanted to get back in bed because she was in pain. He stated she was not crying, but she was whining and grunting. He stated her family member was rubbing her side and back and telling her it was ok and that she was about to be put back in bed. He stated he moved the wheelchair next to the bed and then he used a gait belt to help lift her from the chair and then he helped her into bed. He stated the resident had already started to try to push herself up on one side and he told her to wait for him to help her. He stated the resident was holding on to his arms and the gait belt was still behind her and he held it to help him steady her. He stated she took about two steps and then she was turned to where her back was to the bed, and she was against the bed. He stated she had to step to the left to get to the bed. He stated the bed was low, so she was able to just sit on the bed without having to have to scoot back onto it. He stated when he came in the room, she was already whining, and her family member said she was in pain. He stated when he finished transferring her into bed, he went and told the nurse that she was complaining of pain. Then he went to answer another call light. In an interview on 09/27/24 at 11:15 AM with LVN F, he stated he did not have many interactions with Resident #10. He stated he was the admitting nurse. He stated she was quiet when she arrived. He stated he remembered having to call her previous nursing facility several times to get report on her because they were not returning his calls. He stated he finally received report on her after she was admitted . He stated one person brought the resident into the facility and she was in a wheelchair. He stated he and an aide transferred the resident to the bed. He stated he could not recall what the paperwork stated as far as how many people were required, but he used two people just to be safe. He stated Resident #10 told him that she was uncomfortable in the wheelchair after a while, and that's when he and an aide transferred her onto the bed. He stated his shift ended at 10:00 PM on 04/03/24. He stated she was still in bed when he got off shift. He stated on 04/04/24, his shift started at 2:00 PM. He stated the off-going nurse reported to him that Resident #10 was out of bed and in her wheelchair. He stated the nurse told him that the resident had been uncomfortable on and off but not to the point of excruciating pain. He stated when he went to see her for the first time that day, the resident told him that she wanted to get back in bed. He stated she did not ask for any medications at that time. He stated there were two aides on shift, and he called for them to transfer her back into bed. The female came first, but then he told C.N.A. G to do it. He stated he was ok with C.N.A. G transferring her alone, because he himself had had time to review her admission paperwork and it said that she was a x1 person assist. He stated when C.N.A. G finished transferring her, he (C.N.A. G) came to him and told him that the resident was in pain from being uncomfortable in the chair. He stated he went to assess the resident and she told him that she was in pain, so he went to get the medication for her. He stated the way she was expressing her pain; he could see that it was more intense than the day before. He stated he checked her orders and then administered pain medication first, then he contacted the PA. He stated the PA told him to send her to the hospital. He stated the admission process was that the nurse would receive a report from the facility or hospital that the new resident was coming from. He stated they verify the transportation method, which the resident would be arriving in. He stated the ADONs enter the care information in the Kardex. He stated some stations enter it in a binder, while others enter it into the system. He stated the C.N.A.s and other nurses receive report from the admitting nurse or the ADON. He stated the kitchen was notified of the new resident's dietary needs. He stated medications are ordered. He stated housekeeping was notified, so they can make sure the room is ready. He stated when the new resident arrived, the admitting nurse will greet them and take them to their room. Then the residents are interviewed, and vitals and weight are taken. Then they see if the resident wants to remain in their wheelchair or get in bed. He stated once the resident was made comfortable, then the nurse was to document the information which they received from the resident during that initial interview. Then the nurse will begin assessments on the resident. Record review of the sign-in schedule for all shifts from 04/03/24 and 04/04/24, revealed six of nine staff who were responsible for the resident, no longer worked at the facility. In an interview on 09/27/24 at 12:48 PM with CMA I, she stated she was on shift when Resident #10 was admitted on [DATE]. She stated she thought it was around lunch time when Resident #10 arrived at the facility, she introduced herself to the resident to make her feel welcome. She stated a lady from the transport service brought the resident into the facility. She stated she was sitting in a wheelchair. She stated the transport driver was talking to LVN F for a little while. She stated staff brought the rest of the resident's belongings in and LVN F took her to her room. She stated the resident was calm and was not complaining of pain at that time. She stated LVN F returned to the nurses' station and entered her information in the system. She stated a little later on, the resident asked for a pain pill, and she checked the system and saw that it was time for another pain pill, so she administered the medication to her. She stated the resident had been getting that pain medication twice a day at the other facility. She stated the aides had put her in bed and she was asleep, by the time she got off shift at 8:00 PM. She stated to her knowledge, the resident had not complained of pain the rest of the night. She stated when she came to work the next day, the resident had already been sent to the hospital. On 09/27/24 at 1:20 PM a call was made to LVN J, there was no answer. A voice message was left. In a follow-up interview on 09/27/24 at 5:00 PM with C.N.A. G, he stated he was in the hall and was called to the room by the older female aide. He stated the female aide started talking to the roommate when Resident #10 and her family member told him that Resident #10 could stand a little bit and could help him transfer her from the [TRUNCATED]

Based observations, interviews, 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 five (Resident #1, Resident #3, Resident #4, Resident #5, and Resident #9) of eleven residents observed for Infection Control. 1. The facility failed to ensure that CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #1. 2. The facility failed to ensure that LVN A would not bring a plastic container containing push button lancets (small, sharp needle used to prick the skin and draw blood), a container of test strips, and alcohol wipes inside Resident #3, Resident #4, and Resident #5's room when she checked the residents' blood sugar. 3. The facility failed to ensure that CNA D and CNA E changed gloves and performed hand hygiene while providing incontinent care to Resident #9. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #1's Face Sheet, dated 09/25/2024, reflected that the resident was an [AGE] year-old male admitted on [DATE]. Resident #1 was diagnosed with cystitis (inflammation of the urinary bladder) and acute kidney failure. Review of Resident #1's Quarterly MDS Assessment, dated 06/11/2024, reflected that Resident #1 had a severe impairment in cognition a BIMS score of 04. Resident #1's Quarterly MDS Assessment indicated that the resident was incontinent for bowel. Review of Resident #1's Comprehensive Care Plan, dated 08/28/2024, reflected that Resident #1 has bowel/bladder incontinence related to benign prostatic hyperplasia (enlarged prostate) and one of the interventions was check as required for incontinence. Observation and interview with CNA B on 09/24/2024 at 1:26 PM revealed CNA B was about to do Resident #1's incontinent care. She put on her gloves, opened a brief, and put it on the other bed. She also put some wipes beside the brief. CNA B raised the bed, lowered the head of the bed, and pulled the resident's blanket towards the feet of the resident. She did not wash her hands before putting on her gloves. She unfastened the tape of the brief on both sides and tucked the front part of the brief in between the resident's legs. CNA B pulled some wipes and started to clean the front part of the resident. After cleaning the front part of the resident, she rolled the resident towards the right and the cleaned the resident's bottom. After cleaning the resident's bottom, CNA B rolled the soiled brief and the bed padding altogether towards the middle of the bed. After rolling the soiled brief and padding, CNA B rolled back the resident and instructed the resident to roll to the other side. After rolling the resident to the other side, CNA B pulled the soiled brief and padding and threw them in the trash can. CNA B took the new brief and put it at the bottom of the resident and fixed it. CNA B did not change her gloves nor sanitize her hands before touching the new brief. CNA B rolled the resident back and said she would clean the resident's front part again. At this point, she pulled the trash can near her, pulled some wipes, and cleaned the resident's front part again. She did not change her gloves nor sanitize her hands after touching the trash can. After cleaning the front part of the resident again, she threw the soiled wipes, fixed the new brief, and taped the brief on both sides. She did not change her gloves nor sanitize her hands after cleaning the resident again and before touching the new brief. She then pulled the resident's blanket towards the resident's chest, tied the plastic bag that was in the trash can into a knot, and went out of the room. She did not wash her hands before going out of the room. CNA B stated hands should be washed or sanitized before and after doing incontinent care. She said the hands should also be sanitized before putting on clean gloves. CNA B said hand hygiene was important to prevent the spread of germs. She said she should have done hand hygiene and changed her gloves after touching the soiled brief, after cleaning the resident's bottom, after touching the trash can, and before touching the new brief. She said not doing hand hygiene and not changing her gloves after touching soiled items could cause cross contamination and infection. She said she had in-services about hand hygiene almost every month. 2. Review of Resident #3's Face Sheet, dated 09/25/2024, reflected that the resident was a [AGE] year-old male admitted on [DATE]. Resident #3 was diagnosed with type 2 diabetes mellitus (body has higher sugar level). Review of Resident #3's Comprehensive MDS Assessment, dated 09/20/2024, reflected Resident #3 was cognitively intact with a BIMS score of 14. The Quarterly MDS Assessment indicated diabetes mellitus as one of Resident #3's active diagnosis. Review of Resident #3's Comprehensive Care Plan, dated 09/2/2024, reflected Resident #3 had diabetes mellitus and one of the interventions was to give diabetes medications as ordered. Review of Resident #3's Physician's Order, dated 07/08/2023, reflected Insulin Regular Human Injection Solution (Insulin Regular (Human). Inject subcutaneously (administer under the skin) with meals for diabetes check FSBS before meals, inject insulin only if actively eating meal; give HS snack. Observation on 09/24/2024 at 11:21 AM revealed LVN A was preparing to check for the blood sugars of the residents on her hall. She said she would do Resident #3's blood sugar first. She went to Resident #3's room, sanitized her hands and the glucometer. LVN A had a square plastic container which contained blood glucose test strips, lancet push buttons, and alcohol wipes. She also put the glucometer on the plastic container. She went inside Resident #3's room, brought with her the plastic container, and placed it on top of the resident's bed. She wiped the resident's right pointing finger, pricked it with a lancet push button, and scooped the blood with the test strip. After pricking the resident's finger, she threw the lancet push button on the plastic container. She said the resident's blood sugar was 255. She went back to her cart and put the plastic container on top of her cart. She logged on to her computer and said the resident would receive 4 units of insulin. She opened the right drawer of her cart and took the resident's insulin. She cleaned the top of the vial, took a syringe for insulin, and drew 4 units of insulin. After getting 4 units of insulin, she returned the vial of insulin back to the drawer. She went inside the room and injected the insulin on the left upper arm of the resident. She was not wearing any gloves when she injected the insulin. Review of Resident #4's Face Sheet, dated 09/25/2024, reflected that the resident was a [AGE] year-old male admitted on [DATE]. Resident #4 was diagnosed type 2 diabetes mellitus. Review of Resident #4's Comprehensive MDS Assessment, dated 08/05/2024, reflected Resident #4 had a moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated diabetes mellitus as one of Resident #4's active diagnosis. Review of Resident #4's Comprehensive Care Plan, dated 08/05/2024, reflected Resident #4 had diabetes mellitus and one of the interventions was to give diabetes medications as ordered. Review of Resident #4's Physician's Order, dated 01/24/2024, reflected Insulin Aspart Flex Pen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject subcutaneously with meals for Hyperglycemia (too much sugar in the blood) related to TYPE 1 DIABETES MELLITUS WITH UNSPECIFIED COMPLICATIONS. Observation on 09/24/2024 at 11:32 AM revealed LVN A went to Resident #4's room. She sanitized her hands and the glucometer. LVN A took the plastic container from the top of her cart. The plastic container contained blood glucose test strips, lancets, and alcohol wipes. She also put the glucometer on the plastic container. She went inside Resident #4's room, brought with her the plastic container, and placed it on top of the resident's overbed table. She wiped the resident's right pointing finger, pricked it with lancet push button, and scooped the blood with the test strip. She said the resident's blood sugar was 352. She went back to her cart and put the plastic container to the top of her cart. She logged on to her computer and said the resident would receive 8 units of insulin. She opened the right drawer of her cart and took the resident's insulin. She cleaned the top of the vial, took a syringe for insulin, and drew 8 units of insulin. After getting 8 units of insulin, she returned the vial of insulin back to the drawer. She went inside the room and injected the insulin on the right upper arm of the resident. She was not wearing any gloves when she injected the insulin. Review of Resident #5's Face Sheet, dated 09/25/2024, reflected that the resident was a [AGE] year-old male admitted on [DATE]. Resident #5 was diagnosed with type 2 diabetes mellitus. Review of Resident #5's Comprehensive MDS Assessment, dated 07/24/2024, reflected Resident #5 had a moderate impairment in cognition with a BIMS score of 10. The Quarterly MDS Assessment indicated diabetes mellitus as one of Resident #5's active diagnosis. Review of Resident #5's Comprehensive Care Plan, dated 08/23/2024, reflected Resident #5 had diabetes mellitus and one of the interventions was to give diabetes medications as ordered. Review of Resident #5's Physician's Order, dated 03/20/2024, reflected Fiasp FlexTouch Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart (with Niacinamide). Inject subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. Observation and interview on 09/24/2024 at 11:42 AM revealed LVN A went to Resident #5's room. She sanitized her hands and the glucometer. LVN A took the plastic container from the top of her cart. The plastic container contained blood glucose test strips, lancets, and alcohol wipes. She also put the glucometer on the plastic container. She went inside Resident #5's room, brought with her the plastic container, and placed it on top of the resident's overbed table. She wiped the resident's right pointing finger, pricked it with lancet push button, and scooped the blood with the test strip. After she pricked the resident's finger, she threw the used lancet in the plastic container. The glucometer displayed error. LVN A placed another strip on the glucometer, took another lancet push button, and prick the resident's finger again. After pricking the resident's finger again, she threw the used lancet on the container again. She said the resident's blood sugar was 207. She went back to her cart and put the plastic container to the top of her cart. She logged on to her computer and said the resident would receive 4 units of insulin. She opened the right drawer of her cart and took the resident's insulin. She cleaned the top of the vial, took a syringe for insulin, and drew 4 units of insulin. After getting 4 units of insulin, she returned the vial of insulin back to the drawer. She went inside the room and injected the insulin on the abdomen of the resident. She was not wearing any gloves when she injected the insulin. She stated she sanitized the glucometer before using it for Residents #3, #4, and #5. She said she brought the whole container with her inside the residents' room in case she needed another test strip or another lancet. She said she did not have to go back to her cart just to get another test strip or another lancet. She said she should have left the plastic container on top of the cart because the test strip and the lancet push button were for all the residents that needed their blood sugar checked. She said bringing the plastic container inside the resident's room, putting it on the resident's table and bed, and then putting it on the cart using it could result to cross contamination. She also said the used lancet should be returned to the plastic container because it was already in contact with resident's skin or blood. She said gloves should also be worn when administering the resident's insulin to minimize the risk of transmission of germs from the staff to the resident or vice versa. In an interview with LVN A on 09/25/2024 at 8:24 AM, LVN A stated hand hygiene was the basic component in the prevention of cross contamination and development of infection. LVN said hand hygiene should be a part of the staff's routine, especially those that were providing direct care. She said staff should do hand hygiene before and after any care, should sanitize their hands in between changing of gloves, should change their gloves after touching anything that was dirty or soiled and before touching the clean items. In an interview with the DON on 09/25/2024 at 8:43 AM, the DON stated all the staff should know that hand hygiene was the most effective way to prevent cross contamination and infection. She said hands should be washed before and after doing incontinent. She said gloves should be changed after touching any soiled items like the soiled brief or the trash can. She said the gloves should also be changed after cleaning the resident's bottom. She said hand hygiene should be done after taking off the gloves. She said the container containing the test strips, lancets and alcohol wipes should stay in the cart. She said staff should only bring what was needed for blood sugar. She said staff could bring with them the glucometer, a couple of test strips, and a couple of lancets in case the first try would result to error. She said bringing the plastic container inside, placing it on the residents' table and bed, and then putting it back on the cart could cause cross contamination. She said any germs from the resident's overbed table and resident's bed could transfer to the plastic container. She also said the used lancets were not supposed to be mixed with the unused lancets because it was already contaminated with blood. She said the expectation was for the staff to do hand hygiene before and after any care, to change their gloves from dirty to clean, to do hand hygiene in between changing of gloves, and not to bring any item used by other residents inside a resident's room. She said she will do an in-service about infection control. In an interview with the Administrator on 09/25/2024 at 9:11 AM, the Administrator stated staff should always wash their hands when they were with the residents. he said the gloves should be changed when appropriate to prevent spread of germs. He said the expectation was for the staff to follow the policy and procedures pertaining to infection control. He said he would collaborate with the clinicians to in-service the staff about infection control. In an interview with the ADON on 09/25/2024 at 10:37 AM, the ADON stated hand hygiene was included in all the procedures of any care and should be done before and after every care. He said gloves should be changed after touching the soiled brief, the soiled padding, and the trash can. He said the hands should be washed or sanitized before putting on a new pair of gloves. He also said the plastic container should stay in the cart and the staff should have just brought a couple of strips and lancets in case there was an error in checking the blood sugar. He said the test strips and lancets brought inside the resident's room should be discarded if not used. He said there might be no specific policy about bringing the plastic container inside the room, but the best practice was not to bring it inside the room. He said used and unused lancet should not be mixed. He said all the issues discussed were causes of cross contaminations and probable development of infections. He said the expectation was for the staff to do hand hygiene before and after every care and before putting on a new pair of gloves, to change their gloves when transitioning from dirty to clean area, not bringing any item inside the resident's room if used for other residents. The ADON said he would coordinate with the DON on how to go forward. 3. Review of Resident #9's Face Sheet, dated 09/25/24, reflected that Resident #9 admitted [DATE]. Resident #9 was diagnosed with dementia (abnormal brain changes), cerebral infarction (also called a stroke: occurs when blood flow cannot reach a part of the brain), cognitive communication deficit, and a need for assistance with personal care. Review of Resident #9's Comprehensive MDS, dated [DATE], reflected in the Care Area Summary that Resident #9 had a BIMS score of 02. This score indicated severe cognitive impairment. Resident #9 was incontinent of bowel and bladder and dependent on staff for personal and toileting hygiene. Review of Resident #9's Care Plan, dated 08/13/24, reflected that Resident #9 had bowel and bladder incontinence related to dementia and impaired mobility. One intervention was to change Resident #9 every two hours and as needed. Another intervention was to wash, rinse, and dry perineum, and change clothing as needed after incontinence episodes. An observation 09/25/24 at 10:56 AM revealed that CNA D and CNA E provided incontinence care for Resident #9. Resident #9's family member was also inside the room. CNA D and CNA E washed their hands and put on clean gloves. The front and back of Resident #9's pants was wet. CNA D assisted CNA E to take off Resident #9's pants. The tabs on the brief were secured at the waist but Resident #9's brief was loose on the sides and Resident #9's bottom was visible. Resident #9 held on to CNA D's and CNA E's arms while being changed. CNA E removed the wet brief and then changed gloves, without performing handwashing or using hand sanitizer. CNA E cleaned the resident's peri area and then changed her gloves, without handwashing or using hand sanitizer. CNA E turned Resident #9 to her right side. CNA D wiped Resident #9's bottom. CNA D did not remove her soiled gloves and continue to provide care. CNA D placed a clean brief under Resident #9 and secured the tabs at the front of the brief. CNA E assisted CNA D to put clean pants on Resident #9. CNA D and CNA E removed their gloves and washed their hands in the Resident #9's bathroom before leaving the room. In an interview with CNA D on 09/25/24 at 11:15 AM, CNA D stated she should have washed her hands or used hand sanitizer after taking off the dirty gloves. She stated this was an infection control issue and it was important to prevent spreading bacteria. In an interview with CNA E on 09/25/24 at 11:18 AM, CNA E stated she should have washed her hands after taking off the dirty gloves. She said this was important to prevent contamination and infection. CNA E stated the staff has in-services regularly about providing incontinence care. In an interview on 09/25/24 at 11:40 AM, the ADON stated that CNA D and CNA E should have performed hand hygiene after removing their soiled gloves. The ADON stated proper hand hygiene was important to contamination and the spread of infection. The ADON the facility staff has skills checks annually and provide in-service training to staff on incontinence care. The ADON stated that the new CNAs are observed performing skills and get checked off. During an interview with the DON on 09/25/24 at 11:45 AM, stated the facility has a male and female mannequin, and that staff was required to demonstrate providing incontinence care. The DON stated if a staff member does not pass the skills check off, they are required to repeat it, and demonstrated that they can provide incontinence care correctly. The DON stated this was important to prevent the spread of infection. The DON stated if she sees a pattern of infection, an in-service was done to ensure staff were providing incontinence care correctly. Review of facility policy, Infection Control Infection Prevention and Control Program revised 10.2022 revealed Goal: Decrease the risk of infection to residents and personnel . Recognize infection control practices while providing care . 3. The facility personnel . provide care in a way that minimizes the spread of infection . b. Facility personnel will wash their hands after each direct resident contact 4. Facility personnel will handle, store, process, and transport . to prevent the spread of infection. Review of facility policy, Hand Hygiene Infection Control revised 10.2022, revealed Purpose: Hand hygiene is one of the most effective measures to prevent the spread of infection . Procedures: b. Before and after direct contact with residents . h. Before moving from a contaminated body site to a clean body site during resident care . m. After removing gloves.

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 6 (room [ROOM NUMBER], #2, #3, #4, #5, and #6) of 10 resident rooms reviewed for cleanliness and sanitization. The facility failed to ensure that Resident Rooms #1, #2, #3, #4, #5, and #6 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 09/24/24 at 12:57 PM of Resident room [ROOM NUMBER] reflected the bathroom floor had built up dirt particles along the walls. The base that the toilet sat on, had thick brownish stains along the front and sides. The air condition unit in the resident's room had dirt stains along the top of the unit and thick black dirt between the vents. The mini fridge in the room had a thick orange stain along the inside bottom. An observation on 09/24/24 at 12:59 PM of Resident room [ROOM NUMBER] reflected the base that the toilet sat on, had thick brownish stains along the front and sides. The air condition unit in the resident's room had dirt stains along the top of the unit and thick black dirt between the vents. The mini fridge in the room had a thick white dust along the top. An observation on 09/24/24 at 01:01 PM of Resident room [ROOM NUMBER] reflected the bathroom floor had built up dirt particles along the walls. The base that the toilet sat on, had thick brownish stains along the front and sides. The air condition unit in the resident's room had dirt stains along the top of the unit and thick black dirt between the vents. An observation on 09/24/24 at 01:03 PM of Resident room [ROOM NUMBER] reflected the bathroom floor had built up dirt particles along the walls. The base that the toilet sat on, had thick brownish stains along the front and sides. The air condition unit in the resident's room had dirt stains along the top of the unit and thick black dirt between the vents. An observation on 09/24/24 at 01:05 PM of Resident room [ROOM NUMBER] reflected the air condition unit had dirt stains along the top of the unit and thick black dirt between the vents. An observation on 09/24/24 at 01:07 PM of Resident room [ROOM NUMBER] reflected the air condition unit had dirt stains along the top of the unit and thick black dirt between the vents. The mini fridge in the room had a brownish stain along the inside bottom. In an interview on 09/25/24 at 09:41 AM, Housekeeping S stated she had been at the facility for 3 years. She stated they are supposed to clean all parts of the room, including the bathrooms and the air condition unit. She stated they are also supposed to dust, mop, and empty trash. She was shown pictures of the concerns observed in the resident rooms and she stated they were supposed to clean the air condition units, but she stated they did not have a good brush to clean the vents. She stated she tried cleaning the base of the toilets, but it was rust. She stated the risk to the residents was that the concerns observed was a hazard and could cause breathing issues. In an interview on 09/25/24 at 10:22 AM, the Housekeeping Supervisor stated she had been at the facility for [AGE] years and in her current position for 4 years. She stated housekeeping staff was supposed to clean bathrooms, floor, windowsills, air condition units. She stated the filter was cleaned once a week at the beginning of the month. She stated housekeeping did not clean out the mini fridges in the resident rooms unless they are very dirty. She stated the family member, or the CNAs clean the mini fridges out. She was shown pictures of the concerns observed in the resident rooms and she stated that there was no excuse and she had completed in services on 09/18/24 about properly deep cleaning the rooms. She stated the resident rooms are scheduled to be deep cleaned once a week. She stated the concerns observed could cause health problems for the resident. In an interview on 09/25/24 at 10:35 AM, the Administrator stated he had spoken with the housekeeping supervisor about the concerns observed in the resident rooms. He was also shown pictures of the concerns observed. He stated housekeeping was to clean all the areas of concern, including cleaning the inside of the resident's mini fridge. He stated the housekeeping supervisor takes her role very seriously and she will ensure that the concerns were corrected. He stated the concerns observed in the resident rooms could cause health problems for the resident. Review of the facility's policy on Cleaning and Disinfection of Environmental Surfaces (08/2019) reflected Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. Review of the facility's policy on Environmental Services (November 2021) revealed To provide a clean, attractive, and safe environment for residents, visitors, and staff. High Dust Wall Articles: Damp Dust the Doors and Wall the tops of items along the resident's room and restroom walls (door frames, picture frames, clocks, over bed lighting, door closures, etc.) that are at or above your shoulder height. Clean and Disinfect the Room Furnishings: A. Clean all furnishings in the resident's room including the bed rails, IV poles, doorknobs, wheelchairs, walkers, and all other high contact surfaces.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #6 and Resident #7) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #6 and Resident #7's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #6 Review of Resident #6's Face Sheet, dated 09//25/2024, reflected that the resident was an [AGE] year-old female admitted on [DATE]. Resident #6 was diagnosed with muscle wasting, muscle weakness, and unsteadiness on feet. Review of Resident #6's Comprehensive MDS Assessment, dated 07/06/2024, reflected that Resident #6 had a moderate impairment in cognition with a BIMS score of 11. Resident #6 required substantial assistance for personal hygiene, toileting, and shower. Review of Resident #6's Comprehensive Care Plan, dated 07/27/2024, reflected Resident #6 was at risk for falls related to Alzheimer's disease and one of the interventions was to be sure the resident's call light was within reach. Observation and interview on 09/24/2024 at 9:44 AM revealed Resident #6 was in her bed, awake. It was observed that the resident's head of the bed was raised and the cord of her call light was dangling below the head of the bed. The resident's call light was observed pressed between the upper right corner of the mattress and the frame of the bed. She said she was looking for her call light earlier but could not find it. She said she cannot even find the cord of her call light. She said she did not know how her call light ended between the mattress and the bed. She said she would just holler if she needed anything. Observation and interview with CNA C on 09/24/2024 at 9:58 AM, CNA C stated the call lights should be with the residents at all times because the residents used the call lights to let the staff know that they needed something. She said the call lights were the residents' lifeline. CNA C went inside Resident #6's room and saw the call light was not with the resident. CNA C pulled the cord of the call light and said she cannot pull it. she followed the cord and saw the call light was pressed between the mattress and the frame of the bed. She pulled the call light and put it where Resident #6 could reach it. She said she was not able to check the call lights during her initial round because she was running late. She said she would do her round and check if the call lights were with the residents. Resident #7 Review of Resident #7's Face Sheet, dated 09/25/2024, reflected that the resident was a [AGE] year-old male admitted on [DATE]. Resident #7 was diagnosed with muscle weakness, unsteadiness on feet, and blindness to both eyes. Review of Resident #7's Comprehensive MDS Assessment, dated 08/09/2024, reflected that Resident #7 had a severe cognitive impairment with a BIMS score of 05. Resident #7 required substantial assistance in toileting, shower, and dressing. Review of Resident #7's Comprehensive Care Plan, dated 09/02/2024, reflected that Resident #7 was at risk for falls related to blind to both eyes and one of the interventions was to be sure the resident's call light was within reach. Observation and interview with Resident #7 on 09/24/2024 at 11:16 AM revealed Resident #7 was in his bed, awake. It was observed that the resident's call light was hanging on the wall near the privacy curtain. The resident only shrugged his shoulder and smiled when asked where his call light was. Observation and interview on 09/24/2024 at 11:53 AM revealed the DOR went inside Resident #7's room and saw the resident's call light was hanging on the wall. The DOR took the call light from the wall and gave it to Resident #7. She said call lights were important for the resident because the residents use the call lights to call the staff if they needed something. Without the call light the staff would not know the residents needed something. In an interview with the DON on 09/25/2024 at 8:43 AM, the DON stated call lights were important for the residents and they should be placed where the residents could access them without difficulty. The DON said the call lights were the residents' mode of communication so they could tell the staff they needed something. She said, without the call lights, the residents' needs would not be addressed. She said all the staff were responsible in ensuring that the call lights were within reach. The DON said the expectation was for the staff to be mindful that the call light was in reach every time they left the residents' room. The DON said she would conduct an in-service about call lights. In an interview with the Administrator on 09/25/2024 at 9:11 AM, the Administrator stated the call lights should be with the residents always. The Administrator said the staff should be make sure the call lights were within reach. The Administrator said he would coordinate with the DON regarding call lights. In an interview with the ADON on 09/25/2024 at 10:37 AM, the ADON stated the call lights should be accessible to the residents at all times because the residents needed them to call the staff. The ADON said if the call lights were not within reach, the residents would not be able to call the staff and their needs would not be met. The ADON said the residents might be having an emergency and staff would not know. The ADON said the expectation was for all the staff to make sure the call lights were within the reach of the residents. The ADON said they would do an in-service about call lights being accessible to the residents. Record review of facility's policy Call Light/Bell Policy/Procedure - Nursing Clinical revised 05/2007 revealed Policy: It is the policy of this facility to provide the resident a means of communication with nursing staff . Procedures: . 5 . Place the call device within resident's reach before leaving the room.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 2 (Resident #1and Resident #2) of 8 residents reviewed for care plans. - The facility failed to document measurable objectives, interventions, or timeframes to address Resident #1's wandering behavior r/t diagnosis of dementia. On 06/05/24 Resident #1 wandered into Resident #2's room and was physically attacked and sustained a serious injury. -The facility failed to document measurable objectives, interventions, or timeframes to address Resident #2's aggressive behaviors after he exhibited combative behaviors in 12/2023. Interventions were not documented on Resident #2's care plan until after an incident occurred on 06/05/24 where he was physically aggressive with Resident #1 and caused serious injury. The non-compliance was identified as past non-compliance (PNC). The IJ began on 06/05/24 and ended on 06/06/24. The facility had corrected the non-compliance before the state's investigation began. This failure could place all residents at risk of not receiving appropriate care and services to meet their needs. Findings included: 1. Record review of Resident #1's face sheet, dated 06/10/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: dementia (loss of memory and thinking), traumatic brain injury, dysphasia (difficulty speaking), unsteadiness on feet, and age-related physical debility (weakness caused by age). Record review of Resident #1's quarterly MDS assessment, dated 03/0724, reflected his BIMS score was 03, which indicated severe cognitive impairment. Record review of Resident #1's care plan, revised 01/30/24, reflected the resident was at risk for impaired thought processes r/t traumatic brain injury with cognitive deficit, new facility, and seizure disorder, with interventions that included communication (identifying self at each interaction, face when speaking, reduce distractions, use simple directives, and provide necessary cues-stop and return if agitated). Further review of the care plan revealed Resident #1 did not have interventions in place to address his wandering behavior. Record review of Resident #1's hospital records, dated 06/05/24, reflected the following: [Resident #1] is a [AGE] year-old male who presents s/p being pushes at his nursing facility in which patient hit his head. Patient has a history of prior head trauma for which he underwent craniectomy and cranioplasty. His [family] was at bedside to help provide history. [Family] reports that he is more confused than usual because he cannot remember his birthdate. On exam, he is able to tell us the date and month of his birthday but mixes up the year. [Resident #1] denied pain and had no obvious signs of trauma. Further review reflected results from a CT scan completed on 06/05/24 with findings of an epidural hematoma (bleed between skull and brain matter and postsurgical changes of right frontal craniotomy (surgical opening of skull) and left pterional craniectomy (brain surgery). Record review of Resident #1's progress note, dated 06/05/24 by LVN A, reflected the following: At about 6:00pm, this writer heard a sound of a fall in the hallway. Upon getting there, found [Resident #1] on the floor lying on his back unconscious with [Resident #2] standing over him. The [Resident #2] said 'I pushed him because I don't want him coming in my room'. Head to toe assessment was done. [Resident #1] was unconscious, no visible injuries were noted unable to follow commands. Respiration even labored, unable to move extremities. EMS was called. [Resident #1] regained consciousness at about 6:15PM before 911 arrival . [Resident #1] then was transported to [local hospital] for treatment and evaluation. NP on-call, DON, ADON, Administrator and family notified. 2. Record review of Resident #2's face sheet, dated 06/10/2024, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: dementia (loss of memory and thinking), cerebral infarction (stroke), congestive heart failure (weakened heart condition that cause a buildup of fluid in the body), chronic kidney disease, and embolism of pulmonary (blood clot in lungs). Record review of Resident 2's PPS MDS assessment, dated 05/0724, reflected his BIMS score was 13, which indicated cognition was intact. Record review of Resident #2's care plan, revised 06/06/24, reflected the resident had the potential to demonstrate physical behaviors r/t dementia, poor impulse control with intervention which included: monitor/document/report to MD of danger to self or others., psychiatric consult as indicated, and transfer to hospital for evaluation and treatment for other medical conditions. Further review reflected there were no interventions in place to address Resident #2's aggressive behaviors prior to 06/06/24. Record review of Resident #2's progress note, dated 12/21/23 by LVN A, reflected the following: [Resident #2] tried to exit the facility twice through the back gate and also through the fence by the dining area. After being stopped twice, he became upset and frustrated. This [nurse] redirected [Resident #2] back to his room. Un [sic] getting there, [Resident #2] saw [Resident #3] and kicked him and [Resident #3] yelled out saying 'He kicked me' and Thia [sic] writer went into the room and removed the attack resident from [Resident #2] room, assessed [Resident #3] from head to toe no injuries and no bruises noted . Record review of Resident #2's EHR reflected the resident was assessed by psychologist on 09/30/23, when he first admitted to the nursing facility, to address adjustment to facility, memory loss and appetite disturbance for an estimated frequency/duration of 4 times a month for 3 months. Further review reflected Resident #2 was evaluated again on 1/10/24 to address mood and aggressive behaviors. Resident #2 was discharged from psychological services in 03/2024. In an interview on 06/07/24 at 9:45 AM with the DON and the Administrator, the DON stated she worked at the facility for 8 years. She stated during dinnertime on 06/05/24 it was reported that the CNAs were assisting residents with eating and LVN A had Resident #1 close to her as he was known to wander; however, she turned to get Resident #1 some water and he wandered into Resident #2's room. The DON stated LVN A heard commotion coming from the room and found Resident #1 on the floor. The DON stated the incident was unwitnessed and she could not state if Resident #1 was pushed to the floor or fell on his own. She stated Resident #2 was alert enough to make some decisions, but he had impulsive thinking. The DON stated Resident #2 would get upset around the 1st of the month because he would get confused and think he needed to leave the facility to go pay his bills, he also thought people were trying to take his money which was why he did not like anyone in his room. The DON stated both Resident #1 and Resident #2 resided on the facility's secured unit for behaviors related to dementia. The Administrator stated he worked at the facility for 1.5 years. He stated the plan was to discharge Resident #2 and there was a discharge meeting with the family scheduled. He stated Resident #2's family agreed to provide 1:1 monitoring of the resident until the facility could find placement. The Administrator stated the facility did not have residents who had aggressive behaviors in general, but any resident who exhibited any type of behaviors, it was related to dementia, and they resided on the facility's secured unit. An attempted interview on 06/07/24 with Resident #1 was unsuccessful due to him being in the local hospital and unable to communicate for an interview. Resident #1 was expected to be discharged from the local hospital and return to the nursing facility on 06/10/24; however, he did not arrive by time of Investigator's exit on 06/10/24. An attempted interview on 06/07/24 with Resident #2 was unsuccessful due to him being in the community with family and not responding to phone call. Resident #2 was discharged from the nursing facility on the evening of 06/07/24 and unable to be observed/interviewed when Investigator returned to the facility on [DATE]. In an interview on 06/07/24 at 1:21 PM. LVN A stated she worked at the facility for almost 5 years. She stated she worked on 06/05/24 when Resident #2 attacked Resident #1. LVN A stated the incident happened during dinnertime when the aides were busy assisting other residents. She stated Resident #1 had finished his meal and she had him near the nurses' station to monitor him closely due to wandering behavior. LVN A stated she turned to get Resident #1 some water when he got up and wandered into Resident #2's room LVN A stated she heard commotion coming from the room and when she rushed there, she found Resident #1 unconscious on the floor with Resident #2 standing over him. She stated Resident #2 did not like anyone in his room and he informed her that he pushed Resident #1 down for coming in. LVN A stated Resident #2 would sometimes become verbally aggressive towards other residents for going into his room, but she had never seen him get physically aggressive. LVN A stated the other residents did not report or appear to be afraid of Resident #2. In an interview on 06/07/24 at 1:55 PM, CNA C stated she worked at the facility for [AGE] years on 2nd shift, 2:00 PM-10:00 PM. CNA C stated she worked on 06/05/24 during the incident between Resident #1 and Resident #2. She stated she was assisting other residents with dinner and did not witness the incident; however, LVN A informed her of what happened. CNA C stated Resident #1 always wandered into Resident #2's room because it used to be his room and he would get confused due to dementia and think that was still his room. She stated the staff would always redirect Resident #1 to his room. CNA C stated Resident #2 would get upset when other residents went into his room, but she had never seen him become physically aggressive. In an interview on 06/07/24 at 2:12 PM, CNA B stated she worked at the facility for 7 months on 2nd shift, 2:00 PM-10:00 PM. CNA B stated she worked on 06/05/24 during the incident between Resident #1 and Resident #2. She stated she was assisting other residents with dinner when she heard a noise and the LVN A yelled for her to come in Resident #2's room to help. CNA B stated when she got in the room, she saw Resident #1 on the floor, and he was unresponsive. She stated Resident #2 was known to have a bad temper and would curse and get upset if a resident went into his room; however, she never observed him become physically aggressive towards anyone. She stated Resident #2 was mostly quiet and stayed to himself in the room. CNA B stated Resident #2's family stayed at the facility with him to help with his behaviors. She stated Resident #1 previously stayed in the room but was moved for Resident #2's family to stay there, and that is why Resident #1 would get confused and wander back into that room. In an interview on 06/07/24 at 3:05 PM, Resident #2's family member stated the facility notified her that Resident #2 had pushed Resident #1 down for entering his room. The family member stated Resident #2 was not usually physically aggressive and knew better then to put his hands on anyone. She stated Resident #2's friend began residing at the facility with him in 12/2023 after Resident #2 attempted to elope from the facility. She stated that was the facility's way of managing Resident #2's behaviors. She stated the facility was not good at implementing interventions and she expressed concerns about Resident #2' care plan to the ombudsman/ The family member stated the facility wanted to discharge Resident #2 back in 01/2024 for behaviors but the ombudsman was able to stop it due to the care plan not properly addressing all of Resident #2's needs. In an interview on 06/10/24 at 8:45 AM, the Administrator stated Resident #2 had been discharged to one of the company's assisted living facilities. He also stated the hospital reported that Resident #1 was stable and expected to be discharged back to the facility on this date. The Administrator stated although Resident #2's care plan did not reflect interventions to address his aggressive behaviors, the facility had interventions in place that included psychological services, training staff on dementia related behaviors and abuse/neglect, and staff knowing to closely monitor redirect all resident away from Resident #2's room. The Administrator stated staff also knew to monitor and redirect Resident #1 from wandering into rooms. In an interview on 06/10/24 at 09:52 AM, Resident #1's family member stated she visited the resident on 06/05/24, prior to the incident and he did not seem like himself as he was not talking as much. The family stated later after she had left the facility, she received a call informing her that Resident #1 had been taken to the emergency room after being pushed down by another resident and hitting his head. The family member stated Resident #1 had a previous brain injury and testing showed the recent incident caused further injury. The family member stated she did not have any concerns for abuse or neglect prior to the incident; however, now had concerns about there being enough staff to properly monitor residents to prevent incidents like that from occurring again. She stated Resident #1 often wandered into Resident #2's room because that used to be his room until they moved him. She stated Resident #1 had good rapport with his new roommate and family, and there had been no issues between them. In an interview on 06/10/24 at 11:50 AM, the MDS Coordinato r revealed she worked at the facility for one year. She stated it was her responsibility to initiate care plans when a resident admitted and to update them as needed; however, the DON also assisted with the task due to the large number of residents. She stated care plans needed to be updated at least quarterly and if there was a significant change in a resident's condition/behaviors. The MDS Coordinator stated any changes in condition/behaviors had to be addressed on the care plan immediately after the first occurrence. She stated any changes or issues with the residents were discussed during morning meeting every day, that was when she received knowledge of any changes that needed to be updated on the care plans. The MDS Coordinator stated she could not recall receiving reports that Resident #2 exhibited any aggressive behaviors and did not update his care plan to reflect so. The MDS Coordinator stated the DON would sometimes be aware of changes in condition that she was not aware of, and the DON would update the care plan herself. The MDS Coordinator stated the importance of a care plan was for nursing staff to know how to provide proper care to each individual resident. She stated the risk of not updating care plans as needed could be improper care being provided to the residents, and in Resident #2's case, his aggressive behaviors were not being addresses and placed other residents in danger. In an interview on 06/10/24 at 4:35 PM with the Administrator and the DON, the DON stated the staff were trained on behaviors related to dementia and knew to monitor for signs and redirect residents when wandering, especially into Resident #2's room. The DON stated Resident #2 was also seeing a psychologist for his behaviors. The DON stated those interventions should have been on Resident #2's care plan; however, she believed that they were care planned back in 12/2023 because she was very thorough and normally care planned any changes immediately. The DON stated she and the MDS Coordinator were very experienced with care planning, and both understood the importance of keeping it updated; however, this was an oversight. The DON stated she may have accidentally erased previous interventions for behaviors when she updated the care plan after the incident occurred on 06/05/24. The DON stated the risk of not having interventions in place to address aggressive behaviors could result in a negative outcome for residents. The Administrator stated his expectation was that care plans addressed all needs for the residents and was updated whenever there was change in condition/behavior to provide staff with interventions on how to provide appropriate care. The Administrator stated the risk of not updating care plans could be not catching something regarding the care of residents. He stated the facility now ensures that all changes in condition/behaviors are captured during daily morning meetings, and the DON and MDS Coordinator work together to make sure everything is addressed. He stated he is also becoming more involved in the care planning process to verify that care plans are updated per policy. The non-compliance was identified as past non-compliance (PNC). The IJ began on 06/05/24 and ended on 06/06/24. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey : Record review of Residents #1, #2, #3, #4, #5, #6, #7, and #8'S EHR revealed their care plans were updated and had interventions to address all care needs. Interviews on 06/10/24 at 12:30 PM were conducted with the DON and MDS Coordinator revealed they conveyed the understanding that care plans had to be developed at the time of a residents' admission, then updated quarterly and when there was a significant change in a resident's condition and/or behavior. Review of the facility's policy titled Nursing Administration: Care Planning, revised 07/2020, revealed in part the following: Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. Procedures: . 9. The resident's plan of care-focus, goals, and interventions-are communicated and implemented by the members of the health care continuum accordingly. 10. The residents' plan of care is reviewed and revised on an ongoing basis, quarterly at a minimum and/or as needed with changes in condition.

Based on interview and record review, the facility failed to ensure the residents' right to be free from abuse for one (Resident #1) of eight residents reviewed for abuse. -The facility failed to have interventions in place to prevent Resident #1 from being abused by Resident #2, who had a history of being aggressive with no interventions care planned until 06/06/24, after the incident. On 06/05/24 Resident #1 wandered into Resident #2's room where he was physically attacked and sustained a serious injury. The non-compliance was identified as past non-compliance (PNC). The IJ began on 06/05/24 and ended on 06/06/24. The facility had corrected the non-compliance before the state's investigation began. These failures could place all residents at risk for abuse that could lead to serious injury, harm, impairment, or death. Findings included: 1. Record review of Resident #1's face sheet, dated 06/10/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: dementia (loss of memory and thinking), traumatic brain injury, dysphasia (difficulty speaking), unsteadiness on feet, and age-related physical debility (weakness caused by age). Record review of Resident #1's quarterly MDS assessment, dated 03/0724, reflected his BIMS score was 03, which indicated severe cognitive impairment. Record review of Resident #1's care plan, revised 01/30/24, reflected the resident was at risk for impaired thought processes r/t traumatic brain injury with cognitive deficit, new facility, and seizure disorder, with interventions that included communication (identifying self at each interaction, face when speaking, reduce distractions, use simple directives, and provide necessary cues-stop and return if agitated). Record review of Resident #1's hospital records, dated 06/05/24, reflected the following: [Resident #1] is a [AGE] year-old male who presents s/p being pushes at his nursing facility in which patient hit his head. Patient has a history of prior head trauma for which he underwent craniectomy and cranioplasty. His [family] was at bedside to help provide history. [Family] reports that he is more confused than usual because he cannot remember his birthdate. On exam, he is able to tell us the date and month of his birthday but mixes up the year. [Resident #1] denied pain and had no obvious signs of trauma. Further review reflected results from a CT scan completed on 06/05/24 with findings of an epidural hematoma (bleed between skull and brain matter and postsurgical changes of right frontal craniotomy (surgical opening of skull) and left pterional craniectomy (brain surgery). Record review of Resident #1's progress note, dated 06/05/24 by LVN A, reflected the following: At about 6:00pm, this writer heard a sound of a fall in the hallway. Upon getting there, found [Resident #1] on the floor lying on his back unconscious with [Resident #2] standing over him. The [Resident #2] said 'I pushed him because I don't want him coming in my room'. Head to toe assessment was done. [Resident #1] was unconscious, no visible injuries was noted unable to follow commands. Respiration even labored, unable to move extremities. EMS was called. [Resident #1] regained consciousness at about 6:15PM before 911 arrival . [Resident #1] then was transported to [local hospital] for treatment and evaluation. NP on-call, DON, ADON, Administrator and family notified. 2. Record review of Resident #2's face sheet, dated 06/10/2024, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: dementia (loss of memory and thinking), cerebral infarction (stroke), congestive heart failure (weakened heart condition that cause a buildup of fluid in the body), chronic kidney disease, and embolism of pulmonary (blood clot in lungs). Record review of Resident 2's PPS MDS assessment, dated 05/07/24, reflected his BIMS score was 13, which indicated cognition was intact. Record review of Resident #2's care plan, revised 06/06/24, reflected the resident had the potential to demonstrate physical behaviors r/t dementia, poor impulse control with intervention which included: monitor/document/report to MD of danger to self or others., psychiatric consult as indicated, and transfer to hospital for evaluation and treatment for other medical conditions. Further review reflected there were no interventions in place to address Resident #2's aggressive behaviors prior to 06/06/24. Record review of Resident #2's progress note, dated 12/21/23 by LVN A, reflected the following: [Resident #2] tried to exit the facility twice through the back gate and also through the fence by the dining area. After being stopped twice, he became upset and frustrated. This [nurse] redirected [Resident #2] back to his room. Un [sic] getting there, [Resident #2] saw [Resident #3] and kicked him and [Resident #3] yelled out saying 'He kicked me' and Thia [sic] writer went into the room and removed the attack resident from [Resident #2] room, assessed [Resident #3] from head to toe no injuries and no bruises noted . Record review of Resident #2's EHR reflected the resident was assessed by psychologist on 09/30/23, when he first admitted to the nursing facility, to address adjustment to facility, memory loss and appetite disturbance for an estimated frequency/duration of 4 times a month for 3 months. Further review reflected Resident #2 was evaluated again on 1/10/24 to address mood and aggressive behaviors. Resident #2 was discharged from psychological services in 03/2024. In an interview on 06/07/24 at 9:45 AM with the DON and the Administrator, the DON stated she worked at the facility for 8 years. She stated during dinnertime on 06/05/24 it was reported that the CNAs were assisting residents with eating and LVN A had Resident #1 close to her as he was known to wander; however, she turned to get Resident #1 some water and he wandered into Resident #2's room. The DON stated LVN A heard commotion coming from the room and found Resident #1 on the floor. The DON stated the incident was unwitnessed and she could not state if Resident #1 was pushed to the floor or fell on his own. She stated Resident #2 was alert enough to make some decisions, but he had impulsive thinking. The DON stated Resident #2 would get upset around the 1st of the month because he would get confused and think he needed to leave the facility to go pay his bills, he also thought people were trying to take his money which was why he did not like anyone in his room. The DON stated both Resident #1 and Resident #2 resided on the facility's secured unit for behaviors related to dementia. The Administrator stated he worked at the facility for 1.5 years. He stated the plan was to discharge Resident #2 and there was a discharge meeting with the family scheduled. He stated Resident #2's family agreed to provide 1:1 monitoring of the resident until the facility could find placement. The Administrator stated the facility did not have residents who had aggressive behaviors in general, but any resident who exhibited any type of behaviors, it was related to dementia, and they resided on the facility's secured unit. An attempted interview on 06/07/24 with Resident #1 was unsuccessful due to him being in the local hospital and unable to communicate for an interview. Resident #1 was expected to be discharged from the local hospital and return to the nursing facility on 06/10/24; however, he did not arrive by time of Investigator's exit on 06/10/24. An attempted interview on 06/07/24 with Resident #2 was unsuccessful due to him being in the community with family and not responding to phone call. Resident #2 was discharged from the nursing facility on the evening of 06/07/24 and unable to be observed/interviewed when Investigator returned to the facility on [DATE]. In an interview on 06/07/24 at 1:21 PM., LVN A stated she worked at the facility for almost 5 years. She stated she worked on 06/05/24 when Resident #2 attacked Resident #1. LVN A stated the incident happened during dinnertime when the aides were busy assisting other residents. She stated Resident #1 had finished his meal and she had him near the nurses' station to monitor him closely due to wandering behavior. LVN A stated she turned to get Resident #1 some water when he got up and wandered into Resident #2's room. LVN A stated she heard commotion coming from the room and when she rushed there, she found Resident #1 unconscious on the floor with Resident #2 standing over him. She stated Resident #2 did not like anyone in his room and he informed her that he pushed Resident #1 down for coming in . LVN A stated Resident #2 would sometimes become verbally aggressive towards other residents for going into his room, but she had never seen him get physically aggressive. LVN A stated the other residents did not report or appear to be afraid of Resident #2. In an interview on 06/07/24 at 1:48 PM, the SSD stated she was in the process of finding placement for Resident #2 to be discharged . She stated she had sent out referrals to different facilities and the family agreed with the discharge. The SSD stated the family felt an assisted living environment would be more appropriate for Resident #2 because it would provide more space and privacy. The SSD stated Resident #2 had not exhibited aggressive behaviors prior to the incident to her knowledge; however, the facility still thought it was best to discharge him for the safety of everyone. In an interview on 06/07/24 at 1:55 PM, CNA C stated she worked at the facility for [AGE] years on 2nd shift, 2:00 PM-10:00 PM. CNA C stated she worked on 06/05/24 during the incident between Resident #1 and Resident #2. She stated she was assisting other residents with dinner and did not witness the incident; however, LVN A informed her of what happened. CNA C stated Resident #1 always wandered into Resident #2's room because it used to be his room and he would get confused due to dementia and think that was still his room. She stated the staff would always redirect Resident #1 to his room. CNA C stated Resident #2 would get upset when other residents went into his room, but she had never seen him become physically aggressive. In an interview on 06/07/24 at 2:12 PM, CNA B stated she worked at the facility for 7 months on 2nd shift, 2:00 PM-10:00 PM. CNA B stated she worked on 06/05/24 during the incident between Resident #1 and Resident #2. She stated she was assisting other residents with dinner when she heard a noise and the LVN A yelled for her to come in Resident #2's room to help. CNA B stated when she got in the room, she saw Resident #1 on the floor, and he was unresponsive. She stated Resident #2 was known to have a bad temper and would curse and get upset if a resident went into his room; however, she never observed him become physically aggressive towards anyone. She stated Resident #2 was mostly quiet and stayed to himself in the room. CNA B stated Resident #2's family stayed at the facility with him to help with his behaviors. She stated Resident #1 previously stayed in the room but was moved for Resident #2's family to stay there, and that was why Resident #1 would get confused and wander back into that room. In an interview on 06/07/24 at 3:05 PM, Resident #2's family member stated the facility notified her that Resident #2 had pushed Resident #1 down for entering his room. The family member stated Resident #2 was not usually physically aggressive and knew better then to put his hands on anyone. She stated Resident #2's friend began residing at the facility with him in 12/2023 after Resident #2 attempted to elope from the facility. She stated that was the facility's way of managing Resident #2's behaviors. She stated the facility was not good at implementing interventions and she expressed concerns about Resident #2' care plan to the ombudsman . The family member stated the facility wanted to discharge Resident #2 back in 01/2024 for behaviors but the ombudsman was able to stop it due to the care plan not properly addressing all of Resident #2's needs. In an interview on 06/10/24 at 8:45 AM, the Administrator stated Resident #2 had been discharged to one of the company's assisted living facilities. He also stated the hospital reported that Resident #1 was stable and expected to be discharged back to the facility on this date. The Administrator stated although Resident #2's care plan did not reflect interventions to address his aggressive behaviors, the facility had interventions in place that included psychological services, training staff on dementia related behaviors and abuse/neglect, and staff knowing to closely monitor redirect all resident away from Resident #2's room. In an interview on 06/10/24 at 09:52 AM, Resident #1's family member stated she visited the resident on 06/05/24, prior to the incident and he did not seem like himself as he was not talking as much. The family stated later after she had left the facility, she received a call informing her that Resident #1 had been taken to the emergency room after being pushed down by another resident and hitting his head. The family member stated Resident #1 had a previous brain injury and testing showed the recent incident caused further injury. The family member stated she did not have any concerns for abuse or neglect prior to the incident; however, now had concerns about there being enough staff to properly monitor residents to prevent incidents like that from occurring again. She stated Resident #1 often wandered into Resident #2's room because that used to be his room until they moved him. She stated Resident #1 had good rapport with his new roommate and family, and there had been no issues between them. In an interview on 06/10/24 at 4:35 PM with the Administrator and the DON, the DON stated the staff were trained on behaviors related to dementia and knew to monitor for signs and redirect residents when wandering, especially into Resident #2's room. The DON stated Resident #2 was also seeing a psychologist for his behaviors. The DON stated those interventions should have been on Resident #2's care plan; however, she believed that they were care planned back in 12/2023 because she was very thorough and normally care planned any changes immediately. The DON stated she and the MDS Coordinator were very experienced with care planning, and both understood the importance of keeping it updated; however, this was an oversight. The DON stated she may have accidentally erased previous interventions for behaviors when she updated the care plan after the incident occurred on 06/05/24. The DON stated the risk of not having interventions in place to address aggressive behaviors could result in a negative outcome for residents. The Administrator stated his expectation was that care plans addressed all needs for the residents and was updated whenever there was change in condition/behavior to provide staff with interventions on how to provide appropriate care. The Administrator stated the risk of not updating care plans could be not catching something regarding the care of residents. He stated the facility now ensures that all changes in condition/behaviors are captured during daily morning meetings, and the DON and MDS Coordinator work together to make sure everything is addressed. He stated he is also becoming more involved in the care planning process to verify that care plans are updated per policy. The non-compliance was identified as past non-compliance (PNC). The IJ began on 06/05/24 and ended on 06/06/24. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of in-service titled Dealing with difficult behaviors/Abuse, Neglect & Exploitation, dated 06/06/24, reflected all staff were educated by the DON on how to identify and report abuse/neglect and protocols for dealing with behaviors. Record review of Residents #1, #2, #3, #4, #5, #6, #7, and #8'S EHR revealed their care plans were updated and had interventions to address all care needs. Record review of incident/accident reports, from 05/07/24-06/07/24, reflected no other resident-to-resident incidents regarding abuse. Interviews were conducted on 06/10/24-06/07/24 with DON, ADON, MDS Coordinator, and staff who worked with residents on secured unit with behaviors: LVN A (1st shift), CNA B (2nd shift), CNA C (2nd shift), and LVN D (1st shift), CNA E (1st shift), CNA L (2nd shift). All staff were able to provide competency regarding in-service over abuse/neglect and dealing with difficult behaviors. All staff were able to provide examples of abuse/neglect, appropriate interventions, and when and who to report it to. All staff were also able to provide appropriate interventions and protocols to manage aggressive behaviors and behaviors related to dementia. Staff stated they were made aware of any changes in condition or new behaviors by the charge nurses, DON, and also by access to care plans. Record review of the facility's policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment: Freedom from abuse, neglect, exploitation, revised 12/2023, reflected in part the following: Policy: It is the policy of this facility that each resident has the right to be free from abuse, neglect misappropriation of resident property, exploitation, and mistreatment Procedure: 1. In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: a. Ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injury of unknown origin and misappropriation of resident property, are reported immediately 2.Ensure that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injury of unknown origin and misappropriation of resident property, are reported to: a. The Administrator of the facility b. The State Survey Agency c. Adult Protective Services 3. Ensure that, after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident(s). 4. Ensure that the results of all investigations are reported within 5 working days of the incident. 5. Ensure that if the alleged violation is verified, appropriate corrective action is taken. .

Based on interviews and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in a resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either, life-threatening conditions or clinical complications) for one (Resident #1) of five residents reviewed for changes in condition. RN A failed to notify the physician when Resident #1 complained of numbness to the left side of the face on 01/27/23. RN A notified the NP via text message of the change in condition instead of the physician and when the nurse did not receive a response from the NP the resident remained in the facility without the physician being notified. Three days later (01/30/23), Resident #1 was assessed with numbness to the face, slurred speech, and drooling. Resident #1 was transferred to the hospital on 01/30/23 and admitted with diagnoses of acute stroke (A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts and can cause parts of the brain to die off). An Immediate Jeopardy (IJ) was identified on 02/16/ at 4:13 p.m. and the facility was provided the IJ template on 02/16/23 at 4:28 p.m. While the IJ was removed on 02/17/23, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal. These failures could place residents at risk for preventing the physician an opportunity to intervene on their behalf, delays in medical treatments and care which could result in clinical complications, disability, and/or death. Findings included: Review of Resident #1's undated admission record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. Physician's active order summary dated from 12/29/22 to 01/27/23 reflected diagnoses included cerebral infarction (A cerebral infarction-stroke occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction and hypertension (high blood pressure). Review of Resident #1's admission MDS assessment dated [DATE] revealed Resident #1 was always incontinent of bowel/bladder, required extensive physical assistance of two or more persons for bed mobility and transfers. The assessment reflected the resident used a wheelchair for mobility, required extensive physical assistance of one person for dressing/personal hygiene and had functional limitations in range of motion in the upper and lower extremities on one side of the body. Review of Resident #1's change in condition form dated 01/30/23 and authored by RN A revealed the resident was assessed with increased weakness and numbness on the left side. The form further reflected the change in condition was first noted during the afternoon of 01/27/23 at 12:43 p.m. and the NP had been notified on 01/27/23. The form did not reflect the physician had been notified. Interview with the DON on 02/14/23 at 11:18 a.m., in the presence of the Administrator, revealed she stated she had provided in-service training to all nurses related to always obtaining a response when they called the physician or NP and to call the physician/NP back or send the resident out if necessary and administration would take care of it later as far as an order was concerned because if a resident was experiencing a change in condition, they should be sent out to the hospital immediately. Interview with RN A on 02/14/23 at 12:25 p.m. revealed she was the charge nurse providing care for Resident #1 during the day and evening shifts (6:00 a.m. to 10:00 p.m.) on 01/27/23, 01/28/23 and 01/29/23. She stated during the afternoon on Friday 01/27/23, Resident #1 complained of numbness to the left side of his face. RN A stated she texted the NP that Resident #1 was complaining of numbness to his face but never received a response/call back from the NP. RN A further stated she made no further attempts to contact the NP and did not notify the physician. RN A provided no explanation as to why she did not follow-up with the NP or physician regarding Resident #1's change in condition. When asked why, she stated the resident was stable. Review of progress notes dated 01/30/23 reflected the NP assessed Resident #1 on 01/30/23 (Monday) with slurred speech and facial drooping. The notes reflected the NP ordered the resident be sent to the hospital for neurological workup on 01/30/23. Review of Resident #1's hospital records dated 01/30/23 revealed the resident was admitted on [DATE] with a diagnosis of acute stoke. The resident's neurological assessment in theER on [DATE] reflected drool in left corner of the mouth, no facial droop and sensation on the left side was decreased. The resident was treated with an anticoagulant (decreases the blood's ability to clot) and discharged to another facility on 02/14/23. Interview with the DON on 02/14/23 at 11:18 a.m. revealed expectations were for nursing staff to send residents out to the hospital if necessary because if a resident was experiencing a change in condition, they should be sent out to the hospital immediately. Review of the in-service training records provided by the DON on 02/14/23 and dated 01/31/23 related to changes in condition, physician notification and S/S of stroke reveled RN A was listed as having received the training, but RN B was not listed. Interview with the NP on 02/15/23 at 10:46 a.m. revealed she received a text message from RN A on the afternoon of 01/27/23. The NP stated the text message reflected Resident #1 had mild drooling, facial numbness and a blood pressure that was a little elevated. The NP stated she recalled responding to the text and ordered Resident #1 be sent out to the hospital for evaluation. She stated she does not know why RN A did not receive the text message response and was not sure if she had pressed send after typing in her response. The NP stated when she arrived at the facility on Monday (01/30/23) she was surprised to find Resident #1 still in the facility as she thought the nurse had received her text to send the resident out on Friday (01/27/23). She stated her expectation was for facility nurses to call the 24-hour answering services and not send text messages. The NP further stated if the nurse's assessment determined a resident needed to go to the hospital or if they did not receive a call back within 10 to 15 minutes, she and the physician expected facility nurses to send residents to the hospital and not wait for a response/call back. Additionally, the NP stated it was important for Resident #1 to go to the hospital on 01/27/23 because better and acute care could be provided in the hospital, diagnostics and labs were more readily available in the hospital and there was a four-hour window to use a clot buster medication if needed. The NP stated Resident #1's symptoms on 01/27/23 could have indicated a new onset stroke. Interview with RN B on 02/15/22 at 6:25 p.m. she stated she provided care for Resident #1 during the night shifts (10:00 p.m. to 6:00 a.m.) on Friday 01/27/23, Saturday 01/28/23 and Sunday 01/29/23. RN B stated RN A told her something about Resident #1 drooling. RN B stated she did not contact the physician because RN A told her the physician was aware. RN B further stated she did not notice any changes in Resident #1 as the resident slept throughout the night shift. Interview with DON on 02/16/23 at 10:39 a.m. revealed in-service training related to changes in condition, physician notification and S/S of stroke had not been completed for all facility nurses. The DON stated the facility used agency nurses and she had planned to in-service agency nurses before they worked in the facility again. The facility's P/P entitled Significant Change in Condition, Response, dated revised 01/2022 and identified as current by the DON. The P/P reflected in part: 5. The nurse shall use his/her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified in the event the Attending Physician or on-call Physician cannot be reached. The Administrator and the DON were notified on 02/16/22 at 4:13 p.m. that an Immediate Jeopardy (IJ) was identified. The IJ template was provided 02/16/23 at 4:28 p.m. and the facility was asked to provide a Plan of Removal to address the immediate Jeopardy. The Facility's Plan of Removal was accepted on 02/17/23 at 12:39 p.m. and reflected the following: The facility failed to notify the physician of the resident's change in condition on 1/27/23 or at any time prior to 1/30/23. An in-service was initiated on 1/30/23, however, all facility nurses had not received the in-service training prior to 2/14/23, upon the surveyor's entrance. Immediate Action 1. The Medical Director, [Medical Director's name] was notified of IJ on 2/16/2023 at 4:47 p.m. 2. Education was initiated with Nurses on 2/16/2023 at 5:00 p.m. and will be completed on 2/16/2023 at 10:30 p.m. by the DON, ADON and Clinical Resource. The training included Nurse Assessment, Signs and symptoms of a stroke, Change in Condition Process / Policy, vital sign documentation, documentation of the change in condition, notification to the physician, reviewing the resident's health condition with the attending physician, and when to reach out to the Medical Director if the assigned physician is not available. The DON, ADONs and Clinical Resource used facility policy on change in condition, facility procedures on head-to-toe assessment, signs and symptoms of a stroke and clinical examples to ascertain understanding of the material and a knowledge check form was created. 3. A knowledge check form, to ascertain staff understanding of training, will be initiated with nurses 2/16/2023 and will be completed for all nurses either in-person or via telephone on 2/16/2023. The Clinical Resource will complete tracking for education and knowledge check form completion for each nurse. 4. This education and knowledge check will be completed with facility nurses on 2/16/2023 and 2/17/2023, all nurses will complete education prior to start of their next shift. This reeducation may be in-person or over the phone with the DON, ADONs or Clinical Resource. This education will also be included in the new hire orientation and will be included for agency/ PRN staff. 5. An ad hoc meeting regarding items in IJ template will be completed on 2/16/2023 at 6:00pm. Attendees included Administrator, DON, Medical Director, and Clinical Resource. The Plan of removal items and interventions were developed, reviewed, and agreed upon. Identification others Affected 6. Currently there are 113 residents residing in the facility. All residents could have been affected by the deficient practice. Systemic Change to Prevent Re-occurrence 7. Education was initiated with Nurses on 2/16/2023 at 5:00 p.m. and will be completed on 2/16/2023 at 10:30 p.m. by the DON, ADON and Clinical Resource which included Nurse Assessment, Signs and symptoms of a stroke, Change in Condition Process / Policy, vital sign documentation, documentation of the change in condition, notification to the physician, reviewing the resident's health condition with the attending physician; and when to reach out to the Medical Director if the assigned physician is not available. The DON, ADONs and Clinical Resource used facility policy on change in condition, facility procedures on head to toe assessment, signs and symptoms of a stroke and clinical examples to ascertain understanding of the material and a knowledge check form was created. 8. A knowledge check form, to ascertain staff understanding of training, will be initiated with nurses 2/16/2023 and will be completed for all nurses either in-person or via telephone on 2/16/2023. The Clinical Resource will complete tracking for education and knowledge check form completion for each nurse. 9. The DON and ADON initiated a monitoring form on 2/16/2023 to track all changes in condition daily on weekdays and weekends via review the electronic 24-hour reports found on PCC, new orders, new medication orders, hospital transfers and nursing documentation of a change in condition and notification to family and physician. Follow up on interventions and updates to the plan of care will be completed by the DON and ADON. The daily monitoring by the DON and ADON began 2/16/2023 and will be ongoing. 10. Changes in condition will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions. The Administrator, DON, ADON, MDS and/or designees to attend weekly clinical meetings to include review of residents with change in conditions, hospital transfers and update of care plan interventions, notifications of Resident Responsible Parties, and Physicians. Monitoring 11. Knowledge checks were initiated on 2/16/2023 will be completed on all nurses by 2/17/23 either by phone or one on one conversations by the DON, ADONs or Clinical Resource. These knowledge checks will be ongoing throughout the Quality Assurance process, reported weekly to the QAPI committee meeting for 4 weeks or until substantial compliance is established and then monthly for 90 days. 12. This knowledge check will be completed for 5 random nurses weekly by the DON, ADONs or Clinical Resource. The knowledge check questions include: o If a resident has a change of condition the nurse should? o Get a full set of vital signs o Notify the attending physician Notify Family o Notify nurse management o Follow the facility policy o All of the above o If a resident develops a change of condition the nurse must document for 72 hours or longer if necessary. o True o False o Signs and Symptoms of a stroke include: o Facial droop, weakness on one side, slurred speech o Bilateral leg weakness, pain in legs o Abdominal pain, foul smelling urine, sediment in urine o If the resident develops signs of a stroke and has abnormal vital signs, it is best to call: o The physician o Calf 911 for medical emergency o The family to come talk to them o If a resident has a change of condition the care plan must be updated with the interventions. o True o The nurse should document the change of condition using the e-lnteract change of condition form? o True o False If the attending physician is unavailable who do you contact o Nobody o Medical Director o Another Nurse 13. Daily review of all changes in condition daily via review of 24-hour report, new orders, new medication orders, change in condition assessments, hospital transfers and nursing documentation by the DON and ADONs. This information will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance is established, then monthly for 90 days. 14. Weekly clinical meetings to discuss changes in condition and hospital transfers. Meeting attendees will include the Clinical IDT; DON, ADON, Administrator, MDS, Dietary Manager, Activities Director, Social Services, and Rehab Director. Meeting minutes will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 15. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. QAPI meetings content will include changes in condition, hospital transfers and residents requiring antiseizure medications. 16. Follow up on IJ Plan of Removal and monitoring will be verified by the DON and the Administrator by review of change on condition documentation through the weekly clinical meeting, review of nurse knowledge check obtained throughout the week, hospital transfer logs, and the weekly QAPI meeting. The following interviews, and record reviews were conducted to verify the implementation of the facility's Plan of Removal and revealed the following: Interviews were conducted with 11 licensed nurses (LVN G, RN D, LVN E, LVN F, RN G, LVN H, LVN I, LVN J, RN K and LVN L) across multiple shifts on 02/17/23 from 12:42 p.m. to 1:50 p.m. and from 3:00 p.m. to 3:10 p.m. The nurses were able to verbalize comprehension of the in-service training provided. They stated they had been in-serviced on S/S of a stroke, completing a full assessment to include obtaining a full set of vital signs for residents with changes in condition, contacting the primary physician, and contacting the Medical Director if they were unable to reach the primary physician. Review of the in-service training records dated 02/16/23 revealed licensed nurses staff received training related to completing head-to-toe assessments, who to notify when residents experienced changes in condition, S/S of a stroke, completing a full assessment to include obtaining a full set of vital signs for residents with changes in condition, contacting the primary physician, summoning 911 if changes in condition were emergent and contacting the Medical Director if they were unable to reach the primary physician. The Administrator was notified on 02/17/23 at 4:00 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 02/17/23, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring their plan of removal.

Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #1) of four residents reviewed for quality of care. Facility staff failed to recognize and respond when Resident #1 complained of numbness to one side of the face on 01/27/23. RN A notified the NP of a change in condition on 01/27/23 at 12:43 p.m. via text message. When RN A did not receive a response to her text message, she did not follow-up for orders, instructions or monitor the resident's condition. Resident #1 was noted three days later on 01/30/23 with numbness to the face, slurred speech, and drooling. Resident #1 was transferred to the hospital on 01/30/23 and admitted with diagnoses of acute stroke (A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts and can cause parts of the brain to die off). An Immediate Jeopardy (IJ) was identified on 02/16/23 at 4:13 p.m. and the facility was provided the IJ template on 02/16/23 at 4:28 p.m. While the IJ was removed on 02/17/23, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal. These failures could place residents at risk for delays in medical treatments and care which could result in clinical complications, disability, and/or death. Findings included: Review of Resident #1's undated admission record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] and discharged [DATE]. Physician's active order summary dated from 12/29/22 to 01/27/23 reflected diagnoses included cerebral infarction (A stroke). Review of Resident #1's admission MDS assessment dated [DATE] revealed Resident #1 was always incontinent of bowel/bladder, required extensive physical assistance of two or more persons for bed mobility and transfers. The assessment reflected the resident used a wheelchair for mobility, required extensive physical assistance of one person for dressing/personal hygiene and had functional limitations in range of motion in the upper and lower extremities on one side of the body. Review of Resident #1's change in condition form dated 01/30/23 and authored by RN A revealed the resident was assessed with increased weakness and numbness on the left side. The form further reflected the change in condition was first noted during the afternoon of 01/27/23 at 12:43 p.m. and the NP had been notified on 01/27/23. The form reflected no interventions were implemented on 01/27/23 and the RN had been awaiting a response from the NP. Record reviews of nurses' notes, progress notes, reflected no documentation of a change in condition, neurological checks, or assessments of Resident #1 after his complaint on 01/27/23, 01/28/23 or 01/29/23. Review of progress notes dated 01/30/23 reflected the NP assessed Resident #1 on 01/30/23 (Monday) with slurred speech and facial drooping. The notes reflected the NP ordered the resident be sent to the hospital for neurological workup on 01/30/23. Review of Resident #1's hospital records dated 01/30/23 revealed the resident was admitted on [DATE] with a diagnosis of acute stoke. The resident's neurological assessment in theER on [DATE] reflected drool in left corner of the mouth, no facial droop and sensation on the left side was decreased. The resident was treated with an anticoagulant (decreases the blood's ability to clot) and discharged to another facility on 02/14/23. Interview with the NP on 02/15/23 at 10:46 a.m. revealed she provided her phone for review that reflected she received a text message from RN A on the afternoon of 01/27/23. The text message reflected Resident #1 had mild drooling, facial numbness and a blood pressure that was a little elevated. The NP stated she recalled responding to the text and ordered Resident #1 be sent out to the hospital for evaluation. She stated she does not know why RN A did not receive the text message response and was not sure if she had pressed send after typing in her response. The NP stated RN A did not provide any blood pressure or vital sign results and due to Resident #1's symptoms she did not need blood pressure or vital signs results to make the decision to send the resident to the hospital. The NP stated when she arrived at the facility on Monday (01/30/23) she was surprised to find Resident #1 still in the facility as she thought the nurse had received her text to send the resident out on Friday (01/27/23). She stated her expectation was for facility nurses to call the 24-hour answering services and not send text messages. The NP further stated if the nurse's assessment determined a resident needed to go to the hospital or if they did not receive a call back within 10 to 15 minutes, she and the physician expected facility nurses to send residents to the hospital and not wait for a response/call back. Additionally, the NP stated it was important for Resident #1 to go to the hospital on 01/27/23 because better and acute care could be provided in the hospital, diagnostics and labs were more readily available in the hospital and there was a four-hour window to use a clot buster medication if needed as the medication could not be used past four hours and other methods of treatment would need to be considered. The NP stated Resident #1's symptoms on 01/27/23 could have indicated a new onset stroke. Interview with RN B on 02/15/22 at 6:25 p.m. she stated she provided care for Resident #1 during the night shifts (10:00 p.m. to 6:00 a.m.) on Friday 01/27/23, Saturday 01/28/23 and Sunday 01/29/23. RN B stated RN A told her something about Resident #1 drooling. RN B stated she did not contact the physician or NP because RN A told her the physician was aware. RN B further stated she did not notice any changes in Resident #1 and provided no additional monitoring other than her normal rounds every two-hours. Interview with DON on 02/16/23 at 10:39 a.m. revealed in-service training related to changes in condition, physician notification and S/S of stroke had not been completed for all facility nurses. The DON stated the facility used agency nurses and she had planned to in-service agency nurses before they worked in the facility again. Review of the in-service training records provided by the DON on 02/14/23 and dated 01/31/23 related to changes in condition, physician notification and S/S of stroke reveled RN A was listed as having received the training, but RN B was not listed. Interview with the DON on 02/14/23 at 11:18 a.m. revealed expectations were for nursing staff to send residents out to the hospital if necessary because if a resident was experiencing a change in condition, they should be sent out to the hospital immediately. Interview with the DON on 02/15/23 at 4:30 p.m. revealed she was unable to locate any assessments, neurological checks or change in condition forms prior to 01/30/23 to address Resident #1's change in condition exhibited on 01/27/23. On 02/16/23 at 12:00 p.m. the facility's 24-hour nursing report dated from 01/27/23 through 01/30/23 was requested from the DON. The DON stated Resident #1 was not listed on the report and she was not sure why. She stated that it was possibly due to the resident being discharged . She stated the way the electronic system worked the 24-hour report would just be a duplicate ot the resident's nurse's notes. Interview with Resident #1's physician on 02/16/23 at 12:15 p.m. he stated the NP made the correct decision to send Resident #1 out to the hospital on 01/27/23 (Friday). He stated it was better for the resident to have been evaluated at the hospital out of an abundance of caution. The physician stated strokes could potentially be fatal due to complications and timely evaluation and treatment was essential because if you don't go you don't know. He stated complications of a stroke included lasting neurological damage and/or increased cranial hemorrhage. He further stated complications of a stroke could lead to death. Interview with RN A on 02/17/23 at 12:55 p.m. she stated she did not obtain a measurement of Resident #1's blood pressure or vital signs on Friday during the time the resident complained of numbness. She stated the blood pressure she was referring to in the text message to the NP was obtained during the morning hours around 7:00 a.m. before the resident's change in condition. RN A stated she did not know she needed to perform a full assessment on 01/27/23 that included vital signs as she did not associate the resident symptoms with a need to obtain vital signs. The facility's P/P entitled Significant Change in Condition, Response, dated revised 01/2022 and identified as current by the DON. The P/P reflected in part: 1. If at any time, it is recognized by any one (sic) of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. 2. The Nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. (SBAR-situation, background, assessment, and recommendation is a tool used to aid in facilitating and strengthening communication between nurses and prescribers-change in condition form). 5. The nurse shall use his/her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified in the event the Attending Physician or on-call Physician cannot be reached. The P/P did not reflect a specific method to use when contacting the physician. The Administrator and the DON were notified on 02/16/22 at 4:13 p.m. that an Immediate Jeopardy (IJ) was identified. The IJ template was provided 02/16/23 at 4:28 p.m. and the facility was asked to provide a Plan of Removal to address the immediate Jeopardy. The Facility's Plan of Removal was accepted on 02/17/23 at 12:39 p.m. and reflected the following: The facility failed to notify the physician of the resident's change in condition on 1/27/23 or at any time prior to 1/30/23. An in-service was initiated on 1/30/23, however, all facility nurses had not received the in-service training prior to 2/14/23, upon the surveyor's entrance. Immediate Action 1. The Medical Director [Medical Director's name] was notified of IJ on 2/16/2023 at 4:47pm. 2. Education was initiated with Nurses on 2/16/2023 at 5:00pm and will be completed on 2/16/2023 at 10:30pm by the DON, ADON and Clinical Resource. The training included Nurse Assessment, Signs and symptoms of a stroke, Change in Condition Process / Policy, vital sign documentation, documentation of the change in condition, notification to the physician, reviewing the resident's health condition with the attending physician, and when to reach out to the Medical Director if the assigned physician is not available. The DON, ADONs and Clinical Resource used facility policy on change in condition, facility procedures on head-to-toe assessment, signs and symptoms of a stroke and clinical examples to ascertain understanding of the material and a knowledge check form was created. 3. A knowledge check form, to ascertain staff understanding of training, will be initiated with nurses 2/16/2023 and will be completed for all nurses either in-person or via telephone on 2/16/2023. The Clinical Resource will complete tracking for education and knowledge check form completion for each nurse. 4. This education and knowledge check will be completed with facility nurses on 2/16/2023 and 2/17/2023, all nurses will complete education prior to start of their next shift. This reeducation may be in-person or over the phone with the DON, ADONs or Clinical Resource. This education will also be included in the new hire orientation and will be included for agency/ PRN staff. 5. An ad hoc meeting regarding items in IJ template will be completed on 2/16/2023 at 6:00pm. Attendees included Administrator, DON, Medical Director, and Clinical Resource. The Plan of removal items and interventions were developed, reviewed, and agreed upon. Identification others Affected 6. Currently there are 113 residents residing in the facility. All residents could have been affected by the deficient practice. Systemic Change to Prevent Re-occurrence 7. Education was initiated with Nurses on 2/16/2023 at 5:00pm and will be completed on 2/16/2023 at 10:30pm by the DON, ADON and Clinical Resource which included Nurse Assessment, Signs and symptoms of a stroke, Change in Condition Process / Policy, vital sign documentation, documentation of the change in condition, notification to the physician, reviewing the resident's health condition with the attending physician; and when to reach out to the Medical Director if the assigned physician is not available. The DON, ADONs and Clinical Resource used facility policy on change in condition, facility procedures on head to toe assessment, signs and symptoms of a stroke and clinical examples to ascertain understanding of the material and a knowledge check form was created. 8. A knowledge check form, to ascertain staff understanding of training, will be initiated with nurses 2/16/2023 and will be completed for all nurses either in-person or via telephone on 2/16/2023. The Clinical Resource will complete tracking for education and knowledge check form completion for each nurse. 9. The DON and ADON initiated a monitoring form on 2/16/2023 to track all changes in condition daily on weekdays and weekends via review the electronic 24-hour reports found on PCC, new orders, new medication orders, hospital transfers and nursing documentation of a change in condition and notification to family and physician. Follow up on interventions and updates to the plan of care will be completed by the DON and ADON. The daily monitoring by the DON and ADON began 2/16/2023 and will be ongoing. 10. Changes in condition will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions. The Administrator, DON, ADON, MDS and/or designees to attend weekly clinical meetings to include review of residents with change in conditions, hospital transfers and update of care plan interventions, notifications of Resident Responsible Parties, and Physicians. Monitoring 11. Knowledge checks were initiated on 2/16/2023 will be completed on all nurses by 2/17/23 either by phone or one on one conversations by the DON, ADONs or Clinical Resource. These knowledge checks will be ongoing throughout the Quality Assurance process, reported weekly to the QAPI committee meeting for 4 weeks or until substantial compliance is established and then monthly for 90 days. 12. This knowledge check will be completed for 5 random nurses weekly by the DON, ADONs or Clinical Resource. The knowledge check questions include: o If a resident has a change of condition the nurse should? o Get a full set of vital signs o Notify the attending physician Notify Family o Notify nurse management o Follow the facility policy o All of the above o If a resident develops a change of condition the nurse must document for 72 hours or longer if necessary. o True o False o Signs and Symptoms of a stroke include: o Facial droop, weakness on one side, slurred speech o Bilateral leg weakness, pain in legs o Abdominal pain, foul smelling urine, sediment in urine o If the resident develops signs of a stroke and has abnormal vital signs, it is best to call: o The physician o Calf 911 for medical emergency o The family to come talk to them o If a resident has a change of condition the care plan must be updated with the interventions. o True o The nurse should document the change of condition using the e-lnteract change of condition form? o True o False If the attending physician is unavailable who do you contact o Nobody o Medical Director o Another Nurse 13. Daily review of all changes in condition daily via review of 24-hour report, new orders, new medication orders, change in condition assessments, hospital transfers and nursing documentation by the DON and ADONs. This information will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance is established, then monthly for 90 days. 14. Weekly clinical meetings to discuss changes in condition and hospital transfers. Meeting attendees will include the Clinical IDT; DON, ADON, Administrator, MDS, Dietary Manager, Activities Director, Social Services, and Rehab Director. Meeting minutes will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 15. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. QAPI meetings content will include changes in condition, hospital transfers and residents requiring antiseizure medications. 16. Follow up on IJ Plan of Removal and monitoring will be verified by the DON and the Administrator by review of change on condition documentation through the weekly clinical meeting, review of nurse knowledge check obtained throughout the week, hospital transfer logs, and the weekly QAPI meeting. The following interviews, and record reviews were conducted to verify the implementation of the facility's Plan of Removal and revealed the following: Interview with RN A on 02/14/23 at 12:25 p.m. revealed she was the charge nurse providing care for Resident #1 during the day and evening shifts (6:00 a.m. to 10:00 p.m.) on 01/27/23, 01/28/23 and 01/29/23. She stated during the afternoon on Friday 01/27/23, Resident #1 complained of numbness to the left side of his face. RN A stated she rubbed a toothpick alone the side of Resident #1's face and the resident told her he was able to feel it. She stated she did not perform a complete neurological assessment to include assessing the resident's hand grips. She stated the resident's blood pressure was ok but was not able to recall the results. RN A further stated she texted the NP that Resident #1 was complaining of numbness to his face but never received a response/call back from the NP. Additionally, RN A stated she checked on the resident frequently throughout the weekend and the resident was stable, vital signs including blood pressure readings were stable and the resident voiced no further complaints. RN A stated she expected some type of response from the NP even if it was just an ok to acknowledge the message was received. RN A stated she made no further attempts to contact the NP or physician. RN A provided no explanation as to why she did not follow-up with the NP or physician regarding Resident #1's change in condition. When asked why, she stated the resident was stable. RN A stated on Monday 01/30/23 Resident #1 complained of numbness to his forehead and to his face. The NP was in the facility on 01/30/23 and ordered the resident to be transferred to the ER. RN A stated she did not recognize Resident #1's signs/symptoms could have been related to the resident having another stroke. She further stated she had received training after the resident was transferred to the hospital on signs and symptoms of stroke and if she did not receive a response after contacting the physician or NP, she should call again within 30 minutes. RN A was able to verbalize she was now aware that signs and symptoms included numbness/weakness, on one side of the body, headache, change in mental status, facial drooping, or problems with speech. Review of the in-service training records dated 02/16/23 revealed licensed nurses staff received training related to completing head-to-toe assessments, who to notify when residents experienced changes in condition, S/S of a stroke, completing a full assessment to include obtaining a full set of vital signs for residents with changes in condition, contacting the primary physician, summoning 911 if changes in condition were emergent and contacting the Medical Director if they were unable to reach the primary physician. Review of knowledged check tests reveled all nursing staff had completed and passed the knowledge check. Interviews were conducted with 11 licensed nurses (LVN G, RN D, LVN E, LVN F, RN G, LVN H, LVN I, LVN J, RN K and LVN L) across multiple shifts on 02/17/23 from 12:42 p.m. to 1:50 p.m. and from 3:00 p.m. to 3:10 p.m. The nurses were able to verbalize comprehension of the in-service training provided. They stated they had been in-serviced on S/S of a stroke, completing a full assessment to include obtaining a full set of vital signs for residents with changes in condition, contacting the primary physician, and contacting the Medical Director if they were unable to reach the primary physician. The Administrator was notified on 02/17/23 at 4:00 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 02/17/23, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring their plan of removal.

Based on interview, observation, and record review the facility failed to ensure the resident environment remained free of accident hazards, each resident received adequate supervision, and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for elopement. The facility failed to ensure all facility doors were properly secured. As a result, Resident #1, who had a history of exit seeking behavior eloped from the facility through the unlocked door. The facility exit door failed to alarm when Resident #1 left the facility, the resident was found by staff hours later along a service road of an interstate highway. An Immediate Jeopardy (IJ) was identified to have occurred from 07/27/21 to 07/28/21. This was determined to be a Past Noncompliance IJ due to the facility having implemented actions that corrected the noncompliance 07/28/21 prior to the investigation. This failure placed residents at risk of serious injury, harm, or death. Findings Included: Review of Resident #1's face sheet, dated 07/28/21, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, cognitive communication deficit, and transient cerebral ischemic attack. Review of Resident #1's 5-Day Admission Minimum Data Set assessment, dated 06/09/21 revealed he admitted to the facility with a brief interview for mental status score of 3 indicating sever cognitive impairment . Review of Resident #1's facility elopement assessments, dated 06/05/21 and 06/28/21, revealed he scored a high risk for elopement and wandering due to his diagnosis of Alzheimer's disease, his ability to ambulate independently, resident making statements about going home, and his wandering placing himself at significant risk of getting to a potentially dangerous place. Review of Resident #1's care plan dated 6/9/21, revised 6/28/21 indicated he was care planned for focus Elopement risk/wanderer related to disorientation to place, wandering aimlessly, history of attempts to leave the facility unattended by pulling and checking on doors, and having impaired safety awareness. Interventions put in place were documenting wandering behavior and attempt diversional activities and monitor wander guard placement and functionality on resident on a daily basis. Review of facility WanderGuard daily record of monitoring placement and functionality for Resident #1 for 06/28/21 through 07/27/21, indicated the facility monitored the actual daily placement and functionality of Resident #1's wander guard. Review of facility wall mounted WanderGuard weekly record of monitoring for 06/28/21 through 07/26/21, indicated the facility monitored the proper placement and functionality of all wander guard units on each exit door to the unit from which Resident # 1 eloped. Review of Resident #1's facility physician progress note, dated 06/07/21 at 13:51 PM, revealed, Patient transferred to 1 Jones due to wandering behaviors and exit seeking behaviors Review of Resident #1's eMAR-Medication Administration note, dated 06/29/21 at 13:53 PM, revealed, resident wanders from exit to exit looking for exit alarm set off 8 times doors secure easily redirected . Review of Resident #1's facility nursing note written by LVN D, dated 07/27/21at 11:00 AM , revealed, Resident was making several attempts to elope the building on the 2 x10 shift [2:00 PM-10:00 PM]. Each time his wander guard will set the alarm off. Resident will be redirected to his room and common area. Resident had his dinner and make few more attempts to elope, but was successfully stopped by staff. Aide noted resident in bed at approximately 1:30am, resident aide came to the nurses' station to report that resident is not in his bed. This nurse immediately began total search of the unit, and its surroundings. Resident was nowhere to be found. This nurse notified all units to search and conduct a head count of their resident. This nurse activated the code silver (missing person protocol) by placing a call to resident's wife, Resident's nurse practitioner, 911, ADMN. Resident family arrived at approx. 3:40 AM and joined staff in the search. Two police officers from Dallas police arrived unit and took report and description of resident. Another head count and room to room search was conducted with staff and police. Resident was found wandering on a service road by a staff member and brought back to the facility. Police was on hand and called EMS and resident was taken to ER for evaluation and treatment. Review of facility Fire Drill Report dated 07/27/21 indicated fire drill was conducted at 8:15am. Review of Emergency Generator Test Log dated 07/27/21 indicated all the exit door locks on 1 Jones unit, were inspected by maintenance staff. Review of facility exit door magnetic locks were inspected monthly by maintenance staff. Review of facility provider investigation report dated 07/28/21, indicated Resident #1 was independently ambulatory, had a history of wandering, was wearing a wander guard at the time of the incident. Resident # 1 noted in investigation report to have no injuries after completion of a head to toe assessment. The facility continued to compile investigation report at time of on-site HHS investigation. An observation on 07/27/21 at 9:15am of all fire exit doors on unit from which Resident #1 eloped red signage indicating Keep Door Closed at All Times, Push Until Alarm Sounds, Door Can Be Reopened in 15 Sec. An observation on 07/29/21 at 10:05am of two residents identified for wandering behaviors supervised by staff in front of facility nursing station watching television, within direct line of site of staff engaging residents in activities. An observation on 07/29/21 at 10:12 AM of the ADMN inspecting fire exit doors located on the unit from which Resident #1 eloped revealed when approached with a wander guard, and audible alarm triggered and heard throughout the unit. As ADMN, approached door and pushed on the door to open it a second audible alarm triggered as the door is allowed to close, and key code entered once by the ADMN the door automatically locks and alarm reset. In an interview on 07/29/21 at 10:15 AM LVN A stated Resident #1 eloped from the facility on 07/27/21 and when she arrived to work at 6:00 AM on 07/28/21, the resident was still missing . She stated her aide, CNA B, called her the morning of 07/28/21 stating she saw someone looking like Resident #1 near the service road of Interstate 20. She stated reporting to CNA B Resident #1 was gone from the facility and CNA B picked up the resident and brought him back to the facility. She stated on 07/27/21 during the day around lunch the facility had a fire drill. She stated during the fire drill elevators shut off and exit doors don't lock and believing that Resident #1 was able to leave the facility because the exit door he used, and the alarms remained disarmed after the fire drill. She indicated later the night hours of 07/27/21 is when Resident #1 eloped from the facility. In an interview on 07/29/21 at 10:27 AM CNA B stated on 07/28/21 around 6:30 AM on her day off she saw someone resembling Resident #1 walking up the entrance ramp to the interstate which was about 3.5 miles away from the facility. She stated caring for Resident #1 prior and he being a very confused resident ambulatory without a gait aide. She stated she called LVN A about 6:32 AM to tell her she saw someone resembling Resident #1 and was told by LVN A Resident #1 was missing. She stated she exited the freeway and looped around to go back to the highway where she saw the individual and found him on a service road alongside the highway. She called out to Resident #1 by his name and got a response with him turning toward her and stating Girl I was looking for you, and assisted Resident #1 to her car and returned back to the facility with him. She stated when encountering Resident #1 he did not appear hurt and not complaining of any pain. In an interview on 07/29/21 at 2:35 PM ADON stated previously working as a charge nurse the night shift 10pm-6am where Resident #1 resided. He stated he observed Resident #1 wander from place to place down the hallways, and go to the exit doors and check the doors on numerous occasions, the doors were locked and Resident #1 would leave the door and turn around. The ADON stated when Resident #1 would check the door the alarm would go off because of the wander guard bracelet Resident #1 wore. The ADON stated staff had to respond to the door when it alarmed and redirect the resident and Resident #1 would almost immediately return to wandering and checking doors after spending a few minutes distracted by an activity. The ADON stated he got a call on from a nurse assisting LVN D on 07/28/21 about 2:45 AM stating Resident #1 was missing and the ADMN and police had been notified. The ADON stated he was told by the staff nurse a door was found open at the opposite hallway from where Resident #1's room was located. The ADON stated Resident #1 was found by a staff member 07/28/21 around 6:00 AM to 6:20 AM. He stated he assessed Resident #1 along with EMS personnel on site and there were no injuries noted to the resident. In an interview on 07/29/21 at 3:18 PM LVN D stated they worked the evening of 07/27/21 to morning of 07/28/21 and cared for Resident #1. LVN D stated Resident #1 eloped from the building around 10:00 PM. LVN D stated on 07/27/21 between 2:00 PM and 10:00 PM Resident #1 made several attempts to actively push on the exit doors of the building. LNV D stated each time he pushed on the doors the alarm went off, he redirected the resident and reset the alarm. LVN D stated he last saw the resident after dinner between 6:30 PM and 7:00 PM. He stated after dinner CNA E assisted residents with showers and he (LVN D) went to retrieve medications around 10:00 PM. He stated around 1:30 AM CNA E came to him stating she did not see Resident #1 in bed. He stated CNA E told him the last time she saw Resident #1 in bed was at 10:00 PM. He stated he immediately performed a search from room to room, called other units requesting them to search, activated the silver code for missing person, and notified family/police/nurse practitioner/and ADMN. LVN D stated after last seeing Resident #1 after dinner around 7:00 PM on 07/27/21, not hearing any alarms sounding at any of the exit doors as they had alarmed each time prior that shift when Resident #1 was redirected by him away from the exit doors. He stated he checked all the exit doors on the unit as part of the search and the door on the wing opposite of where Resident #1's room was located was open and that was not normal. He stated there was also no beeping, alarms, or buzzing at the door when open. He stated normally the door light was red to reflect it was locked or the alarm was activated and at the time he saw it was green indicating it was unlocked. LVN D stated Resident #1 did not approach the unlocked door during his observations of him earlier in his shift and he had not had to reset the alarm code to the door because the resident never approached it or set off the alarm during his shift. He stated Resident #1 was wearing a wander guard that when he approached an exit door and that would trigger an alarm, and previous attempts made by Resident #1 to approach and test unit doors during the shift the doors had alarmed. In an interview on 07/30/21 at 8:08 AM DON stated Resident #1 was moved to a unit in which he was placed with a wader guard. DON stated when Resident #1 went near an exit door the wander guard would set off the alarm. DON stated Resident #1 was placed with a wander guard because he was observed wandering in and out of resident rooms before. The DON stated they were told by CNA E on 7/28/21 around 1:00 AM that Resident #1 was not in his bed and was last seen in his bed between 10:00 PM and 11:00 PM . In an interview on 07/30/21 at 8:48 AM the ADMN stated he received a call from LVN D on 7/28/21 around 3:00 AM stating the facility had a missing resident, family had been notified, and a search was being conducted with police assistance. The ADMN stated on 07/28/21 around 6:30 AM CNA B picked up Resident #1 on a service road near the highway. She stated an assessment was performed on Resident #1 and no injuries were noted. He stated the facility camera system had footage of the exit door Resident #1 left from on 07/27/21. He stated Resident #1 could be seen on the camera pushing the door open and letting it close, turning and walking away, and a few minutes later returning to the same door, opening it and exiting. The ADMN stated when he arrived to the facility at 3:30 AM on 07/28/21 he inspected the door Resident #1 eloped from. He stated the door required a key pad code to be entered twice before the lock was engaged and it was a glitch and that that was the first time he encountered the exit door key code needing to be input twice in order for the door lock to be engaged, and previously the door code would only need to be input once and the door would auto lock after a few seconds. He stated there was a fire drill on 07/27/21 at 8:30 AM and the staff exiting that particular door to perform the fire drill routine, expecting when they typed in the code to exit that door would auto lock as it had in the past during past fire drills. The ADMN stated in addition to the fire drill a generator test was conducted the same day, 07/27/21, which the facility did not usually perform on the same day as a fire drill. He stated he believed the generator test and fire drill being performed on the same day caused some type of factory reset on the keypad to the stairwell door from which Resident #1 eloped. He stated both the wander guard and exit door alarm were on the same electrical system. He stated he did not know if the wander guard system on the exit door malfunctioned but it did not go off when Resident #1 eloped. He stated he did not believe the wander guard system went off because it was really loud and there was no evidence of staff on camera responding to the door to turn it off when the resident was seen leaving the door. He stated a technician came out to the facility to check all the exit doors to ensure they were functioning properly, wander guard units on doors were adjusted to increase the sensitivity and distance for which residents were detected in proximity to the door to alarm before residents were allowed to get close to the door, staff continued head counts of all residents every hour and would continue accountability checks for the next two weeks, staff across all shifts had been in-serviced on elopement procedures and the need to inspect all doors after a fire drill to ensure each was locked. He stated Resident #1 had been discharged to the hospital for further evaluation and placement in a more secured unit at another facility, all residents at risk for elopement/wandering behaviors were reassessed by nursing staff, all door alarms were tested and inspected and continue to be tested by staff each shift for the next two weeks, door lock company reprogrammed all door key pads to auto lock after entry of the key code once to each door, facility initiated review through the Interdisciplinary team assessment of what elopement risk residents were allowed to be housed within the facility, facility hung red signs on fire exit stairwell doors indicating each was for emergency use only. The ADMN stated in the event a future resident displayed exit seeking behavior that resident would be placed on 1:1 staff monitoring and the administration/management team would be notified. He stated after both fire drills and generator tests were conducted staff/maintenance were required to check all exit doors and key pad/locking mechanisms to ensure they were functioning properly , codes to all keypad exits had been changed, both CNA E and LVN D were suspended pending the results of the facility investigation of the incident. In an interview on 07/30/21 at 9:54 AM the Plant Mgr stated maintenance directors on site checked all mag lock doors after a fire drill to ensure the key pad was on red indicating the door was closed and locked, they checked the doors to make sure they were locked and if the key pad was green that indicated the door would open and the alarm would sound. She stated on 07/27/21 there was a fire drill and generator test conducted, which had not been done prior. The Plant Mgr stated generator tests were performed weekly. She stated never before had the doors required a key code to be input twice before automatically locking and once the door contractor came out it was determined the door the resident eloped from required the key code to be input twice before locking. She stated the contractor disassembled, checked the wiring and reprogrammed the door to ensure it did not happen again and would automatically lock after just inputting the code once. In an interview on 07/30/21 at 10:03am CNA E stated she cared for Resident #1 and when he went to the other doors on the unit in the TV area during her shift the alarm sounded and several times he was successfully redirected away from the door. She stated Resident #1 was redirected from a door 07/27/29 by LVN D shortly after dinner. She stated after assisting another resident around 7:00 PM she saw Resident #1 lying in bed. She stated she was making rounds on all residents around 10:00 PM and Resident #1 was in his bed, and while changing his roommate for bed she asked if Resident #1 needed a blanket to which he responded No. CNA E stated she performed a second rounding on residents between 12:00 AM and 1:00 AM, and Resident #1's bed was empty. She stated she immediately looked for Resident #1 in his room and told LVN D she could not find the resident. CNA E stated LVN D found an exit door on the hall opposite of Resident #1's room open, and was told by LVN D that the Resident #1 might have left through the door . CNA E stated after last seeing Resident #1 in his room at 10:00 PM she had not heard any alarms go off at the exit doors on the unit. CNA E stated when the door alarms went off they were extremely loud . Review of facility policy Life Safety Subject 1 Jones Exit Doors, revised July 2021, revealed, It is the policy of this facility that all 5 exit doors on 1 Jones unit will be checked immediately after any generator testing, fire alarm, or power outage. Staff will ensure each mag lock is engaged and key pad is functioning properly. If any malfunction is noted, a resident head count will be performed. Maintenance/Administrator will be notified, and a staff member will remain at the malfunctioned door until the issue is resolved. The ADMN was informed on 07/30/21 at 3:10 PM that a past non-compliance IJ was identified to have existed from 07/27/21-07/28/21. The facility took the following actions to correct the deficient practice prior to the investigation: Review of facility in-service training on elopement, dated 07/28/21 through 07/30/21 revealed staff were trained on the facility's policy on wander system monitoring program, testing procedure, actions to take should a resident be exit seeking, to check all fire door exits after fire drills/sounding of an alarm/generator test to ensure doors are locked, hourly resident head count rounding sheets for residents of 1 Jones unit dated 07/28/21 to 07/30/21 to continue 2 weeks after the incident, elopement reassessments dated 07/28/21 for all twenty one residents of 1 Jones unit, daily wander guard testing and door alarm testing logs dated 07/27/210-07/30/21. On 07/29/21 and 07/30/21 separate interviews from 10:00 AM to 4:00 PM were conducted with LVN A, CNA B, ADON, LVN D, CNA E, CNA F, LVN G, RN H, CNA I, LVN J, CNA K who work across all three shifts 6:00 AM-2:00 PM, 2:00 PM- 10:00 PM and 10:00 PM-6:00 AM, and weekends Each member was able to demonstrate competency in identifying residents with exit seeking behaviors, the procedures to take to ensure resident safety, demonstrate when to inspect and identify which exit doors should be locked and secured on the 1 Jones unit, and what actions to take along with who should be notified should an exit door malfunction.