Every finding on record at Trinity Care Center

Based on observation, interview and record review, the facility failed to establish a system of accurate reconciliation and determine that drug records were in order, and that an account of all controlled drugs were maintained and periodically reconciled for 3 of 6 medication carts ( RN G's Medication Cart #1, RN H's medication cart #2, and RN I's Medication Cart #3) in the facility effecting 3 residents (Resident #5, Resident #55, and Resident #148) reviewed for pharmacy services.1. The facility failed to ensure RN G accurately reconciled Resident #5's narcotic medication log when she administered but did not sign for Resident #5's Lorazepam (controlled medication used for anxiety) 1 tablet and Acetaminophen/APAP (controlled medication used for pain) 1 tablets on 01/22/2026 at 8:48 a.m.2. The facility failed to ensure RN H accurately reconciled Resident #55's narcotic medication log on the medication cart 2 by omitting the count of Resident #55's morphine sulfate (controlled medication used for pain and shortness of breath) after this resident left the facility a 17 days earlier (01/05/2026) and medication was not returned to the resident, not turned in to DON for destruction, and not counted with other controlled medications on the medication cart 2.3. The facility failed to ensure RN I accurately reconciled Resident #148's narcotic medication log which revealed the controlled medication discrepancy for Resident #148's morphine sulfate (controlled medication used for pain and shortness of breath) with lesser amount (27ml) in the bottle than amount documented on the control medication log (28ml) for this medication.These failures could place residents at risk for loss of prescribed medications, potential for not receiving their prescribed medications, and risk of drug diversion.Findings included: During the medication cart #1's reconciliation and interview on 01/22/2026 at 08:46 a.m., RN G stated she administered the medications to Resident #5 but failed to document the administration of one Ativan Oral Tablet 0.5 MG (Lorazepam) and one Hydrocodone-Acetaminophen Oral Tablet 5-325 MG on Resident #5's narcotic record. RN G stated she was responsible for documenting the resident's narcotic record when narcotic medication was administered but she forgot to sign for Resident #5's controlled medications since she was very busy all morning. RN G stated that not documenting the narcotic medication was administered could cause a discrepancy or a medication error, since someone will not know the resident had already received the narcotic medication. Record review of Resident #5's face sheet, indicated Resident #5, [AGE] year-old male, admitted [DATE] with diagnoses which included Alzheimer's disease with late onset (the most common form of dementia with progressive memory loss, confusion, behavioral changes, and requires 24-hour care in advanced stages), schizoaffective disorder, bipolar type (a mental health condition characterized by symptoms of schizophrenia like hallucinations and delusions, co-occurring with mood episodes of mania and sometimes depression), and chronic pain. Record review of Resident #5's Significant change in status MDS assessment, dated 07/16/2025, did not reveal Resident #5's score. The MDS assessment indicated Resident #5 received scheduled opioid pain and antianxiety medication. Record review of Resident #5's comprehensive care plan, dated 10/24/2025, indicated Resident #5 had anti-anxiety medications related to anxiety and restlessness with intervention to administer antianxiety medication as ordered. Resident #5 had the risk for both acute and chronic pain related to diabetic neuropathy, mood changes and fluctuating behaviors. The care planned interventions were to anticipate the resident's need for pain relief and respond immediately to any complaint of pain with administration of pain medications as ordered. Record review of Resident #5's order summary report, indicated he had an order for Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth in the morning for restlessness/anxiety with an order start date of 07/23/2025 and Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth two times a day for chronic pain with an order start date of 11/03/2025. Record review of Resident #5's medication administration record, dated 01/22/2026, indicated Resident #5 received Ativan Oral Tablet 0.5 MG (Lorazepam) one time a day and Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) two times a day including 01/22/26 when medications were not documented in controlled medication administration record. During the medication cart #2 reconciliation and interview on 01/22/2026 at 09:41 a.m., RN H stated she did not count controlled medications Morphine Sulfate (controlled medication for pain and shortness of breath) for Resident #55 because Resident #55 was discharged a while ago and left her medication at the facility. RN H stated she was responsible for counting all controlled medication on her cart in the beginning and at the end of her shift. She stated that all discontinued or discharged residents 'controlled medications should be taken to the DON for destruction. She stated until discontinued medications were properly discarded, they should be counted twice every shift with other controlled medications locked on the cart. RN H stated that omitting the controlled medication from the regular count could cause a discrepancy or risk of drug diversion. The Resident #55's bottle of Morphine Sulfate 20mg/ml was not opened, and top was sealed. Record review of Resident #55's face sheet, date 01/22/2026, indicated an [AGE] year-old female, admitted [DATE], diagnoses which included Alzheimer's disease with late onset (the most common form of dementia with progressive memory loss, confusion, behavioral changes, and requires 24-hour care in advanced stages), chronic kidney disease, and anxiety. Record review of Resident #55's None of the above (respite care -short term stay) MDS assessment, indicated Resident #55 had a BIMS score of 3, which indicated severe cognitive impairment. The MDS assessment indicated Resident #55 was in hospice care and did not have pain in the last five days of assessment. Record review of Resident #55's comprehensive care plan, dated 12/31/2025, indicated Resident #55 had acute/chronic pain. The care plan interventions included anticipating the resident's need for pain relief and responding immediately to any complaint of pain through PRN pain medication. Record review of Resident #55's order summary report, indicated Resident #55 had an order for Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.25 ml by mouth every 1 hour as needed for Pain/SOB with a start date of 06/20/2025. Record review of Resident #55's medication administration record, dated 01/01/2026-01/31/2026, indicated Resident #55 did not receive Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) during her stay in this facility. During the medication cart #3 reconciliation on 01/22/2026 at 9:12 a.m., the discrepancy in Resident 148's controlled medication Morphine Sulfate Solution 100/5ml count was revealed with 27ml in Morphine Sulfate Solution bottle and 28ml documented on the controlled medication log. During an observation and interview on 01/22/2026 at 9:12 a.m., RN I stated she did not administer Morphine Sulfate Solution to Resident #148, and she did not count the controlled medications at the beginning of her shift today, 01/22/2026 at 6:00 a.m., as she came late and an unidentified nurse already counted her medication cart with the night nurse. RN, I stated that she had training on controlled medication storage, and she was responsible for medications on her cart including counting controlled medications at each shift change to make sure the count was correct. She stated if she did not follow the proper medication storage and controlled medication counting policy, it could lead to medication errors and drug diversion. RN, I stated that when a medication discrepancy was found, the DON should be notified immediately. Observation revealed she took the medication to the DON. During the interview on 1/23/2026 at 12:28 p.m., with RN K, she stated that she received training on proper controlled drug storage and counting at shift change annually and few months ago. She stated that each nurse or medication aide was responsible for counting the controlled medications on their carts. She stated that if controlled medications were not counted, it could cause residents would not get medications as prescribed and their conditions would be not properly treated. She stated a controlled drug discrepancy should be reported immediately to the ADON and the DON to start investigation. She stated she forgot to date the spillage on the controlled log for Resident #148 during her shift 3-4 months ago, with agency nurse. She stated she did not remember that nurse's name. Record review of Resident #148's face sheet, dated from 01/22/2026, indicated an [AGE] year-old female, who was admitted to the facility on [DATE], diagnoses included cerebral infarction (a type of stroke caused by a blocked blood vessel to the brain, leading to brain tissue death), type 2 diabetes mellitus (a chronic condition causing high blood sugar due to insulin resistance and insufficient insulin production), and major depression. Record review of Resident #148's quarterly MDS assessment, dated 11/18/2025, indicated Resident #148 BIMS' score of 6, indicating severe cognitive impairment. Record review of Resident #148's comprehensive care plan, dated 03/31/2022, indicated Resident #148 had chronic pain with interventions to monitor and evaluate the pain routinely to address pain management needs. Pain medications would be administered per physician orders. Pain medication effectiveness would be documented and reported as needed. Record review of Resident #148's order summary report, indicated Resident #148 had an order for Morphine Sulfate (Concentrate) Solution 20 MG/ML give 0.5 ml by mouth every 1 hour as needed for moderate pain and give 1 ml by mouth every 1 hour as needed for severe pain with a start date of 05/15/2025. Record review of the controlled log for Resident #148's medication Morphine Sulfate Solution 20 MG/ML, undated, revealed RN K documented a spillage of 1.5ml with an agency nurse on the controlled log and corrected count to 28.0ml without documenting the date of spillage on the controlled log. During an interview on 01/23/2026 at 12:11 p.m., the DON, stated, regarding the narcotic discrepancies found the day prior (01/22/2026), were submitted to the state for an investigation. She stated they started the investigation and in services. She stated that interviews with the residents revealed they all received their medications. She stated that she started interviewing nursing staff on different shifts and those who worked with the cart the night prior. She denied any history of suspicious behavior from staff regarding medications or any history of narcotic discrepancies. The DON stated there was no harm or impact on the residents regarding the incorrect counts. She stated the ADON and herself were doing the random cart audit and MARs. She stated that each nurse or medication aides were responsible for their medication carts and counting controlled medication at shift change. She stated she had training on medication storage and controlled medication annually and staff get that training through computer modules annually. During an interview on 01/23/2026 at 2:21 p.m., the ADM stated she was not trained in medication administration and storage as she was not medically licensed. She stated the DON, ADON, charge nurses and medication aides were responsible for counting controlled medications at shift change and monitor for medications' discrepancies especially with controlled medication to prevent drug diversion. She stated the DON randomly audit medication carts and MARs. She stated if discrepancy is noted, nurse of CMA was responsible to notify ADON, DON or herself. She stated that if not monitored and properly counted, it would potentially harm affect residents. Record review of the facility's Drug Diversion policy, undated, revealed Drug diversion is the unauthorized taking, use, or distribution of prescription medications – especially controlled substances – for personal use or sale. Examples: falsifying or skipping narcotic waste documentation. Inventory red flags: narcotic count discrepancies. Missing medications. Prevention/Best Practices: count narcotics at shift change. Chart after administration. Ensure accuracy and timeliness.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. There were 15 errors in 43 opportunities resulting in a 34.88% error rate, which involved 3 of 5 residents (Resident #70, Resident #109, and Resident #114) and 2 of 3 staff (MA C and MA D) observed during medication administration reviewed for medication errors.MA D failed to administer Spironolactone 25 mg (treating high blood pressure) ordered by physician for Resident #70. MA C failed to administer Namenda 5 mg (treating moderate to severe dementia) as ordered by physician for Resident # 114.MA C administered Resident #109's 13 medications outside of the allotted time frame. These failures could place residents at risk of their medications not being administered according to Physician's orders, getting their medications late, or not receiving the intended therapeutic benefits of their medications.Findings included: During observation of the medication pass on 01/21/2026 at 7:44 a.m., MA D did not administer Spironolactone 25 mg one tablet ordered by physician for Resident # 70 to treat her hypertensive heart disease as this medication was not available on her cart. MA D went to check with charge nurse to see if there was a dose available in the emergency medication kit but returned without medication available to give to Resident #70. During an interview on 1/21/2026 at 7:47 a.m., MA D stated Spironolactone 25 mg was not administered as ordered including one dose yesterday, 1/20/2026. She stated that whoever worked on the medication cart was responsible for reordering resident #70's medications. She stated that she was trained on medication administration annually. She stated she knew the 5 rights of medication,: with right time and right medication. She stated that not providing Resident #70 with ordered medication, especially if it was important medication like blood pressure, could make Resident #70's blood pressure go high and cause harm to her health. She stated that medication aides and nurses were responsible for reordering medications. She stated that usually she makes sure to reorder medications when there were 5 or less pills left in the blister packs. She stated she was off for a week and did not work on this cart, so she did not know what happened. She stated that she told the nurse and the medication was reordered. Record review of Resident #70's MAR, dated January 2026, revealed Spironolactone 25 mg was scheduled for one time a day at 8:00 a.m. and 2 doses were missed on 1/20/2026 and 1/21/2026. Record review of Resident #70's order summary report, dated, indicated Resident #70 had an order for Spironolactone Oral Tablet 25 MG (Spironolactone). Give 1 tablet by mouth one time a day related to HYPERTENSIVE HEART DISEASE WITH HEART FAILURE with a start date of 12/20/2025. Record review of Resident #70 's face sheet, dated from 01/22/2026, indicated an [AGE] year-old female, admitted [DATE], diagnoses included hypertensive heart disease with heart failure (a serious, often chronic, condition where long-term high blood pressure causes the heart muscle to thicken and weaken), chronic systolic (congestive) heart failure (a long-term condition where the heart's left ventricle becomes weakened and enlarged, unable to contract with enough force to pump sufficient blood), and permanent atrial fibrillation (the heart remains in an irregular rhythm continuously, and efforts to restore a normal rhythm). Record review of Resident #70's quarterly MDS assessment, dated 01/13/2026, indicated Resident #70's BIMS score of 3, indicating severe cognitive impairment. Record review of Resident #70's comprehensive care plan, dated revised 11/11/2025, indicated Resident #70 had cardiac disease related to heart failure with interventions of her cardiac medications as ordered. During an observation of the medication pass on 01/21/2026 at 9:11 a.m., MA C did not administer Namenda 5mg ordered by physician for Resident #114 to treat her moderate to severe dementia as this medication was not available on MA C's medication cart. During the observation, the medication was reordered, but Resident #114 still missed her morning dose of this medication scheduled for 9:00 a.m. Record review of Resident #114 's face sheet, dated from 01/22/2026, indicated a [AGE] year-old female, admitted [DATE], diagnoses included unspecified dementia - moderate with mood disturbance (a general term for a decline in mental ability, such as memory, reasoning, and communication, severe enough to interfere with daily life, resulting from damaged brain cells) and major depressive disorder. Record review of Resident #114's Significant change in status MDS assessment, dated 11/28/2025, indicated Resident #114's BIMS score of 3, indicating severe cognitive impairment. Record review of Resident #114's comprehensive care plan, dated revised 11/24/2025, indicated Resident #114 had impaired cognitive function, dementia, and impaired thought process related to dementia with interventions to administer medications as ordered. Record review of Resident #114's order summary report, indicated Resident #114 had an order for Namenda Oral Tablet 5 MG (Memantine HCl) Give 1 tablet by mouth two times a day for dementia with start date on 11/03/2025. During observation of the medication pass on 01/21/2026 at 9:38 a.m., MA C administered Resident #109's 13 medications scheduled for 8:00 a.m. in more than one hour allotted time frame. Record review of Resident #109's orders and MAR, dated January 2026, revealed orders and scheduled time for administration for Residents 109's 13 medications was 8:00 a.m. and these medications were administered at 9:38 a.m. - one hour outside of medication administration policy: a. Bystolic Oral Tablet 2.5 MG (Nebivolol HCl) Give 1 tablet by mouth one time a day for blood pressure with start date on 02/28/2025. b. Calcitriol Oral Capsule 0.25 MCG (Calcitriol) Give 1 capsule by mouth in the morning for Vitamin D Supplement with start date on 03/01/2025. a. Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 2 capsule by mouth in the morning for Bipolar with start date on 09/10/2025. b. Zoloft Oral Tablet 50 MG (Sertraline HCl) Give 50 mg by mouth one time a day related to bipolar disorder, and major depression with start date on 11/05/2025. c. Eliquis Oral Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day for DVT prevention with start date on 04/15/2025. d. Fluticasone Propionate Nasal Suspension 1 spray in both nostrils two times a day for Nasal Allergies with start date on 03/27/2025 e. GlycoLax Powder (Polyethylene Glycol 3350) Give 17 gram by mouth every morning and at bedtime with start date on 08/22/2025. f. NIFEdipine ER Oral Tablet Extended Release 24 Hour 30 MG (Nifedipine) Give 30 mg by mouth every 12 hours for high blood pressure with start date on 02/28/2025. g. Lokelma Oral Packet 5 GM (Sodium Zirconium Cyclosilicate). Give 1 packet by mouth in the morning every Mon, Wed, Thu, Fri for Hyperkalemia with start date on 10/16/2025. a. Senna Oral Tablet 8.6 MG (Sennosides). Give 1 tablet by mouth every morning and at bedtime for constipation with start date on 06/25/2025. b. Acetaminophen Tablet 500 MG. Give 2 tablet by mouth three times a day for chronic pain with start date on 03/05/2025. c. Hydralazine HCl Oral Tablet 50 MG. Give 1 tablet by mouth three times a day for blood pressure with start date on 07/28/2025. d. Sodium Bicarbonate Oral Tablet 650 MG. Give 2 tablets by mouth four times a day for Antacid Give 1 tablet by mouth with start date on 08/30/2025. Record review of Resident #109's face sheet, dated 01/22/2026, indicated an [AGE] year-old male, admitted [DATE], diagnoses included Type 2 diabetes mellitus (a chronic metabolic condition where the body develops insulin resistance, causing high blood sugar levels because cells cannot effectively use insulin), bipolar disorder (a mental health condition causing extreme shifts in mood, energy, and activity levels, ranging from manic highs to depressive lows), and hypertensive heart disease without heart failure (structural and functional changes in the heart caused by chronic high blood pressure). Record review of Resident #109's quarterly MDS assessment, dated 12/11/2025, indicated Resident #109 BIMS' score of 12, indicating moderate cognitive impairment. Record review of Resident #109's comprehensive care plan, dated 07/29/2025, indicated Resident #109 had electrolyte imbalance related to hypokalemia with interventions to provide supplement per physician orders. Resident#109 has allergic rhinitis (the inflammation of the nasal tissues, causing symptoms like a runny or stuffy nose, sneezing, and mucus in the throat) with interventions to administer medication for allergies per physician orders. Resident #109 has behavior problems, outbursts and agitation secondary to bipolar disorder with interventions to administer medications as ordered. Resident #109 has cardiac disease related to atherosclerosis (a condition in which plaque builds up inside your arteries), high blood pressure with interventions to administer anti-hypertensive medications as ordered. Resident #109 has anticoagulant therapy related to DVT prophylaxes with intervention to administer anticoagulants (medications that prevent or reduce blood clot formation to lower the risk of stroke, heart attack, and embolism) medications as ordered by physicians. During an interview on 1/21/2026 at 9:41 a.m., MA C stated Namenda was not administered to Resident # 114 as ordered MA D stated that she was not sure why medication was not available on the cart and in the facility. MA C stated that she looked in Resident # 114'a cubby in the medication room and asked the charge nurse to check the emergency medication kit and this medication was not available there either. MA C stated she went to ask the charge nurse to reorder this medication when she realized it was not available during the med pass, and it was reordered. She stated that potential risk for Resident #114's if she missed her Namenda 5 mg dose could be decline in her memory or other health issues depending on medication. She stated that she had training on medication administration sometimes in the last year. She stated the right time for administering medication was one hour before and one hour after ordered time. She stated if it was outside of that time window, the medication administration was late, and it would be a medication error. She stated that she was busy and got behind with her medication administration today. She stated that late administration could be potentially harmful to residents especially if this medication was blood pressure or seizure medication. During an interview on 01/23/2026 at 12:11 p.m., the DON, she stated that she had medication administration training last January 2025. She was aware about right time was one of the significant characteristics of medication administration. She stated that medication aides and charge nurses were responsible for timely reordering of medication electronically through point click care medical record system they use. She stated that Spironolactone for Resident #70 was reordered and was already delivered to the facility. She stated that Namenda was available at the facility in the emergency medication kit and was not sure why MA C was not able to find it. She stated the ADON and herself were doing the random cart audit and MARs. She stated if medication was not administered to residents as ordered or administered late, it could affect the residents' health conditions the medications were supposed to treat. She stated medication errors were reported to health care providers and families and staff in service was provided on 1/22/2026. During an interview on 01/23/2026 at 2:21 p.m., the ADM, stated she was not trained in medication administration and storage as she was not medically licensed. She stated that DON, ADON, charge nurses, and medication aides were responsible for reordering medications and monitoring proper medication administration. She stated the DON randomly audits med carts and MARs along with the pharmacist's audits every month. She stated if medication error occurred like late medication administration, wrong medication administration, or medication omission, nurses or med aides were responsible to notify ADON, DON or herself. She stated that if medications administration was not performed properly, it would potentially harmfully affect residents. Record review of facility's staff in-services revealed 6 rights of medication administration, dated 6/27/2025, signed by MA C and MA D,. included information on right time for medication administration. Record review of the facility's Medication Administration policy, undated, revealed, Facility staff should take all measures required by Facility Policy, Applicable Law, and the State Operation Manual when administering medications. Medications are administered as prescribed in accordance with good nursing principles and practice. During medication administration, the facility staff should observe the 6 Rights. Medications are administered within 60 minutes before or after the scheduled time.

Based on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 9 of 15 residents (Resident #18 and 8 residents in the dining room near nursing station C) reviewed for infection control.1. CNA E did not change gloves between dirty and clean peri-care tasks and did not sanitize her hands between glove changes during peri-care for Resident #18.2. CNA F and RN G did not sanitize their hands between passing meal trays for 8 residents in the dining room near nursing station C. These failures could place the residents at risk of infection transmission, sepsis, and hospitalization.Findings included: An observation on 01/22/2026 at 12:18 p.m. of peri-care for Resident #18, revealed CNA E did not change her gloves after cleaning dirty peri-care area with bowel movement and front peri-care area. CNA E changed her gloves without conducting hand hygiene. CNA E touched bedside table, blanket and pillow in Resident 18's environment while assisting Resident #18 with repositioning without changing her gloves. An observation of Resident #18's skin in the peri area appeared red without apparent skin break down. An interview with CNA E on 01/22/2026 at 12:21 p.m., she stated that she received hand hygiene in-service sometimes in the last year. She stated that she was supposed to sanitize her hands between gloves and change gloves between dirty and clean peri-care areas. She stated that potential risk to residents if not following hand hygiene could lead to cross contamination. Record review of Resident #18's face sheet, dated 1/22/2026, revealed a [AGE] year-old female, who was admitted to the facility on [DATE]. Her diagnoses included chronic diastolic congestive heart failure (when the heart muscle becomes stiff, preventing the left ventricle from filling properly with blood, leading to back up in the lungs/body, causing shortness of breath, fatigue, and swelling), aphasia (a language disorder caused by brain damage, most often from stroke, that impairs communication by making it difficult to speak and understand), and functional quadriplegia (complete immobility requiring total assistance with daily living). Record review of Resident #18's admission MDS assessment, dated 12/16/2025, revealed no BIMS score entered. Further review of Resident #18's assessment revealed she was frequently incontinent with bladder and bowel and required total assistance for her activities of daily living. Record review of Resident #18's Care Plan, dated 12/06/2025, reflected: Resident #18 had actual impairment to skin integrity of the right cheekbone/trauma and right upper posterior thigh/MASD. Is at risk related to incontinence, PEG tube, edema, contractures and needs assistance with ADLs. An observation on 1/20/2026 at 12:21 p.m. of staff passing lunch trays to the 8 residents in the dining room near nursing station C, revealed CNA F and RN G did not sanitize their hands while passing trays to some of the residents. CNA F touched her face and without sanitizing her hands, touched the lunch tray, and took it to the residents in the dining room. An interview on 01/20/2026 at 12.:24 p.m., CNA F stated she had hand hygiene training 4-6 months ago. She stated staff needed to wash or sanitize their hands between passing food trays between each resident to prevent the spread of infection. She stated she should have washed her hands after she touched her face. She stated that she was distracted and had to move fast and forgotten to sanitize her hands. An interview on 01/20/2026 at 1:34 p.m., RN G, stated she had an in-service on hand hygiene not too long ago. She stated according to the facility's policy she was supposed to sanitize her hands between each resident's tray during meal tray pass. She stated not sanitizing her hands properly could lead to potential cross contamination. During an interview on 1/23/2026 at 12:05 p.m., the ADON, stated charge nurses should monitor how staff were conducting hand hygiene and following infection control measures, and the DON conducted oversight. The ADON further stated the policy on hand hygiene and providing peri-care, wound care, urinary catheter care was to conduct handwashing before and when they left the room with wound care, aides would wash when they come in and out. She stated when going in and coming back out, they sanitized their hands. She further stated there was an order in how you do things from the cleanest to the dirtiest, depending on if providing peri-care for male and female, who should be cleansed from front to back. She stated for wound care you cleanse the wound, remove gloves, wash hands or gel, put on clean gloves and apply the wound treatment. The ADON stated she was trained on infection control and hand hygiene many times, and the potential negative outcome for the residents when not practicing good hand hygiene was cross-contamination. During an interview on 01/23/2026 at 2:11 p.m., the DON, stated she and the Infection Preventionist were responsible for ensuring staff were conducting proper hand hygiene/following infection control measures when providing care for the residents. She stated she and ADONs conducted periodic audits and provided hand hygiene in-services to staff. She stated the policy on hand hygiene, providing peri-care, wound care, and foley catheter care was to conduct hand hygiene before going in the room, between dirty and clean area, between changing gloves and when coming out of the room. The DON stated training on infection control and hand hygiene was taught during annual skills training. The DON stated a potential negative outcome for the residents would be transmission of bacteria. During an interview on 1/23/2026 at 12:21 p.m., the ADM, stated she had hand hygiene training sometimes within the last year which covered the policy for conducting handwashing/hand hygiene when providing care/passing meal trays included all staff were to be using hand sanitizer between each meal pass unless something happened and they needed to wash their hands. She stated a negative outcome to the residents could be cross contamination. During an interview on 01/23/2026 at 2:30 p.m., the Infection Preventionist RN K stated she was responsible for ensuring staff were conducting proper hand hygiene and following infection control measures when providing care for the residents. She stated the policy on hand hygiene during providing peri-care and passing food trays should be washing or sanitizing hands before entering residents' room, between changing gloves, exiting resident' rooms and between each individual food tray. Infection Preventionist RN K stated she had the training on infection control and hand hygiene during the annual skills training. The DON stated a potential negative outcome for the residents would be cross contamination. Review of Handwashing/ Hand Hygiene Policy, dated 08/2019, reflected, This facility considers hand hygiene the primary means to prevent the spread of infections. Policy interpretation and implementation 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Use an alcohol=based hand rub or alternatively, soap and water for the following situations: h. Before moving from a contaminated body site to a clean body site during residence. m. Before/After removing gloves. o. Before and after assisting a resident with meals.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1.The facility failed to ensure sanitation practices including cleaning the ice machine, cleaning the juice dispenser nozzle, cleaning the front of the convection oven, and cleaning the dish rack storage cart.2. The facility failed to label and date all food items in the kitchen.3. The facility failed to properly cover all food items to prevent contamination.These failures could place residents at risk of foodborne illness.Findings Included: During an observation on 1/20/26 at 9:22 a.m., revealed a container of spaghetti meat sauce and a container of winter vegetable blend on stovetop griddle uncovered. This should be covered to prevent cross contamination from a physical contaminant. During an observation on 1/20/26 at 9:23 a.m. revealed a bag of corn chips undated, unlabeled, and not closed securely. Further observation revealed a bag of oatmeal undated, unlabeled, and not closed securely under the steam table on a lower shelf in the kitchen. During an observation on 1/20/26 at 9:24 a.m. of reach in refrigerator revealed: -a tray of individually portioned pudding cups unlabeled and undated -a tray of individually portioned glasses of nectar thick tea unlabeled and undated -a pitcher of red juice unlabeled and undated -a pitcher of orange juice unlabeled and undated -a container of hot dogs with a date of 1/18/26 and unlabeled if this was the receipt date, opened date, or discard date, without a lid securing the container. -a container of lunch meat slices dated 1/18/26 and unlabeled if this was the receipt date, opened date, or discard date, without a lid securing the container. During an observation on 1/20/26 at 9:26 a.m. of ice scoop receptacle revealed brown, white, and black food debris and mineral deposit buildup(whitish chalk like residue) in the bottom of the container. During an observation on 1/20/26 at 9:27 a.m. of kitchen ice machine revealed, inside of the ice machine lid and inner upper plastic shield, was a white, black, and brown substance all over it. During an observation on 1/20/26 at 9:28 a.m. of a pitcher of red juice in a tub of ice on a utility cart with a label dated 1/6/26, unlabeled if this was the preparation date or discard date. During an observation on 1/20/26 at 9:9:29 a.m. of pitcher of red juice in tub of ice on a utility cart with a label dated 1/13/26, unlabeled if this was the preparation date or discard date. During an observation on 1/20/26 at 9:30 a.m. of tray of individually bowled dry cereal dated 1/6/26 unlabeled if this was the preparation date or discard date. During an observation on 1/20/26 at 9:32 a.m. of 5 separate large plastic storage bags with sandwiches, peanut butter crackers, cookies, and cheese snack crackers unlabeled and undated on utility cart. During an observation on 1/20/26 at 9:33 a.m. of juice dispenser nozzle revealed inside of juice dispenser nozzle was black, orange, red, slimy substance covering the inside of the dispenser nozzle. During an observation on 1/20/26 at 9:35 a.m. of lower steam table shelf revealed container of dry ring cereal, dated 10/29/24, unlabeled if this was preparation date or discard date. Further observation revealed a container of raisin flake dry cereal labeled pudding, dated 9/5/25. Observation of a container of rice puff dry cereal, dated 3/21/25, unlabeled if this was preparation date or discard date. During an observation on 1/20/26 at 9:42 a.m. of convection oven revealed front of convection oven with dried food debris and grease buildup on front bottom under doors. During an observation on 1/20/26 at 9:45 a.m. of dish rack storage cart with trash, food debris, and black substance. During an interview on 1/22/26 at 2:14 p.m., MS stated he had worked at the facility for 22 years. MS stated they received training regarding Abuse, Neglect, and Exploitation, Resident Rights but they were unsure of the exact date of the last training. MS stated a contract company comes every six months and cleaned the ice machine and he was responsible for changing the filters every three months. MS stated when the contract company comes, they clean the ice machine for mold and mineral build up. MS showed surveyor pictures on his phone from the last time the contract company came to the facility kitchen to clean the ice machine dated 10/13/25, showing no mold or substance build-up on the ice machine components. MS stated it could possibly negatively affect a resident if the ice machine was not cleaned properly depending on where the sludge buildup was located or if it encountered the ice. During an interview on 1/22/26 at 4:22 p.m., [NAME] stated they worked at the facility for one year. [NAME] stated they received training regarding Abuse, Neglect, and Exploitation, Resident Rights, Kitchen sanitation, and Food labeling and dating. [NAME] stated they received training monthly at meetings and as needed and when there were new hires. [NAME] stated DA was responsible for cleaning the juice machine dispenser nozzle and DA cleaned them daily. [NAME] state the service provider periodically and flushed the machine, but was unsure of the frequency. [NAME] stated MS cleaned the ice machine, and DA sends the ice scoop receptacle through the dish machine to clean it. [NAME] states it could negatively affect the residents if the juice dispenser nozzles and the ice machine were not properly cleaned because of cross contamination. [NAME] states anybody who handles food in the kitchen is responsible for labeling and dating the food. [NAME] states the food items are dated upon receipt, when opened or prepared with the preparation date and the discard date. [NAME] stated by not labeling and dating there would be no way for staff members to know the quality of the food, and it could be expired. During an interview on 1/22/26 at 4:31 p.m., DA stated they had worked at the facility for 3 years. DA stated they had been trained regarding Abuse, Neglect, and Exploitation, Resident Rights, Kitchen sanitation, and Food labeling and dating. DA stated they have received training bi-weekly and monthly at staff meetings. DA stated DA is responsible for cleaning the juice dispenser nozzle, and the DA cleans it daily it is left soaking in soapy water. DA takes the black cover to the dispenser off and cleans the inside of the nozzle. DA states MS is responsible for cleaning the ice machine, but they are unsure of how often. DA states that they are responsible for cleaning the ice scoop receptacle daily. DA stated it can negatively affect a resident if the juice dispenser nozzles and the ice machine are not cleaned properly because mold can build up and the residents can become sick. DA stated all dietary staff are responsible for labeling and dating food items. DA stated all items are dated upon receipt, at preparation with the prep date and the discard date. DA stated it can negatively affect the residents if food items are not labeled and dated properly because residents can get sick from consuming old food. During an interview on 1/22/26 at 4:40 p.m., DM stated they had worked at the facility for 2 1/2/ years. DM stated they had received training regarding Abuse, Neglect, and Exploitation, Resident Rights, Kitchen sanitation, and Food labeling and dating. DM stated they conduct training monthly. DM stated the drink DA is responsible for cleaning the juice dispenser nozzle and that it is cleaned nightly. DM stated MS is responsible for cleaning the ice machine and DA are responsible for cleaning the ice scoop receptacle. DM stated it could potentially negatively affect the residents if the juice dispenser nozzles and the ice machine are not cleaned because the residents could become sick. DM stated all dietary staff are responsible for labeling and dating food items. DM stated the process for food labeling and dating is that all items are dated upon receipt, items are dated upon opening or preparation with a preparation date and a discard date. DM stated it could negatively affect a resident if food items are not labeled and dated properly because expired foods could make a resident sick. During an interview on 1/23/26 at 11:39 a.m., DON stated they had worked at the facility for 5 years. DON stated they had received training regarding Abuse, Neglect, and Exploitation, and Resident Rights. DON stated they had not received any specific training regarding kitchen sanitation and food labeling /dating but stated they were aware that the food is supposed to be labeled and dated but was unsure of the timeframes. DON stated they were unsure of who was responsible for cleaning the juice machine dispenser nozzle, ice machine, and ice scoop receptacle. DON stated that there would be DM responsibilities regarding her staff. DON stated it could potentially negatively affect a resident if the juice dispenser nozzles and the ice machine are not cleaned properly because the residents could become sick. DON stated I would assume whatever dietary staff prepare the food items are responsible for labeling and dating of those items. DON stated she was unsure of the food labeling and dating process regarding timeframes. DON stated it could potentially negatively affect a resident if food items are not labeled and dated because if the food has not been labeled and has been in the facility for a little bit there could be a poor outcome if the resident receives the food. During an interview on 1/23/26 at 12:24 p.m., ADM stated they had worked at the facility for 4 years. ADM stated they had received training regarding Abuse, Neglect, and Exploitation, and Resident Rights. ADM stated she had not received training regarding kitchen sanitation or food labeling /dating, but she was aware that all food items are to be labeled and dated. ADM stated DA is responsible for cleaning the juice dispenser nozzle, but she was unaware of the frequency. ADM stated MS, DM, and a contract company were responsible for cleaning the ice machine. ADM stated she was unsure who was responsible for cleaning the ice scoop receptacle. ADM stated it was her expectation for the kitchen to be clean and for the staff to follow the cleaning schedule. ADM stated it could potentially negatively affect a resident if the juice dispenser nozzle or the ice machine were not cleaned because the residents could get an infection. ADM stated all kitchen staff and ultimately DM are responsible for food labeling and dating. ADM stated she was unsure of the process for food labeling and dating. ADM stated it was her expectation that the food items always be labeled and dated. ADM stated it could potentially negatively affect the residents if food items are not labeled and dated by foodborne illness. Record review of daily cleaning schedule, dated 1/18/26-1/24/26, reflected under column of ice machine to be cleaned by maintenance. Further review reflected no column for juice machine or dispenser nozzle cleaning. Record review of weekly cleaning schedule, dated January 2026, reflected under column of ice machine to be cleaned by maintenance, with last cleaning date of 1/9/26 by MS and contract company cleaning dated 1/14/26. Further review reflected no column for juice machine or dispenser nozzle cleaning. Record review of kitchen in-service, dated 1/8/25, reflected topics discussed by the DM were to label & date every item with 12 staff signatures of attendance. Record review of kitchen in-service, dated 4/10/25, reflected the title was labeling & dating all food items with 9 staff signatures of attendance. Record review of facility food storage policy, dated 10/1/2018 and revised on 6/1/2019, reflected under heading policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to state, federal, and US Food Codes and HACCP guidelines. Under heading dry storage -To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. -Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that older items are used first. Under heading refrigerators -Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Record review of facility general kitchen sanitation policy, dated 201,8 reflected under heading policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes to minimize the risk of infection and food borne illness. Under heading procedure -Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities, and equipment. -Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil. -Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition.

Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 (Resident #16, Resident #17, and Resident # 26) of 20 residents reviewed for resident rights.The facility failed to ensure Resident #16, Resident #17, and Resident #26's bedrooms had no scratches or holes on the walls next to their beds.The facility failed to ensure that the walls and carpets in 2 of 3 (200 hall, 400 hall) hallways were in good condition. These failures could place residents at risk of decreased quality of life. Findings included:During an observation on 01/20/2026 at 9:25 AM revealed tattered floors, walls and stains in the carpets of the hallways on 200 hall and 500 hall. The carpets had a foul urine odor to it in the hallways of 200 hall and 400 hall.1. Record review of Resident #26's admission Face sheet, reflected a [AGE] year-old female, admitted to the facility on [DATE], with a diagnoses of hypertensive heart disease without heart failure (structural and functional changes in the heart, such as left ventricular hypertrophy (LVH) or diastolic dysfunction, caused by chronic high blood pressure), vascular dementia (common form of dementia caused by an impaired supply of blood to the brain, such as may be caused by a series of small strokes), Xerosis Cutis (abnormally dry, rough, and itchy skin caused by a lack of moisture in the epidermis, often resulting from a damaged skin barrier) and Anorexia (eating disorder that involves severe calorie restriction and, often, a very low body weight). Record review of Resident #26's Quarterly MDS Assessment, dated 12/09/2025, reflected, Resident #26 had a BIMS score of 3 indicating the Resident's cognition was severely impaired.Record review of Resident #26's Comprehensive Care Plan, dated initiated 11/18/2021, reflected Resident #26 had little interest in activities and enjoyed hanging out in her bedroom.During an observation on 01/20/2026 at 10:20 a.m., of Resident #26's bedroom revealed holes and scratches in the wall next to the head of her bed.During an interview on 01/20/2026 at 10:20 a.m., with Resident #26 revealed that the walls were ruined when she arrived at the facility. Resident #26 stated she did not like that the walls are messed up and stated that it did not make her feel at home.2. Record review of Resident #16's admission Face sheet, undated, reflected a [AGE] year-old female, admitted to the facility on [DATE], with a diagnosis of Quadriplegia (paralysis of all four limbs and the torso, typically caused by damage to the cervical spine (neck) from injuries, infections, or disorders). Record review of Resident #16's Quarterly MDS Assessment, dated 11/06/2025, reflected, Resident #16's had a BIMS score of 15 which indicated the resident's cognition was intact.Record review of Resident #16's Comprehensive Care Plan, dated initiated 09/22/2025, reflected Resident #16 was dependent on staff to meet emotional, physical and social needs.During an interview on 01/20/2026 at 11:30 a.m., Resident #16 stated that there were scratches and holes in the bedroom wall, when she had moved in on 08/22/2024. Resident #16 stated there were not any repairs made at the facility since she arrived. Resident #16 stated the room did not look homelike with the wall issues.3. Record review of Resident #17's admission Face sheet, undated, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (a progressive, irreversible lung disease-comprising chronic bronchitis and emphysema-that blocks airflow and makes breathing difficult ) and Anxiety Disorder (persistent, excessive fear or worry that interferes with daily life).Record review of Resident #17's Quarterly MDS assessment dated [DATE] reflected, Resident #17 had a BIMS score of 15 which indicated the Resident's cognition was intact.Record review of Resident #17's Comprehensive Care Plan initiated 09/22/2025 reflected Resident #17 had little to no activity interest and preferred to stay in his bedroom.During an observation on 01/20/2026 at 11:30 a.m., Resident #17's and Resident #17's bedroom revealed walls with scratches and holes throughout the bedroom. During an interview on 01/20/2026 at 11:30 a.m., Resident #17 stated that there were holes next to his bed since he arrived. Resident #17 stated he did not know where it came from. Resident #17 stated the holes does did not make him feel good.During an interview on 01/22/2026 at 2:14 p.m., the MD stated they worked at the facility for 22 years where he had received training on resident rights which included residents have the right to make their own choices. MD revealed the policy regarding maintaining carpets and walls included when maintenance received a work order, they were to work on the repair. MD stated he would go around every three months to complete painting in the facility. MD stated he would complete rounds around the facility, which included checking residents' bedrooms, every day. MD also stated there were no current work orders for 500 halls where the identified residents reside. MD also stated the conditions of the bedrooms and hallways could negatively affect residents as the residents feel like their conditions of their home were worn down. During an interview on 01/23/2026 at 11:45 a.m., the DON stated she had received training on resident rights which included the right to make choices. The DON stated her expectation for residents' bedrooms would be for the rooms to be clean, and tidy, and decorated to the residents' preference. The DON stated that all staff were responsible for ensuring that the environment in the facility was clean and maintained. The DON stated that during Angel Rounds (every morning managers go around the facility and look at bedrooms), every room is accounted for and checked on by a manager at the facility. The DON stated that the bedrooms are monitored by the same managers every day. The DON stated that the conditions of the facility and bedrooms being torn and scratched could negatively impact residents by the facility did not feel homelike and comfortable. The DON stated to her that there were repairs scheduled regarding the carpets in the facility due to their conditions.During an interview on 01/23/2026 at 12:45 p.m., the ADM stated she was employed at the facility for four years. The ADM stated she had received training on resident rights which included residents have the right to speak up. The ADM stated her expectation for condition of resident's bedrooms was to ensure that the beds were made, and maintenance would repair reported issues that have been reported. The ADM stated that housekeeping was responsible for ensuring the facility was clean, whereas maintenance would be responsible for making sure the facility was repaired. The ADM stated things were often repaired daily at the facility. The ADM stated that if a resident had scratches and holes in their wall in their bedroom, which were not caused by them, it could negatively impact the resident by not having access to a nice environment. The ADM stated that there were current work orders in place which included replacing the carpet with laminate flooring.Record review of undated work order provided by the facility included the following:Supplies were ordered for the replacement of the carpets in the facility.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of ten residents (Resident #32, Resident #100, and Resident #113) reviewed for ADLs. The facility failed to ensure Resident #113's fingernails were trimmed and clean. The facility failed to ensure Resident #32's and Resident #100's facial hair was shaved. These failures could place residents at risk of not receiving care services, diminished quality of life, and decreased self-esteem.Findings included: 1. Record review of Resident #32's face sheet, dated 01/21/2026, revealed an [AGE] year-old female, admitted [DATE], diagnoses included chronic venous hypertension (condition of sustained high blood pressure in leg veins caused by damaged valves or, less commonly, venous obstruction, leading to blood pooling), major depressive disorder (severe mental health condition marked by persistent, overwhelming sadness, loss of interest (anhedonia), and fatigue lasting at least two weeks), and raynaud's syndrome with gangrene (a rare, severe complication, usually associated with secondary raynaud's rather than the primary form). Record Rreview of Resident #32's quarterly MDS record, dated 12/31/2025, revealed Resident #32 had a BIMS of 12 which indicated mild cognitive impairment. The MDS also revealed that Resident #32 required 1-person maximum assist for ADL care, including shaving. Record review of Resident #32's care plan, dated initiated on 03/04/2025, revealed Resident #32 had an ADL deficiency related to weakness, polyneuropathy and chronic pain. The care plan revealed Resident #32 required substantial/maximum assist with 1 person. During an observation and interview on 01/20/2026 at 10:00 a.m., revealed Resident #32 had chin hair on her face.An interview on 01/20/2026 at 10:00 AM with Resident #32 stated she plucked her chin hair because she had never been offered to be shaved at the facility and knew she had chin hair. Resident #32 stated she did not feel comfortable with her chin hair on her face. She stated that it would be helpful if she had the resources to complete her facial hair care.2. Record review of Resident #100's face sheet revealed a [AGE] year-old woman, admitted to the facility on [DATE], Resident #100 had diagnoses included of essential hypertension (high blood pressure without a single, identifiable cause), osteoporosis (common, often asymptomatic silent disease characterized by low bone mass and structural deterioration, making bones fragile and prone to fractures, particularly in the hip, spine, and wrist), and pain in right shoulder. Record review of Resident #100's quarterly MDS, dated [DATE], revealed Resident #100 had a BIMS of 7 which indicated severely cognitive impairment. The MDS also revealed that Resident #100 had required supervision or touching assistance for ADL care such as shaving. Record review of Resident #100's care plan, dated initiated on 11/15/2022, revealed Resident #100 had an ADL self-care deficit related to dementia and weakness. The care plan revealed Resident #100 required limited assistance with one person. During an observation and interview on 01/20/2026 at 11:05 a.m., revealed Resident #100 had facial hair on her face. Resident #100 stated that the facility had not offered to shave her face. She stated that she did not like to have facial hair.3. Record review of Resident #113's Face Sheet, dated 01/21/2026, reflected an [AGE] year-old male, admitted [DATE], with diagnoses that included dementia ( the loss of cognitive functioning, thinking, remembering, and reasoning), obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), heart disease (refers to a range of conditions that affect the heart), kidney disease (renal disease or nephropathy, occurs when the kidneys can no longer effectively do their job of removing excess waste and fluids from your body), cognitive communication deficit (a condition that affects how individuals think and communicate), and age-related physical debility (physical debility refers to the gradual decline in physical and sometimes cognitive functions such as weakness, fatigue, and diminished stamina, often coexisting with chronic diseases). Record review of Resident #113's quarterly MDS, dated [DATE], reflected a BIMS Score of 14, which indicated cognitively intact. Record review of Resident #113's Care Plan, dated 11/28/2025, reflected Resident #113 required supervision assistance with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goal was for Resident #113 to maintain current level of function with assistance in his ADL care needs. During an observation on 01/20/2026 at 11:32 a.m., Resident #113's fingernails on both of his hands were approximately one inch long from the fingernail bed. Observation revealed Resident #113's fingernails had untrimmed jagged edges including a crack at the tip of Resident #113's right middle finger. During an interview on 01/20/2026 at 11:33 a.m., Resident #113 stated long fingernails were bothering him. Resident #113 stated nursing staff had not asked him if he wanted his fingernails trimmed. Resident #113 stated his fingernail length had been bothering him, and he accidentally hit his fingernails when rolling his wheelchair wheels with his hands. Resident #113 stated he was afraid he would hurt himself by breaking a fingernail and it made him feel discouraged. Resident #113 stated staff had not trimmed his fingernails in a long time, but he did not have an exact time frame since it was long ago. During an observation on 01/21/2026 at 10:22 a.m., Resident #113's fingernails appeared trimmed and filed. During an interview on 01/21/2026 at 10:23 a.m., Resident #113 he liked the length of his fingernails now that the nursing staff trimmed his fingernails. Resident #113 stated his fingernails did not hurt him anymore since being trimmed. During an interview on 01/23/2026 at 10:42 a.m., CNA A stated she worked here at the facility for one year. CNA A stated she received training on ADL care and trimming resident's fingernails timely. CNA A stated ADL care and trimming resident's fingernails timely training included if residents had diabetes, then a charge nurse trimmed their fingernails and how to properly trim the resident's fingernails. CNA A stated resident's fingernails should be trimmed and cleaned on every shower day, which was three times a week. CNA A stated if resident's fingernails were not trimmed over a few months, it would be considered neglectful. The CNA A stated ADL care and trimming resident's fingernails timely were monitored by the DON and nursing staff. The CNA A stated she had not received complaints from residents that staff were not trimming their fingernails. CNA A stated it is the responsibility of nursing staff to ensure ADL care and trimming resident's fingernails is taking place. CNA A stated if ADL care and not trimming resident's fingernails was not taking place, it could affect and diminish the resident's quality of life by potentially causing infections, resident cutting themselves, or causing skin tears. CNA A stated it was ultimately the overall responsibility of the nurses and the DON and nursing staff to ensure ADL care and residents fingernails were trimmed timely. CNA A reported she received training regarding facial hair care which included how to shave the residents' faces, where to dispose of the used razors and to go with the grain of the hair while shaving. CNA A stated CNAs and LVN/RN were responsible for facial hair care for residents. CNA A stated residents should have their faces shaved or offered to be shaved during shower days. CNA A stated if the residents refused to be shaved, staff were to notify the charge nurse. CNA A stated all floor staff monitored that shaving was taken care of but it does not have its own documentation tab. CNA A stated it could negatively impact a resident if they were not offered to be shaved, specifically as a woman, by causing them to feel neglected, not received proper care and could affect their dignity. During an interview on 01/23/2026 at 10:56 a.m., LVN B stated he worked at the facility for ten years. The LVN B stated he received ADL care and trimming resident's fingernails timely training. LVN B stated ADL care and trimming resident's fingernails timely training included a nurse trimmed resident's fingernails with a diabetes diagnosis and for other residents CNAs trimmed residents' fingernails. LVN B stated he does not remember the last time that he received that training. LVN B stated it was the CNAs responsibility to ensure residents' fingernails were trimmed and cleaned during each bath or shower times during the week. LVN B stated ADL care and trimming resident's fingernails timely were monitored by CNAs and reported to charge nurses. LVN B stated he has not received complaints from residents that staff were not trimming their fingernails. The LVN B stated it was the responsibility of the charge nurse and nursing staff to ensure ADL care and trimming resident's fingernails is taking place. The LVN B stated if ADL care and not trimming resident's fingernails was not taking place, it can affect and diminish the resident's quality of life by potentially having dirty fingernails, long fingernails, infection control, and residents can have a hard time putting on clothes. LVN B stated it's ultimately the overall responsibility of the DON to ensure ADL care and resident's fingernails are trimmed timely for all residents. LVN B stated he had received training regarding the cleanliness for residents. LVN B stated the charge nurse should look at the residents and ensure that they are properly cared for. LVN B stated all floor staff are responsible for facial hair care for the residents. LVN B also stated residents should be offered every shower day, or PRN, to be shaved. LVN B stated all employees monitor that the care is completed. LVN B stated they do not document if shaving had been offered. LVN B stated it could negatively impact a resident if they aren't being offered to be shaved, specifically for women, by feeling neglected and not taken care of.During an interview on 01/23/2026 at 11:38 a.m., the DON stated she worked here at the facility for five years. The DON stated she received ADL care and trimming for resident's fingernails training in nursing school and not at this facility as it is not usually what the facility goes over with DON's. The DON stated that ADL care and trimming resident's fingernails timely training for the nursing staff goes over, any residents' fingernails that are observed by nursing staff to be too long then nursing staff need to be trimmed resident's fingernails, there is no specific timeline, but it is done during shower days. DON stated residents who have diabetes diagnosis, fingernails need to be trimmed and cleaned by nurses. The DON stated ADL care and trimming of resident's fingernails are monitored by CNA's, nurses, and all staff members. The DON stated she has not received complaints from residents that staff are not trimming fingernails. DON stated if a resident's fingernails are not being offered to be trimmed by nursing staff, it can be an issue for the residents. The DON stated that if ADL care and not trimming resident's fingernails is not taking place, it can affect and diminish the resident's quality of life such as the resident's fingernails can be sharp or jagged, fingernails may collect dirt underneath, and if a resident uses a wheelchair, fingernails may hit the wheel when pushing it around themselves. The DON stated it's the responsibility of the DON to ensure ADL care and trimming resident's fingernails is taking place. The DON stated it's ultimately the overall responsibility of the nursing staff including the DON to ensure ADL care and resident's fingernails are trimmed for all residents. The DON stated her expectation for facial hair care would be to offer and complete during showers, which should be offered by the CNAs. The DON stated that showers are offered/provided 3 times a week, and residents should be offered during those times at least. The DON stated that CNAs complete the task, Nurses should check to ensure that it was completed, and all staff above them are also involved in ensuring that it was completed. The DON stated it could negatively affect a resident if they aren't offered to be shaved, specifically for females, by causing a dignity issues/concern. During an interview on 01/23/2026 at 12:22 p.m. with ADM, she stated the following: has worked here at the facility for almost four years. The ADM stated she has not received ADL care and trimming resident's fingernails training as it is not necessary since she does not provide ADL services to residents. The ADM stated it's the CNA's job to look at residents during baths to ensure ADL care and fingernails are being trimmed. The ADM stated ADL care and trimming resident's fingernails training goes over, from what is understood, that CNAs are not to trim resident's fingernails with diabetes diagnosis, but she does not know since she does not receive the ADL care training as a ADM. The ADM stated ADL care and trimming resident's fingernails are monitored by the charge nurses, ADON, DON, nursing staff, and the ADM. The ADM stated she has not received complaints from residents that staff are not trimming fingernails, and if a resident complains about not having fingernails being trimmed it will be an issue, but the nursing staff would take care of it. The ADM stated it's the responsibility of nursing staff to ensure ADL care and trimming resident's fingernails is taking place. The ADM stated if ADL care and not trimming resident's fingernails is not taking place, it can affect and diminish the resident's quality of life by resident's fingernails getting too long, fingernails harboring food or feces underneath fingernails, and residents may potentially scratch themselves. The ADM stated it's ultimately the overall responsibility of the charge nurses, ADON, DON, and the ADM to ensure ADL care and residents fingernails are trimmed for all residents. The ADM stated it's her expectation for ADL care and fingernails being trimmed is taking place for residents and it's her expectation that nursing staff are asking residents if they need fingernails trimmed during bath times. The ADM stated that her expectation for facial hair care would be to provide it during their shower days, including their hair, nails and facial hair. The ADM stated that CNAs are responsible for facial hair care at least 3 times a week. The ADM stated that the charge nurse should monitor the shower list and ensure that facial hair care is completed. The ADM stated it could negatively affect a resident if they aren't offered to be shaved by the feeling of embarrassment if they had known there was facial hair. The ADM stated that it could result in seclusion ultimately.Record review of facility in-service education for ADL documentation, dated 06/18/2025, reflected to have been provided and completed by nursing staff, and not by CNA A and LVN B. ADL documentation in-service stated it was mandatory to be completed by staff by end of shift. Record review of facility in-service education for neglect, dated 12/02/2025, reflected to have been provided and completed by nursing staff, including CNA A and LVN B. The neglect in-service stated failure to provide necessary care, or services to avoid physical harm, pain, mental anguish, or emotional distress. The neglect in-service stated examples included failing to provide hygiene. Record review of Resident #113 point click care files, dated 01/23/2026, reflected there was no ADL documentation for fingernail trimming for the past three months in the ADL tasks checklist. Record review of Resident #113's nursing progress notes file, dated 01/23/2026, reflected no documentation of Resident #113 receiving ADL care for fingernail trimming in the past three months. Record review of ADLs supporting policy, dated 03/2018, reflected residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical conditions) demonstrate that diminishing ADLs are unavoidable. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the residents and in accordance with the care plan, including appropriate support and assistance with hygiene.

Based on observation, interview, and record review, the facility failed to ensure that each resident has the right to secure and confidential personal and medical records for 1 of 15 residents (Resident #87) reviewed for Privacy and Confidentiality. The facility failed to ensure Resident #87's clinical records were protected from being viewed by unauthorized persons when LVN J left Resident #87's personal information visible on the computer's screen on unattended medication cart. This failure could place residents' personal information at risk of being exposed to unauthorized individuals. Findings included:Observation on 1/21/2026 at 4:24 p.m., revealed the computer screen on LVN J's medication cart on side C was open and unlocked, with Resident #87's MAR information displayed and visible to unauthorized individuals, including visitors or other residents not observed at that time near that cart.During an interview on 1/21/2026 at 4:26 p.m., with LVN J, she stated she was in-serviced on HIPAA a few months ago via computer module which included instructions on not discussing residents' private clinical information with unauthorized individuals and locking the computer screen when stepping away from the medication cart. She stated everybody who worked with charting computers was responsible for closing and locking them when not in attendance. She stated that leaving the screen unlocked with resident's clinical information displayed could be harmful for residents as anybody could see it. She stated she was at fault for not locking the computer.Record review of Resident's #87's face sheet, date 1/22/2026, revealed a [AGE] year-old female, admitted on [DATE]. Resident #87 had diagnoses which included hemiplegia affecting right dominant side (the paralysis of one side of the body), type 2 diabetes mellitus (a chronic condition causing high blood sugar due to insulin resistance and insufficient insulin production), and aphasia followed cerebral infarction (an acquired language disorder resulting from damage to brain areas responsible for speech).During an interview on 1/23/2026 at 12:05 p.m., with the ADON, she stated that nursing staff in this facility had HIPAA training annually and the facility's policy was not sharing the residents' information with unauthorized people and locking computers' screens when not in front of them. She stated that if the screen was not minimized, somebody could falsify information or use it inappropriately and harm residents.During an interview on 1/23/2026 at 12:11 p.m., with the DON, she stated the facility's policy was to minimize the charting computers' screens when stepping away. She stated that if the screen was not minimized, someone could have unauthorized access to private clinical information displayed on the screen. She stated HIPAA in-services were provided to all employees at hire and annually through computer modules which included instructions on locking the computer screens. She stated that she had the HIPAA in-service in January 2025. She stated the person who worked with residents' private clinical information should lock the screen before walking away. She stated the potential negative effect was unauthorized disclosure of residents' confidential information.During an interview on 1/23/2026 at 12:21 p.m., with the ADM, she stated she had HIPAA training sometimes within the last year which covered the importance of maintaining the residents' private information. She stated whoever used the computer was responsible for shutting it down to ensure the residents' information was not visible to visitors. She stated the potential risk for not shutting down the charting computers was a breach of residents' privacy. She stated that all staff completed HIPAA in-services at hire and annually through computer modules. She stated LVN J completed her annual training but could not provide documentation.Record review of facility's HIPAA in-services for the last six months dated 06/2025-12/2025, did not reveal HIPAA in-services completed by LVN J and documented before this incident.Record review of facility's HIPAA policy and staff education curriculum HIPAA and You, undated, revealed, HIPAA's Privacy Rule - Administrative Safeguards:Policies - Must be in place to safeguard information.Environment - Must be structured in a way that PHI is not easily accessible.Example of Inappropriate Uses of PHI: unattended workstation with PHI.Protecting Patient Privacy - Electronic Devices:- Log off or lock your computer if you walk away.

Based on interviews and record review, the facility failed to ensure residents had the right to be free of misappropriation of resident property and exploitation for 1 of 2 residents (Resident #1) reviewed for misappropriation and exploitation.The facility did not prevent misappropriation when on 11/04/2025 CNA A accessed Resident #1's personal cell phone and used Resident # 1's mobile cash application to transfer amounts of $ 31.00 and $50.00 to herself. This failure could place residents at risk of misappropriation of money, possessions, and feelings of loss.Record review of the facility provider investigation report written by the facility ADM, dated 11/05/2025, reflected: Resident #1 was a [AGE] year-old woman who resided at the facility for Rehabilitation care services. Resident # 1 reached out to facility letting the facility know that Resident #1's cell phone cash application was used to make payments to CNA A on 11/04/2025 at 7:15 PM. The facility started an investigation of the incident and filed a police report with The Round Rock Police. Photos were obtained from Resident # 1's phone and cash application supporting 2 transactions made by the night CNA A. The facility suspended CNA A on 11/5/2025 and terminated CNA A on 11/6/2025. Record review of Resident #1's MDS assessment dated [DATE] revealed she scored a 15 on her mental status exam (indicating an intact cognitive response) and she has a normal cognitive functioning and requires minimal support. Resident # 1 required helper assist only prior to or following activities. Record review of Resident #1's chart revealed Resident #1 admitted on [DATE] was a [AGE] year-old female with diagnosis which include: GENERALIZED ANXIETY DISORDER, ESSENTIAL (PRIMARY) HYPERTENSION (High Blood Pressure and PAIN IN LEFT SHOULDER. Resident was discharged from the facility on 11/09/2025.During an interview on 11/19/2025 @ 3:03 PM, CNA B stated, she has worked at this facility for almost 1 year and has received annual training regarding Abuse, Neglect, Exploitation and Misappropriation of funds. CNA B understands from her training that she is to immediately report if she suspects Abuse, Neglect, Exploitation or Misappropriation of funds. CNA B stated, on the morning of 11/05/2025, she was walking in the hallway pushing another resident when she heard Resident # 1 call out her name. Resident #1 said to her, the Night CNA had stolen money from me. CNA B left the room and started toward the Administrators office when she ran into the Social Worker. She reported the incident to the Social Worker and 15 minutes later confirmed that the Administrator was in Resident # 1's room and they were discussing the resident's reported loss. CNA B stated, Resident # 1 appeared upset due to this incident. During an interview with the Social Worker on 11/19/2025 @ 2:35 PM, she stated she has worked at this facility since July of 2023, and she has had training annually and periodically on Misappropriation of funds. She has also been trained in resident rights which include residents be treated with dignity, respect and to have privacy and a safe environment to live in. The Social Worker stated, a CNA told her that Resident #1 said, CNA A, from the night shift had transferred money to her own account from Resident # 1's mobile phone. The Social Worker stated that she interviewed Resident #1, and she told her she was looking at her cash application and CNA A from the night shift had borrowed her phone and transferred money to herself from her cash application. She stated she went to the Administrator as she was the Abuse Coordinator and reported the incident, and they began gathering information and evidence. She stated, the Police were notified. She stated, we do our due diligence to prevent this from happening and I know that background checks are run on every employee prior to employment. During an interview on 11/19/2025 @ 9:39 AM and a second interview at 2:19 PM, the HR stated, CNA A's employment was terminated on 11/06/2025 after the facility completed this investigation. She also stated that a police report had been filed, CNA A's pre-hire background check came back clear, CNA's references had been checked with positive results and Nurse's Aide registry confirmed licensing was current and it expires in 2026. The HR stated she did not make a referral to the licensing board regarding CNA A license as she was waiting for the state to decide. The HR stated this resident has been discharged from the facility as insurance funds no longer pay for rehabilitation for this resident. T During an interview on 11/19/2025 at 8:55 AM, the ADM stated that it was determined that CNA A had used the resident's mobile phone to access the residents' cash application and she subsequently made payments to herself. The ADM stated she carried out an investigation in which she obtained photos of the cash application transfers. CNA A was put on suspension on 11/5/2025 and she was terminated on 11/06/2025. The ADM stated she did not submit a referral to the licensing board for employee CNA A as she believed the state was going to submit a referral. The ADM stated the staff did have in-service training regarding misappropriation on the following days. The ADM stated she had contacted all 3 of Resident # 1's family members including the Responsible Party on 11/05/2025. In an interview on 11/05/2025 at 4:52 PM with Resident# 1's RP, it was revealed that he and his family members were notified on 11/05/2025 by the facility's ADM of an investigation regarding an incident of Misappropriation of funds. The RP confirmed that Resident # 1 had been at the facility due to some recent health issues and Resident # 1 has been discharged and she has returned to her home. Interview on 11/20/2025 at 7:01 AM, PD Officer #1 confirmed this incident was reported to the police department by the ADM. He confirmed the case number and stated his investigation and charges were ongoing. In an interview on 11/19/2025 at 4:00 CNA A stated, I don't have any cash apps and I did not take funds from that person. CNA A stated, she did not have any contact with the police about this incident and later, CNA A said she had been interviewed by the police. Record review of facility in-service training dated 11/05/2025 after the incident reflected that all staff had been trained on abuse, neglect, and misappropriation after this incident occurred. Record review of facility policy titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated revised 09/2022, reflected, The administrator or the individual making the allegations immediately reports his or her suspicion to the following persons or agencies:A. The state licensing/certification agency responsible for surveying/ licensing the facility.B. Local / State ombudsmanC. The resident's representative E. Law enforcement officesAnd corrective actions are to be taken including:All relevant professional and licensing boards are notified when an employee is found to have committed abuse

Based on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for three (Resident #1, Resident #2, and Resident #17) of 18 residents reviewed for resident call system in that: The facility failed to ensure call lights were within reach for Resident #1, Resident#2, and Resident #17.This failure could have placed residents at risk of being unable to obtain assistance when needed Findings included:Record review of Resident#1's admission Record updated 7/9/25 revealed, Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. She had diagnosis of nontraumatic intracerebral hemorrhage (stroke), acute respiratory failure (difficulty breathing), dysphagia following cerebral infarction (difficulty swallowing after stroke).Record review of Resident#1's care plan updated 7/8/25 revealed, Problem: The resident has an ADL self-care performance deficit r/t CVA with hemiplegia of left side and weakness. Intervention revealed Resident #1 required 1 person assist with bathing, dressing, bed repositioning, and eating.Record review of Resident#1's MDS dated [DATE] revealed, Resident #1 was dependent on oral hygiene, toileting, upper and lower body dressing, and putting on/off footwear.In an observation and interview on 7/8/25 at 12:02 pm Resident #1 revealed she did not know where the call light was. She was looking on the wall but the plug for the call light was behind her head on her left side. She reached for the wall but was unable to locate the call light on her own. The call light itself was observed on the floor under her bed. She further stated when she needed assistance she yells out for help because she did not know where the call light was located. She stated last night she yelled for help for a long time before someone finally came to assist her.In an interview on 7/8/25 at 2:08 PM the DON stated the facility does not have a policy regarding call lights.Record review of Resident#2's admission Record updated 6/6/25 revealed, Resident #2 was a [AGE] year-old female with a diagnosis of unspecified dementia (memory loss); essential hypertension (elevated blood pressure); sarcopenia (age related muscle loss).Record review of Resident#2's care plan updated 7/8/25 revealed, Intervention for fall risk; Be sure Resident#2's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Intervention for ADL self-care encourage Resident #2 to use bell to call for assistance.Record review of Resident#2's MDS dated [DATE] revealed, supervision or touching assistance for transfers and not applicable or not attempted for walking 10 feet.In an observation 7/8/25 at 3:25 pm Resident #2 the call light was on the floor behind the bed where Resident #2 could not locate without assistance. In an interview on 7/8/25 at 3:25 pm Resident #2 said the staff always put the call light where she cannot reach it. She said she has asked them multiple times to leave it where she can push it when she needs help, but they never do as she asked.Record review of Resident#17's admission Record updated 7/9/25 revealed, Resident #17 was an [AGE] year-old female with diagnosis of unspecified dementia (memory loss) hyperlipidemia (elevated cholesterol), essential tremor (rhythmic shaking)Record review of Resident#17's care plan updated 7/8/25 revealed, an ADL self-care performance.deficit r/t dementia, parkinsonism, tremors, gait with Intervention: Encourage the resident to use bell to call for assistance. High risk for falls intervention; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.In an observation 7/9/25 at 10:10 am Resident #17 the call light was on the floor behind the bed where Resident #17 could not locate without assistance. In an observation on 7/9/25 at 10:17 am RN A came into Resident #17's room. RN A located the call button tangled up off the left-hand side of bed, not within reach of resident. RN A untangled the call button. In an interview on 7/9/25 at 3:54 pm ADON stated the expectation for a call light is that a call light should be placed where a resident can reach the button in case care is needed. The ADON stated it is all staff's responsibility to place call light within resident's reach. The ADON stated if a call light is not within reach, then a resident would have to yell out if they can, to notify staff care is needed, but staff should be verifying call light placement prior to leaving the room.In an interview on 7/9/25 at 4:05 pm RN B stated the expectation for a call light is that a call light should be placed where a resident can reach the button in case care is needed. RN B stated it is all staff's responsibility to place call light within resident's reach. RN B stated if a call light is not within reach, then a resident would have to yell out if they can, to notify staff care is needed, but staff should be verifying call light placement prior to leaving the room.In an interview on 7/9/25 at 4:15 pm CNA C stated the expectation for a call light is that a call light should be placed where a resident can reach the button in case care is always needed. CNA C stated it is all staff's responsibility to place call light within resident's reach. CNA C stated if a call light is not within reach, then a resident would have to yell out if they can, to notify staff care is needed, but staff should be verifying call light placement prior to leaving the room.In an interview on 7/9/25 at 4:25pm the DON stated the expectation for a call light is that a call light should be placed where a resident can reach the button in case care is needed. The DON stated it is all staff responsibility to place call light within resident's reach. The DON stated if a call light is not within reach, then a resident would have to yell out if they can, to notify staff care is needed. The DON stated there is not a facility policy or procedure regarding call lights.Record review of Resident#17's MDS dated [DATE] revealed, Resident #17 required extensive assistance with bed mobility, transfers, and toilet use.

Based on observation, interview, and record review the facility failed to ensure maintain medical records on each resident that are- Complete and accurately documented, for 3 (Resident #1, Resident #9, and Resident #10) of 5 residents reviewed for assessments in that: -The facility did not ensure Resident #1, Resident #9, and Resident #10's wound assessments accurately reflected current wound locations, measurements, or wound typeThis failure could place residents needing wound care at risk of not receiving proper care, treatments, and interventions.Findings included:Record review of Resident#1's admission Record updated 7/9/25 revealed, Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. She had diagnosis of nontraumatic intracerebral hemorrhage (stroke), acute respiratory failure (difficulty breathing), dysphagia following cerebral infarction (difficulty swallowing after stroke).Record review of Resident#1's care plan updated 7/8/25 revealed, IN INTERVENTION: The resident requires SKIN inspection per facility protocol. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse.Record review of Resident#1's MDS dated [DATE] revealed, Resident #1 has a stage 2 pressure ulcer that was present upon admission. Resident#1 is receiving Ulcer/Injury treatment: pressure reducing device for bed; pressure ulcer/injury care; applications of ointments/medications.Record review of Weekly Skin Observation dated 6/11/25 for Resident#1 revealed, Location 14 abdomen, peg tube site; location 38 left knee (front) scar; location 53 Sacrum, Pressure, Measurements 1x0.5x0.1, Stage II; Other IC/Sub q/implanted port; neck trach removed 0.5x0.4x0.1.Record review of Weekly Wound Progress dated 6/12/25 for Resident#1 revealed, Wound#1 Pressure ulcer to Sacrum 100% Epithelial, Stage II to Sacrum measuring 1x0.5x0.1.Record review of Weekly Skin Observation dated 6/18/25 for Resident#1 revealed, location 14 abdomen peg tube; location 31 right buttock pressure depth 0; location 34 left thigh (front) blister; Anterior neck surgical incision.Record review of Weekly Wound Progress dated 6/19/25 for Resident#1 revealed, pressure ulcer 100% epithelial, stage II, sacrum, 1x0.5x0.Record review of Weekly Skin Observation dated 6/25/25 for Resident#1 revealed, document is marked yes for Does resident have any observed skin issues? The rest of the document is blank.Record review of Weekly Wound Progress dated 6/26/25 for Resident#1 revealed, pressure ulcer 100% epithelial, stage II, sacrum, 2x2x0.Record review of Weekly Skin Observation dated 7/2/25 for Resident#1 revealed, document is marked yes for Does resident have any observed skin issues? Then in notes it stated, wound to sacrum area.Record review of Weekly Wound Progress dated 7/3/25 for Resident#1 revealed, pressure ulcer 50% granulation 50% epithelial, stage II, sacrum, 2x2x0.Record review of Resident#9's admission Record updated 7/9/25 revealed, Resident #9 was a [AGE] year old male with HEMIPLEGIA (complete or severe paralysis to one side of the body) AND HEMIPARESIS (weakness on one side) FOLLOWING CEREBRAL INFARCTION affecting the right dominant side; Hepatic encephalopathy (serious brain condition caused by liver dysfunction, leading to the accumulation of toxins in the blood that affect brain function.).Record review of Resident#9's care plan updated 4/18/25 revealed, Weekly skin assessments started 12/9/21. Monitor/document/report PRN: Edema (swelling caused by too much fluid trapped in skin tissue), Bruising/discoloration of skin. Provide skin care to keep clean and prevent skin breakdown.Record review of Resident#9's MDS updated 5/13/25 revealed, Skin and Ulcer/Injury Treatments: Pressure reducing device for bed; Applications of ointments/medications other than to feet; Application of dressings to feet (with or without topical medications).Record review of Weekly Skin Observation dated 6/16/25 for Resident#9 revealed, wound to left heel (location 50), pressure without measurements; left shin open area without location # or measurements; left forearm skin tear without location # or measurements.Record review of Weekly Wound Progress dated 6/19/25 for Resident#9 revealed, 1 wound to Sacrum with measurements 4.5 X 4 X 0.1 with 100% granulation for deep tissue wound.Record review of Weekly Skin Observation dated 6/23/25 for Resident#9 revealed, under notes section left heel wound, scabs to BLE (bilateral lower extremities), skin tear both arms. There was no site location # or measurements. Record review of Weekly Wound Progress dated 6/26/25 for Resident#9 revealed 1 wound pressure ulcer to Sacrum with measurements 4 X 2.8 X 0.1 with 100% granulation for deep tissue wound. Record review of Weekly Skin Observation dated 6/30/25 for Resident#9 revealed, under notes section left heel wound, scabs on BLE (bilateral lower extremities), scabs on arms.Record review of Weekly Wound Progress dated 7/3/25 for Resident#9 revealed, 1 wound pressure ulcer to Sacrum with measurements 3.5 X 2.5 X 0.1 with 100% granulation for stage II ulcer.Record review of Weekly Skin Observation dated 7/7/25 for Resident#9 revealed, under notes section wound to left heel.Record review of Skin Monitoring: comprehensive CNA shower review dated 7/8/25 for Resident#9 revealed, a diagram of the back of the body with a circle to the left arm stating, scabbed 1,2 and the left heel circled stating pressure.Record review of Resident#10's admission Record updated 7/9/25 revealed Resident #10 was a [AGE] year-old male with VASCULAR DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE (memory loss), hyperlipidemia (elevated cholesterol), type 2 diabetes mellitus (frequently elevated blood sugar).Record review of Resident#10's care plan updated 1/7/25 revealed, Intervention: skin care to keep clean and prevent skin breakdown; Monitor/document/report PRN any s/sx (signs and symptoms) of poor wound healing; Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: Inform the resident/family/caregivers of any new area of skin breakdown. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size (length X width X depth), stage. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Monitor skin rashes for increased spread or signs of infection.Record review of Resident#10's MDS updated 7/8/25 revealed, Resident #10 Skin Conditions included: Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Formal assessment instrument/tool (e.g., Braden, [NAME], or other). Clinical assessment. Resident #10 had 1 Stage 2 pressure ulcers: 1 Stage 3 pressure ulcers. Other problems: Skin tears. Skin and Ulcer/injury treatments: Pressure reducing device for bed, Nutrition, or hydration intervention to manage skin problems, Pressure ulcer/injury care, Application of nonsurgical dressings (with or without topical medications) other than to feet, Applications of ointments/medications other than to feet.Record review of Weekly Skin Observation dated 6/12/25 for Resident#10 revealed, location 13 vertebrae (upper-mid) shear; location 26 left trochanter (hip) pressure wound; location 53 Sacrum pressure wound. Notes: LAL mattress in place, treatment in place for wounds.Record review of Weekly Wound Progress dated 6/12/25 for Resident#10 revealed, wound #1; pressure ulcer left hip 100% granulation, Stage 2, minimal exudate measurements 2.5x2.5x0.1. Wound #2: sacrum 50% granulation 50% slough, Stage 3 minimal exudate, measurements 4x2.5x0.1. Wound #3 abrasion upper back left side 100! Granulation 2x2x0.1 scant red exudate.Record review of Weekly Skin Observation dated 6/19/25 for Resident#10 revealed, observed skin issue at site #53 sacrum pressure; left hip pressure.Record review of Weekly Skin Observation dated 6/26/25 for Resident#10 revealed, location 13 vertebrae (upper-mid) pressure wound; location 26 left trochanter (hip) pressure wound; location 53 Sacrum pressure wound. Notes: Tx in progress LAL mattress . improvement to areas noted.Record review of Weekly Wound Progress dated 6/26/25 for Resident#10 revealed, wound #1; pressure ulcer left hip 50% epithelial 50% granulation, Stage 2, scant tan exudate measurements 2x0.5x0.1. Wound #2: sacrum 50% granulation 50% slough, Stage 3 minimal exudate, measurements 4x2.5x0.1. Wound #3 abrasion upper back left side 100! Granulation 2x2x0.1 Record review of Weekly Wound Progress dated 7/3/25 for Resident#10 revealed,Wound #1; pressure ulcer left hip 100% epithelial, Stage 2, scant red exudate measurements 2x2x0.1. Wound #2: sacrum 25% granulation 75% slough, Stage 3 moderate exudate, measurements 2x0.9x0.1. Record review of Weekly Skin Observation dated 7/7/25 for Resident#10 revealed, location 26 left trochanter (hip) pressure wound; location 53 Sacrum pressure wound. Notes: Tx in progress see wound care notes. improvement noted. In an interview on 7/9/25 at 3:54 pm the ADON revealed skin assessments are completed weekly by the charge nurses and the CNAs do a shower sheet with any abnormalities. The ADON stated anytime on an assessment where a body is seen the nurse is to indicate location with the number on the picture. Then under notes if you need to add more information you would use the notes section. The ADON stated when documenting any observed skin issues the nurse should document anything noted on the skin during an assessment. The ADON stated if a skin issue is documented on one skin assessment it should be documented on the following skin assessment. The ADON stated if a previous listed skin issue has healed it should be indicated on the notes section or in a progress note when care was discontinued. If documentation of wounds did not make it to the new assessment it could lead to the wound getting worse. In an interview on 7/9/25 at 4:05 pm RN B revealed she had been one of the nurses that documented the skin assessments on Resident #1, Resident #9, and Resident #10's wound assessments. She said skin assessments are completed weekly by the charge nurses and the CNAs do a shower sheet with any abnormalities. RN B stated anytime on an assessment where a body is seen the nurse is to indicate location with the number on the picture. RN B stated when documenting any observed skin issues the nurse should document anything noted on the skin during an assessment. RN B stated if a skin issue was documented on one skin assessment it should be documented on the following skin assessment. RN B stated if a previous listed skin issue has healed it should be indicated on the notes section or in a progress note when care was discontinued. RN B said the diagram of the body did not mark every part of the body and that measurements were not always documented on those forms even though they should have been. In an interview on 7/9/25 at 4:15 pm CNA C revealed she does a skin assessment every day because she knows what she saw the day before. CNA C stated anytime on an assessment where a body is seen the CNA is to indicate location with the number on the picture. CNA C stated when documenting any observed skin issues the nurse should document anything noted on the skin during an assessment. CNA C stated if a skin issue is documented on one skin assessment it should be documented on the following skin assessment. CNA C stated if a previous listed skin issue has healed it should be indicated on the notes section or in a progress note when care was discontinued. In an interview on 7/9/25 at 4:25pm the DON revealed skin assessments are completed weekly by nurses. The DON stated anytime on an assessment where a body is seen the nurse is to indicate location with the number on the picture. The DON stated when documenting any observed skin issues the nurse should document anything noted on the skin during an assessment. The DON stated if a skin issue is documented on one skin assessment it should be documented on the following skin assessment. The DON stated if a previous listed skin issue has healed it should be indicated on the notes section or in a progress note when care was discontinued. The DON stated there is not a policy or procedure related to skin assessments. She said if a wound goes without being documented correctly it could lead to a wound getting worse.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 18 residents (Resident#1, Resident #3, and Resident #4) reviewed for dignity. The facility failed to ensure catheter bag was covered and not visible Resident#1, Resident #3, and Resident #4. This failure placed residents at risk of embarrassment and diminished quality of life. Findings included: Record review of Resident#1's admission Record updated 7/9/25 revealed, Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. She had diagnosis of nontraumatic intracerebral hemorrhage (stroke), acute respiratory failure (difficulty breathing), dysphagia following cerebral infarction (difficulty swallowing after stroke).Record review of Resident#1's care plan updated 7/8/25 revealed, IN INTERVENTION: The resident requires SKIN inspection per facility protocol. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Record review of Resident#1's MDS dated [DATE] revealed, Resident #1 has a stage 2 pressure ulcer that was present upon admission. Resident#1 is receiving Ulcer/Injury treatment: pressure reducing device for bed; pressure ulcer/injury care; applications of ointments/medications.[JM1] In an observation 7/8/25 at 12:02 pm Resident #1 revealed her catheter bag was half full of a pale-yellow liquid visible from the hallway. There was not a cover on the catheter bag to disguise or cover the fact Resident #1 had a catheter bag. In an interview 7/8/25 at 12:02 pm Resident #1 revealed she has no modesty or dignity while at the facility. She said the staff does not care about her, they show no empathy, treat her like a child or like she is not even human. She said she did not know why she had a catheter because she could go to the restroom with assistance. Resident #1 said she was a nurse for many years, and she knows when things are wrong. Record review of Resident#3's admission Record updated 7/9/25 revealed, Resident #3 was an [AGE] year-old female with a diagnosis of Type II Diabetes (elevated blood sugar), Chronic Kidney Disease, Stage 3, and Pain in unspecified toes. Record review of Resident#3's care plan updated 7/8/25 revealed, Problem #1 The resident has an arterial ulcer to right heel. Intervention 1: Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated. Intervention 2: Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Problem #2: The resident has potential/actual impairment to skin integrity r/t immobility, foley catheter, history of wounds and bowel incontinence. Intervention#1: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration etc. to MD. Intervention #2 Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Problem #3: The resident has an ADL self-care performance deficit r/t had surgical procedure of right hip, previous right shoulder replacement, chronic pain, OA of right shoulder, and weakness. Intervention: SKIN INSPECTION: The resident requires SKIN inspection per facility protocol Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Record review of Resident#3's MDS dated [DATE] revealed, Section M- Skin Conditions revealed, Determination of Pressure Ulcer/Injury risk Formal assessment instrument/tool and Clinical Assessment. Yes, this resident is at risk of developing pressure ulcers/injuries. No, this resident does not have one or more unhealed pressure ulcers/injuries. Other Ulcers, Wounds, and Skin Problems: E: surgical wounds Skin and Ulcer/injury treatments: E: Pressure ulcer/injury care; F: Surgical wound care; H: Applications of ointments/medications. In an observation 7/8/25 at 3:17 pm Resident #3's catheter bag was half full of a pale-yellow liquid visible from the hallway. There was not a cover on the catheter bag to disguise or cover the fact Resident #3 had a catheter bag. In an interview on 7/9/25 at 3:54PM the ADON revealed a catheter bag should have a cover over it or not be visible to the public. They should have privacy bags/covers. The ADON said it is the CNA and nurses' responsibility to ensure all catheter bags are covered. The ADON stated it is the responsibility of all staff members to ensure each resident's dignity is intact to prevent embarrassment or quality of life. Record review of Resident#4's admission Record updated 7/9/25 revealed, Resident #4 was an [AGE] year-old male with no listed diagnosis. Record review of Resident#4's care plan updated 7/8/25 revealed, Problem: The resident has potential/actual impairment to skin integrity of the (specify location) r/t. Intervention: Educate Resident/family/caregivers of causative factors and measures to prevent skin injury. Record review of Resident#4's MDS dated [DATE] revealed, No mention of any skin related problems. In an observation 7/8/25 at 3:15 pm Resident #4's catheter bag was half full of a pale-yellow liquid visible from the hallway. The bag did not have a cover to disguise and prevent any dignity issues for Resident #4. In an interview on 7/9/25 at 4:05 PM RN B revealed a catheter bag should have a cover over it or not be visible to the public. They should have privacy bags/covers. RN B said it is the CNA and nurses' responsibility to ensure all catheter bags are covered. RN B stated it is the responsibility of all staff members to ensure each resident's dignity is intact to prevent embarrassment or quality of life. n an interview on 7/9/25 at 4:15 PM CNA C revealed a catheter bag should have a cover over it or not be visible to the public. They should have privacy bags/covers. CNA C said it is the CNA and nurses' responsibility to ensure all catheter bags are covered. CNA C stated it is the responsibility of all staff members to ensure each resident's dignity is intact to prevent embarrassment or quality of life. In an interview on 7/9/25 at 4:25PM The DON revealed a catheter bag should have a cover over it or not be visible to the public. DON said it is all staff's responsibility to ensure all catheter bags are covered. The DON stated it is the responsibility of all staff members to ensure each resident's dignity is intact to prevent embarrassment or quality of life. The DON stated the facility did not have a policy regarding privacy bags to disguise/cover catheter bags.

Based on observation, interview and record review the facility failed to ensure the resident 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 2 of 16 (Resident #1 and Resident #2) residents reviewed for accommodation of needs. 1. The facility failed to provide a working communication system, which was easily at reach at the bedside, which would allow Resident #1 to call for assistance. From 06/10/25 until 06/18/25, Resident #1 did not have a working communication system in her room. 2. The facility failed to provide a working communication system for Resident #2 on 06/18/25 when her call light was broken. These failures could place residents at risk of not having a means of directly contacting caregivers in an emergency, a delay in assistance, a decreased quality of life and a loss of dignity. Findings included: 1. Record review of Resident #1's face sheet, printed on 06/18/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included nontraumatic intracerebral hemorrhage (stroke) and acute respiratory failure with hypoxia (lungs not functioning properly lead to low oxygen levels). Record review of Resident #1's admission MDS assessment, dated 06/12/25, was In Progress. Record review of Resident #1's care plan, initiated on 06/11/25, reflected the resident had an ADL self-care performance deficit. The goal was to maintain current level of functioning. Interventions included total assistance by staff for bathing, bed mobility, dressing, eating, and personal hygiene. The care plan reflected the resident had a communication problem. The goal was to make basic needs known on a daily basis. Interventions included anticipate and meet needs and speak on an adult level. The care plan did not address a call light. Record review of Resident #1's progress note, dated 06/16/25 at 9:01 AM, written by the APRN, reflected in part the resident had expressive dysphasia (difficulty speaking), hemiplegia (paralysis on one side of the body) of left nondominant side, and required a g-tube (a surgically placed tube into the stomach) for medications and nutrition. An observation on 06/18/25 at 9:04 AM, revealed there was no call light or bell in Resident #1's room. Resident #1 was not in the room. During an interview on 06/18/25 at 10:00 AM, the DON stated if a call light was not working, maintenance was notified. The DON stated they had bells that were used if the call light was not working. She stated they used an electronic program for submitting maintenance requests. She stated the maintenance request system was linked to their electronic medical record system, so everyone had access to submit requests. The DON stated they did not have a Policy & Procedure for call lights or maintenance requests . During an observation and attempted interview on 06/18/25 at 10:59 AM, revealed Resident #1 was lying in bed with the head of the bed elevated. A visitor was at the bedside. Resident #1, spoke just above a whisper, was able to state she was comfortable, but not able to say how she contacted staff for assistance. During an interview on 06/18/25 at 11:00 AM, the visitor in the room stated she had not seen a call light in Resident #1's room on previous visits, and she had visited a few times. During a telephone interview on 06/18/25 at 12:30 PM, a FM stated there had not been a call light in the room when she visited Resident #1 on 06/15/25. During an interview on 06/18/25 at 11:03, LVN A stated there had not been a call light in Resident #1's room since the resident moved into the room on 06/10/25. LVN A stated a maintenance request for a call light was placed on 06/10/25 . She stated she would round more frequently on residents if they did not have a call light in the room to ensure their needs were met. She stated without a call light, residents needs or requests may not be met. During an interview on 06/18/25 at 11:13 AM, the DOM stated he had not received a maintenance request for a call light in Resident #1's room until 06/18/25. He stated he was not aware there was not a call light in the room. The DOM stated he had just received the requests for Resident #1 and Resident #2s call lights. During an interview on 06/18/25 at 11:17 AM , CNA B, stated she worked through and agency and was at the facility two or three times a week. She stated Resident #1 and Resident #2 were both on the hall where she was assigned to work. She stated as far as she knew, Resident #1 had a call light in her room. She stated a nurse had been working with the resident earlier, so she had not provided care to the resident yet. She stated she did not know Resident #2's call light was not working. She stated she made rounds on her residents every two hours. She stated without a call light, the residents would not be able to call for assistance to have their needs met. 2. Record review of Resident #2's face sheet, printed on 06/18/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included unspecified cerebral infarction (stroke), type 2 diabetes (a condition that affects the way the body processes blood sugar), arthritis (swelling and tenderness of the joints), and dementia . Record review of Resident #2's quarterly MDS assessment, dated 05/18/25, reflected a BIMS score of 3, which indicated severely impaired cognition. Record review of Resident #2's care plan, revised 06/06/25, reflected Resident #2 was at risk for falls related to debility with a goal the resident would remain free of falls. Interventions included the call light within reach and encourage the resident to use it for assistance as needed and, The resident needs prompt response to all requests for assistance. An observation on 06/18/25 at 9:14 AM revealed Resident #2 lying in bed with her eyes closed. The head of the bed was elevated. The resident's call light button cord was wrapped around the side rail on the left side of the resident's bed. The end of the call light cord was observed on the floor under the head of the bed. The call light was not plugged into the receptacle on the wall. A connector was plugged into the wall receptacle . During an observation and interview on 06/18/25 at 11:06 AM, LVN A entered Resident #2's room. LVN A told Resident #2 she was going to test the call light. LVN A pushed the button on the call light, but the light did not activate. LVN A looked under the bed and stated, It must have broken. She stated she did not know how long the call light had not been working. She stated Resident #2 used her call light frequently. Resident #2 stated the staff usually answered her light promptly. Resident #2 did not remember the last time she used her call light. During an interview on 06/18/25 at 12:23 PM, the DON stated she did not know how long Resident #1 had been without a call light in the room. She stated it did not meet her expectation that there was not a call light or a bell in the room. She stated if there was not a functioning call light, residents would not be able to notify staff when they needed help. The DON stated she did not know how long Resident #2's call light had been broken. She stated sometimes the cords got caught and broke when the bed positions were adjusted so they always kept extra call lights in stock . During an interview on 06/18/25 at 1:04 PM, the ADM stated it was her expectation every room had a functioning call light. She stated Resident #1 was close to the nursing station and observed frequently. The ADM stated without a functioning call light, residents were not able to let staff know if they needed something. Record review of the facility's Resident Rights Policy, revised December 2016, reflected in part, .f. communication with and access to people and services, both inside and outside the facility

Based on observations, interviews, and record reviews, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to label and date all food items located in the reach-in refrigerator, walk-in refrigerator, and walk-in freezer on [DATE], [DATE], and [DATE]. 2. The facility failed to effectively reseal all food items in the walk-in refrigerator and walk-in freezer to prevent contamination or spoilage on [DATE], [DATE], and [DATE]. 3. The facility failed to dispose of expired foods items located in the walk-in refrigerator. 4. The facility failed to clean the ice machines properly resulting in the presence of slime and an unidentified black substance build up in the ice machines on [DATE] and [DATE]. 5. The facility failed to ensure kitchen staff held cold foods (fortified vanilla pudding and fruit cups) at a temperature of 41 degrees Fahrenheit or less on [DATE]. 6. The facility failed to ensure Resident #38, and Resident #84 were free from potentially hazardous food when they were served vanilla pudding at lunch on [DATE] that was held at inappropriate temperatures. 7. The facility failed to ensure one hand-washing sink in the kitchen next to the dishwasher was easily accessible when it was cluttered with two brooms, a dustpan, dishwasher rack, a meal cart with dirty trays, and the trash receptacle was blocked by a box of gloves and rolls of trash bags on top of the trash lid. 8. The facility failed to ensure the dry food pantry floor was free of dust, dirt, food particles, thick white stains, and red residue. These failures could place residents and staff at risk for health complications, food contamination, and foodborne illnesses and at risk for unsanitary conditions. Findings included: During the initial tour of the kitchen on [DATE] at 07:05 AM the following was observed: The reach-in refrigerator contained two trays of fresh cut cantaloupe and green melon cups that were not labeled or dated. One of the fruit cups was open with the lid off and not properly sealed. The walk-in freezer contained an open clear plastic bag of fried okra that was not labeled, dated nor properly sealed. The fried okra was exposed to air. A small clear plastic bag of something yellow in color was tied at the top. It was not labeled nor dated. The walk-in refrigerator contained a square clear container, with a lid, of an orange-colored gelatinous substance that was not labeled nor dated. There was also a square clear container of sliced beets. It was labeled Beets Pureed and dated [DATE]. Four trays of premade shredded cheese cups were stacked, labeled, and dated [DATE]. The ice machine was observed to have multiple white streaks and stains consisted with hard water on both exterior sides of the stainless-steel sides of the machine from the top of the door, extending all the way to the floor. The prefilter container that was on the wall next to the ice machine was clear plastic and the filter inside was green in color. The lid of the ice machine was propped open by an empty cardboard box. Observation of the inside of the ice machine revealed a black/brown substance on the inside of the chute sending ice into the ice machine storage bin. The substance resembled slime, dirt, or mildew and could be removed with a paper towel. Water drops were dropping off the soiled areas into the ice and on the surveyor's cell phone while the surveyor was taking photos. The storage bin was full of ice cubes. One hand washing sink in the dishwasher room was cluttered with two brooms, a dust pan, a dishwasher rack on the floor, a meal tray cart full of old meal trays from the previous day, chemicals hanging from the shelf above sink, a trash receptacle next to the sink with two rolls of trash bags and a box of vinyl exam gloves on top of the trash can top so that the trash can could not be opened. The dry food pantry floor was dusty, dirty, stained, and visually soiled with gum, food, and trash on the floor. There was a thick white residue on the floor in the corner with some red staining on top that appeared to be ketchup or other type of condiment. During an observation and an interview on [DATE] at 07:20 AM, CK A stated that the fresh fruit cups in the reach-in refrigerator should have been labeled and dated. CK A said he thought the fruit cups might have been prepared on [DATE], but he was not sure because the food was not dated. Observed CK A remove the fruit trays from the reach-in refrigerator and place the trays on the kitchen counter and walked away. CK A stated that bag of fried okra in the walk-in freezer should have been sealed in a zip top bag to keep the food fresh and avoid freezer burn. CK A stated the other container in the freezer was fried chicken nuggets and stated the food in the freezer should have been properly sealed, labeled, and dated to maintain freshness. CK A stated he would throw away the bag of okra and chicken nuggets because he saw freezer burn on the food. CK A stated he did not know what the container of orange stuff in the walk-in refrigerator was because it was not labeled. He stated he thought it could be cheese sauce but was not sure. CK A stated that the container labeled Beets Pureed was wrong and it was expired. Observed CK A leave the unlabeled container and the beets container in the walk-in refrigerator. CK A stated it was the facility's policy to properly store, label, and date all food and all kitchen staff shared that responsibility. CK A stated that it was important to label and date the food to ensure the food was fresh and so that kitchen staff knew what the food was. CK A stated old food could make a resident sick and it was important to serve residents fresh food. He did not know how long freshly made food could stay in the refrigerator. He said, 3 days or maybe 7 days. I'm not really sure. CK A stated he was not responsible for cleaning the ice machine. During an interview on [DATE] at 07:28 AM and 11:00 AM, the DM stated it was the facility's policy to properly seal, label, and date all food and all kitchen staff shared that responsibility and that was her expectation. The DM stated it was important to seal, label, and date the food to ensure the food was fresh. She stated that it was her expectation that kitchen staff would throw away open food or seal it in zip top baggies and label and date food that would be kept. The DM said, I'm not going to lie. Packing, labeling, and dating the food is a real problem. She stated not storing food properly could lead to cross-contamination and could result in a negative outcome to the residents that ate that food. The DM stated that they used a vendor that provided cleaning and maintenance on the ice machine, but she did not know the details. She would have to ask the maintenance worker. The DM stated kitchen staff do not clean the ice machine or change the filter. The DM stated the dietary aides were supposed to sweep and mop the dry food pantry every day. She stated that the soiled area on the floor was from preparing snacks on [DATE] and the staff did not clean the floors. The DM stated her expectations were that the kitchen floors were swept and mopped daily. She stated there was a risk of cross contamination with dirty floors. The DM stated that both she and her staff use the hand washing sink by the dishwasher. The DM stated it was her expectation that staff wash their hands when coming from the dishwasher to the kitchen as that area (by the dishwasher) was considered the dirty area. During a follow up tour of the kitchen on [DATE] at 08:04 AM the following was observed: The reach-in refrigerator contained one tray of fresh cut cantaloupe and green melon cups that was not labeled. One of the fruit cups was dated [DATE], but none of the other fruit cups were dated. Observation of the walk-in refrigerator revealed a block of margarine that was not properly sealed and open to the air. A clear plastic bag containing slices of bread in individual plastic baggies and individually packaged oatmeal cookies were not labeled nor dated. There were three trays of premade shredded cheese cups dated [DATE] with loose cheese all over the top of the tray. Observation of the walk-in freezer revealed an open bag of French fries exposed to the air, which was not labeled nor dated. The inside of the ice machine was unchanged from [DATE]. Observation revealed a black/brown substance on the inside of the chute sending ice into the ice machine storage bin. The substance resembled slime, dirt, or mildew. The prefilter container that was on the wall was green. During an interview on [DATE] at 08:27 AM and 9:43 AM, the DM stated it was the kitchen staff's responsibility to clean the outside of the ice machine. The kitchen staff had not been trained on cleaning the inside of the ice maker. The maintenance worker had a log and cleaned the inside of the ice machine. The DM said she thought it was cleaned once a month. The DM did not have a copy of that log. The Surveyor showed the DM the inside of the ice machine and the DM stated she never checked inside the ice machine to see if it was clean or not. The DM stated the area that ice cubes came from had a black/brown slime which was cross contaminating the ice and could cause foodborne illnesses in the residents that consumed the ice in their drinks. The DM stated, The residents could be sick and it's not the food, it's the ice. The DM stated the facility's policy for food storage was that freshly made food could be kept for three days before discarding and throwing it away with day 1 being the day the food was prepared. The DM stated she kept an eye on food, but all kitchen staff were responsible for checking and throwing away expired food by the use by date. The DM had trained kitchen staff on the policy. The DM stated staff were responsible for cleaning their own areas. There were two kitchen aides that were responsible for cleaning the dishwasher area. They were expected to sweep and mop the area and put away the mop, broom, and dishwasher crates. The mop, broom, and dustpan should be stored in the corner of the room, not in front of the sink. After cleaning, staff should be using that sink to wash their hands. During an observation in the kitchen on [DATE] at 11:01 AM, revealed several small plastic cups filled with puddings on trays that were stacked on the kitchen counter. Bowls of canned fruit was observed stacked on a meal cart in the kitchen. During an observation in the kitchen on [DATE] at 11:35 AM, CK A tested the temperature of the vanilla pudding cups with a pocket dial thermometer, and it displayed over 70 degrees Fahrenheit. CK A got a different thermometer that had not been used on the steam table and retested the pudding with a digital thermometer which displayed 66 degrees Fahrenheit. CK B stated CK A was doing it wrong, and it needed to be measured using Celsius. CK A rechecked the pudding for a third time with a digital thermometer which displayed 19 degrees Celsius (66.2 degrees Fahrenheit). CK A tested the temperature of the fruit cups with the same digital thermometer which displayed 44.4 degrees Fahrenheit. During an interview with the DM and CK B on [DATE] at 11:45 AM, CK B stated the vanilla pudding was made with Non-Dairy Frozen Soft Serve Mix, Pie Filling mix, and milk, and had been stored in the reach-in refrigerator. Both the DM and CK B stated that cold food should be held at 41 degrees or lower. CK B stated the fruit cups had been made up that morning, but later stated they had just been pulled out of the walk-in refrigerator. Both the DM and CK B stated their plan was to put the food back in the refrigerator, bring it down to the proper temperature of 41 degrees or lower, and serve it for lunch. The DM stated that residents could get foodborne illnesses by eating food that was not kept at the appropriate temperature. During an observation on [DATE] at 11:53 AM, the vanilla pudding was observed in a bowl of ice on the kitchen counter and in the kitchen sink. At 11:53 AM, CK B led the surveyor to the dry pantry room and showed the surveyor the two mixes used to make the pudding. Review of the Non-Dairy Frozen Soft Serve Mix instructions, reflected to mix, cover, and place in refrigerator (less than 40 degrees [Fahrenheit]). Review of the Pie Filling mix instructions revealed to mix with milk and keep at refrigerated temperatures until served. During an observation and interview on [DATE] at 12:00 PM, CK B and DM both stated they pulled the fruit cups and would serve ice cream instead. They said they would not serve the pudding. Containers of pudding were observed still on the kitchen counter. An observation of the main dining room on [DATE] at 12:01 PM, revealed the pudding had been served to two residents (Resident #38 and Resident #84). Neither one of the residents ate the pudding. Staff took the pudding away. During an observation in the kitchen on [DATE] at 12:15 PM, the surveyor observed all the pudding had been throw in the trash. The Surveyor pulled a pudding cup out of the trash, smelled it, and did not observe any foul odor. During an interview and record review on [DATE] at 03:30 PM the MAIN D. Director stated he just cleaned the inside of the ice machine located in the kitchen because the DM told him the survey team had found a concern. He stated the inside of the ice machine was covered with slime and mold. He stated he had not cleaned the inside of the ice machine in over a year since [VENDOR] was hired to provide service to the ice machine. He provided the surveyor with a copy of a contractor's invoice dated [DATE] which revealed [VENDOR] provided a repair and disassembled all parts and found a large amount of slim and mold on water trough, water pump, water curtain, and water distribution tray. Cleaned and sanitized all parts. Put machine on a cleaning cycle. The MAIN D. stated he had worked at the facility for [AGE] years and had not cleaned the ice machine in 2024 nor checked the inside of the ice machine because [VENDOR] was supposed to be cleaning it and the facility paid [VENDOR] $800 to clean the inside of the machine. He did not know what the recommended cleaning schedule was based on the manual. The Surveyor requested a copy of the vendor's contract and manufacturer's manual. The MAIN D. stated kitchen staff did not clean the inside of the ice machine. During an interview and record review on [DATE] at 03:50 PM the MAIN D. stated he was incorrect earlier as the facility did not have a contract with the vendor. He stated he called [VENDOR] to service the ice machines once a year. Again, the MAIN D. stated he had not cleaned the inside of the ice machines because they paid [VENDOR] $800 to do that. The MAIN D. stated there were two ice machines listed on the [VENDOR] invoices. He provided the surveyor with three invoices dated [DATE], [DATE], and [DATE]. The invoices had two ice machines listed and the MAIN D. stated the first ice machine was the ice machine in the chapel, but it was broken and not used. The bottom machine with the information listed about the large amount of slim and mold was the ice machine in the kitchen that he just cleaned. The MAIN D. stated he changed and put in a new filter because the old filter was dirty. He stated he oversaw checking and changing the filter. During an observation on [DATE] at 03:51 PM of the second ice machine in the chapel revealed it was in use. The inside revealed some black marks/spots that appeared to be mold or mildew. During an interview on [DATE] at 03:54 PM the AAD stated that the ice machine in the chapel was used for residents during activities or special events. During an observation and interview in the kitchen on [DATE] at 05:02 PM, revealed the reach-in refrigerator contained one tray of what appeared to be cups of vanilla pudding that was not labeled nor dated. The DM stated those were vanilla pudding cups that had been remade at lunch on [DATE]. During an interview on [DATE] at 05:02 PM, CK D stated she had received training before she started work. She was knowledgeable on the facility's policy on labeling, dating, and properly sealing and storing food. CK D stated that if she saw food that was not properly labeled, dated, or sealed, she would throw it out. CK D had knowledge of the proper temperatures for hot and cold food and said it was important to have foods stored and distributed properly to avoid possible foodborne illnesses. CK D stated she had never cleaned the ice machine. CK D stated she would mop or sweep the pantry floor occasionally if needed. During an interview on [DATE] at 08:11 AM, DA C stated she had received training before she started work. She had work at the facility for 8 years. She was knowledgeable on the facility's policy on labeling, dating, and sealing food and keeping food at the proper temperatures and stated it was important so that resident do not get sick. DA C stated she had never cleaned the inside of ice machine. She stated food could be stored for 7 days before discarding. DA C stated she washed dishes, swept, mopped, and cleaned the floors in the kitchen daily and stored the mop, broom, and dustpan in the back room. She did not clean the pantry floor. During an interview on [DATE] at 8:13 AM, CK B stated she had received training on her job duties before she started work. She stated all food must be sealed properly, labeled, and dated to know which food had to be served first. She stated it was important to label, date, and store food properly to maintained freshness and prevent cross contamination. It was important to have a clean kitchen because that is where the food was being stored and prepared. CK B stated she does not clean the inside of ice machine. CK B stated she cleaned the kitchen and the pantry floor daily. She stated it was important to have a clean kitchen because that was where the food was being stored and prepared. CK B stated not cleaning the pantry floors could cause cross contamination with the food. During an observation of the walk-in freezer on [DATE] at 8:15 AM revealed an opened bag of chicken nuggets that were not properly sealed, labeled, or dated. During a telephone interview on [DATE] at 09:40 AM the RD stated he was the licensed dietitian for the facility, and he came to the facility 3 times a month. His expectation was that foods would be dated, labeled, and properly sealed to maintain the quality and texture of the food and prevent the food from spoiling. Food not property labeled, dated, and sealed could lead to illness if the residents consumed expired or old food. The RD stated that he did an in-service training last month on proper labeling and dating of food because that had been an issue. He stated it was the DM's responsibility to ensure all food were labeled and dated. The RD stated he did look inside the ice machine during his monthly tour and was told it was cleaned on [DATE]. He stated serving residents ice from a machine that was not properly cleaned and sanitized could led to illness and would not meet his expectation. He had knowledge of proper food temperatures and did an in-service training on [DATE] about food safety and proper temperatures. The training stated that if food was not held at the proper temperature, it was recommended to throw out the food because the food was not safe to eat. The RD stated residents eating food held at improper temperatures had the potential to cause illness. During an interview on [DATE] at 12:30 PM, the ADM stated all food should be labeled and dated including dry goods, refrigerated items, and frozen food with the date packages were opened or when the food was prepared. The ADM stated that the DM and RD was responsible for monitoring food storage, labeling, and dating in the kitchen. The ADM stated all the staff knew to date and label the food, but They did not do it 100% of the time. She stated this did not meet her expectations. The ADM stated she was aware the RD had reported an issue of not labeling, dating, and properly sealing food and they had been working to resolve the issue. The ADM stated food not properly stored, labeled, and dated could cause residents to become ill due to foodborne illness and it could affect the texture or taste of the food. The ADM was knowledgeable about the proper temperature of cold foods to be held at or below 41 degrees Fahrenheit and stated it was the cooks' responsibility to monitor food temperatures on the line and the DM and the RD were also responsible for monitoring food temperatures. The ADM stated that it was the DM's responsibility to ensure the kitchen was cleaned. They have a contract with [VENDOR] and Maintenance Supervisor should ensure the ice machine was properly cleaned. The ADM stated that the ice machine was cleaned as often as it should have been and that did not meet her expectation. The ADM stated an unclean kitchen and dirty ice machine with slime and possible mildew could cause legionnaires disease and/or foodborne illness. The ADM stated the schedule for cleaning the kitchen was posted in the cleaning area in the kitchen. The ADM stated the cooks and dietary aides were responsible for cleaning the pantry floor and the DM was responsible for monitoring to ensure the kitchen was cleaned appropriately. She stated she thought the area by the hand washing sink was cluttered because staff were in a hurry. The clutter and dirty pantry floor did not meet her expectations and stated it was important to keep the kitchen clean to prevent potential illness. Record review of kitchen in-service trainings revealed on [DATE] (no year listed), staff were trained on food temperatures. The training reflected, If state comes in and ask you any questions .Cold items 40 degrees or below for milk, fruit, or anything being served as a cold item. The RD provided training on Labeling and dating on [DATE] and Keeping food safe on [DATE]. Training included, For cold foods, leave in fridge until ready to serve to maintain temperature of 40 F or below. The training also reviewed the policy Cooling and Reheating Foods approved [DATE], which stated, Leftover food much be labeled, dated, and reused within 48 hours. Record review of the facility's policy Food Storage revised [DATE] revealed: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state and US Food Codes and HACCP guidelines. Procedure: 2. Refrigerators d. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. 3. Freezers e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Record review of the indigo ice machine manual titled Installation, Operation, and Maintenance [NAME] revealed: Cleaning and Sanitizing General You are responsible for maintaining the ice machine in accordance with the instructions in this manual. Clean and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company .An extremely dirty ice machine must be taken apart for cleaning and sanitizing. Cleaning/Sanitizing Procedure This procedure must be performed a minimum of once every six months. The ice machine and bin must be disassembled cleaned and sanitized. All ice produced during the cleaning and sanitizing procedures must be discarded. Removes mineral deposits from areas or surfaces that are in direct contact with water. Preventative Maintenance Cleaning Procedure This procedure cleans all components in the water flow path and is used to clean the ice machine between the bi-yearly cleaning/ sanitizing procedure. Exterior Cleaning Clean the area around the ice machine as often as necessary to maintain cleanliness and efficient operation. Wipe surfaces with a damp cloth rinsed in water to remove dust and dirt from the outside of the ice machine . Ice machine cleaner is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime. Record review of facility's policy General Kitchen Sanitation approved [DATE] revealed: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure: 7. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. Record review of kitchen weekly cleaning schedule revealed ice machine maintenance was listed as a task on [DATE] and was not marked or initialed completed. The facility provided a logbook documentation from Direct Supply Tels regarding the ice machine maintenance. It stated Check filters (if present), clean coils, sanitize interior, delime, as necessary. Recurrence: Every 6 months. Next Due: In [DATE] Assigned to: Unassigned. Category: Ice Machines Marked done by MAIN D. on [DATE], with a note about purchasing new filter. Record review of the facility's policy Food Holding and Service revised [DATE] revealed: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be held and served according to the state and US Food Codes and HACCP guidelines. 5. Cold Food Temperatures d. Maintain all cold prepared items at a temperature of 41 F or below until ready to serve. Do not remove from refrigeration until ready to serve. Record review of facility's policy General Kitchen Sanitation approved [DATE] revealed: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure: 1. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. Record review of kitchen weekly cleaning schedule dated [DATE], through [DATE], revealed dry storage clean and organize was listed as a weekly task. On [DATE], cleaned and swept pantry. The daily cleaning schedule dated [DATE], through [DATE], listed: Floors (swept and mopped each shift) assigned to All Staff sinks (each use) clean and sanitize assigned to All Cooks food carts assigned to Aides/Prep.

Based on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 1 resident (Resident #102) reviewed for care plans. The facility failed to ensure Resident #102 had a care plan that reflected her new 7/8/24 diagnosis of unspecified convulsions (seizures). This failure could cause the staff to miss needed safety measures on the resident and place the resident at risk of injury from seizures. Findings include: Record review of Resident # 102's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Diabetes, Hypertension (high blood pressure), Reflux, Dysfunction of Bladder and High Cholesterol. The face sheet also revealed a new diagnosis of Unspecified Convulsions with an onset date of 7/8/24. Record review of Resident #102's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, which indicated the resident's cognitive ability was severely impaired. The MDS did list Seizure Disorder or Epilepsy as an active diagnosis. Record review of Resident #102's undated Care Plan reflected, Unspecified Convulsions listed in the diagnosis list, but not listed in the Problem, Goal, or the Intervention areas of the care plan. Record review of Resident #102's Progress notes reflected the following: 7/8/24 at 08:44 am, staff witnessed pt (patient) having a seizure x 2. 7/9/24 at 09:07 am Continues in hospital. 7/10/24 at 07:53 am resident had returned to the facility and was sitting at nurse's station when vital signs were taken. In an interview on 10/31/24 at 10:25 am the MDS Nurse reviewed Resident #102's care plan and stated, the new July diagnosis of seizures was not added to the care plan. She stated, I don't know how I missed updating the care plan. I did everything else. The MDS Nurse stated the policy was to update the care plan 1 week after the MDS closure date. It was important to keep the care plan current so staff knew how to follow the plan of care for each resident. The potential negative outcome to residents if the care plan was not current then staff could miss something in the care of the residents. In an interview on 10/31/24 at 11:23 am with the DON, she stated the policy is to update the care plan as new diagnosis come up. She stated it is important to keep the care plan current so that all staff are on the same page with care and all staff can see what is going on in the chart. The DON stated the negative outcome to residents if the care plan is not current could be staff could miss treatments or get inappropriate treatments. In an interview on 10/31/24 at 11:27 am with the ADM, she stated the policy on updating diagnosis related to care plan is that once they get a diagnosis the care plan should be updated. She stated it is important to keep the care plan current to make sure residents get the care needed and nothing is missed. The ADM stated the potential negative outcome to residents if the care plan is not current would-be staff could give drugs that are not needed or miss treatments needed. She stated staff must know to know the information, so they could treat the residents best. In an interview on 10/31/24 at 11:30 am with the BOM, she stated that she is unsure of the policy on updating diagnosis related to care plans as she does not do care plans. She stated it is important to keep the care plans current because that is what staff use to go by for resident's care. Staff will not have the appropriate information to provide the care for residents if the care plan is not current. BOM stated the potential negative outcome to residents is they will not get the care needed. A record review of the facility policy titled, Care Plans, Comprehensive Person-Centered dated 2001 with a last revision date of 2016 reflected the following: The comprehensive, person-centered care plan will: o Describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. o Incorporate identified problem areas. o Reflect treatment goals, timetables and objectives. o Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.

Based on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for one of one facility reviewed for environment in that: 1. The facility failed to properly maintain sanitary emergency eyewash station in the kitchen when the protective eyewash covers were not properly positioned, not capped when not in use, and had a roll of paper towels inside the basin. The facility failed to keep the area clear and accessible to kitchen staff when the area was cluttered and blocked with brooms, a dustpan, a meal cart with soiled meal trays, a trash can, box of gloves, and rolls of trash bags. These failures could place staff at risk for an unsafe, unsanitary, and uncomfortable environment. Findings included: During the initial tour of the kitchen on 10/29/2024 at 07:05 AM the following was observed: A sign on the wall reflected, Emergency Eyewash Keep Area Clear. Test All Emergency Equipment Weekly. An emergency eyewash station was mounted to the wall next to the hand washing sink in the dishwasher room. The plastic bowl basin had a roll of paper towels inside it. The basin appeared dirty with a white film or residue on it. The orange protective eyewash flip-top dust covers were flipped back and open exposing the spray-type head. The protective eyewash flip-top dust covers were not capped. The area was cluttered and blocked by a closed trash can with a box of vinyl exam gloves and rolls of trash bags on top of trash can, two brooms, a dustpan, and a meal tray cart full of old meal trays from the previous day. During an interview on 10/30/2024 at 9:43 AM, the DM stated staff were responsible for cleaning their own areas. There were two kitchen aides that were responsible for cleaning the dishwasher area. They were expected to sweep and mop the area and put away the mop, broom, and dishwasher crates. The mop, broom, and dustpan should be stored in the corner of the room, not in front of the emergency eyewash area. The DM stated there could be cross contamination from the dirty broom and dustpan sitting that close to the emergency eye washing station. The DM stated that she had trained staff to keep the eye washing area clear, clean, and accessible. The surveyor requested a copy of the eye washing station training, policy, and procedures. During an interview on 10/30/2024 at 05:02 PM, CK D stated she was unaware that there was an emergency eye washing station and had not received any training about that. She was not sure what she would do if she got something in her eyes. She would probably tell her manager and go into the bathroom. During an interview on 10/31/2024 at 08:11 AM, DA C stated she washed dishes, swept, mopped, and cleaned the floors in the kitchen daily and stored the mop, broom, and dustpan in the back room. DA C stated she was not aware there was an emergency eye wash station and if something got in her eyes, she would tell her manager. During an observation of the kitchen on 10/31/2024 at 08:15 AM, revealed the emergency eye wash station area was blocked with a trash can on the floor in front of the sink. During an interview on 10/31/2024 at 9:43 AM, with the DM the surveyor requested the eye washing station policy, procedure, or training for the second time. The DM stated she did not know if they had a policy, but she did train her staff on where the sink was located and how to use it as part of staff orientation. The DM did not have any documented training regarding the eye wash station. She stated it was the Maintenance Director's responsibility to service the station and make sure it was in working condition. The DM was not sure how often that was done. She expected her staff to keep the area clear and accessible. During an interview and record review on 10/31/2024 at 11:15 AM the DM provided the surveyor with Inspect eyewash stations task sheet that she received from the Maintenance Director. The DM stated that the task was assigned to the Maintenance Director, and he noted all pass if the inspection passed. Record review of the Inspect eyewash stations task sheet revealed instructions, Verify the eyewash station is on the same level as the hazard and accessible and unobstructed. Verify protective eyewash covers are properly positioned, clean, and intact. Verify that eye wash station was disinfected weekly. Verify capped when not in use. During an interview on 10/31/2024 at 12:30 PM, the ADM stated there was not an emergency eye washing station policy. If kitchen staff got something in their eyes, she would expect them to go to eye washing station and flush their eyes out. The ADM stated that the DM was responsible for ensuring staff had access to the emergency eye washing station and for ensuring the kitchen was properly cleaned. The ADM stated if staff got dishwashing chemicals or something else in their eyes and could not access the emergency eye washing station they could trip and fall and injury themselves. She stated she thought the area by the eye wash station was cluttered because staff were in a hurry. The clutter did not meet her expectations and stated it was important to keep the kitchen clean to prevent potential illness.

Based on interview, and record review the facility failed to develop and implement interventions the person-centered care plan to reflect the current condition for 1 (Residents # 1) of 5 residents reviewed for care plan interventions. The facility failed to update Resident # 1's care plan for diet interventions after her diet order was changed. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. The Findings included: Review of Resident # 1's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included Unspecified protein-calorie malnutrition (lack of proper nutrition or an inability to absorb nutrients from food) , hypertensive heart disease (heart conditions caused by high blood pressure), and vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain). Review of Resident # 1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 which indicated severe cognitive impairment. Review of Resident # 1's care plan not dated revealed a problem of Resident # 1 had nutritional problem r/t dysphagia (difficulty swallowing), malnutrition, and dementia (memory loss). There was no goal or intervention of a vegetarian diet. Review of Resident # 1's physician orders dated 08/03/2024 revealed an order with a start date of 07/27/2024 for a vegetarian diet. Interview with the MDS coordinator on 08/03/2024 at 2:55 PM stated that LVN F would have been responsible for updating the care plan on 07/29/2024 when it was known by the order that Resident # 1 was a vegetarian. The MDS coordinator stated she had updated Resident #1's care plan 08/03/2024 when the DON told her to review Resident #1's care plan. The MDS coordinator stated that care plans needed to be updated when the orders are changed. Interview with LVN F on 08/03/2024 at 3:56 PM stated he came into the facility around 6:00 PM on 07/29/2024. LVN F stated he had a request on his desk to update Resident # 1's diet to vegetarian. LVN F stated he updated Resident # 1's order but he did not go into the care plan to update it. LVN F stated he just got too busy with other facility duties which was the reason he did not update the care plan. LVN F stated he was aware care plans should be updated timely. Interview with ADM on 08/03/2024 at 4:20 PM stated the care plans should be updated when the orders are placed and should be updated timely. The ADM stated that the charge nurse was responsible for updating care plan. ADM stated not having a care plan updated the residents needs would not get met and may cause illness. Review of Policy Care Plan, Comprehensive Person-Centered Revised December 2016, revealed 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.

Based on interviews and record review, the facility failed to provide food that accommodates residents allergies, intolerances, and preferences for 1 (Resident # 1) of 5 residents reviewed for food preferences. The staff did not accommodate Resident # 1's dietary preferences for a vegetarian diet. This failure could affect the residents that are provided daily meals by the facility, by placing them at risk for adverse effect from food, frustration, not enjoying meals, and weight loss. The Findings included: Review of Resident # 1's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Unspecified protein-calorie malnutrition (lack of proper nutrition or an inability to absorb nutrients from food) , hypertensive heart disease (heart conditions caused by high blood pressure), and vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain). Review of Resident # 1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 which indicated severe cognitive impairment. Review of Resident # 1's care plan not dated revealed a problem of Resident # 1 had nutritional problem r/t dysphagia (difficulty swallowing), malnutrition, and dementia (memory loss). There was no goal or intervention of a vegetarian diet. Review of Resident # 1's physician orders dated 08/03/2024 revealed an order with a start date of 07/27/2024 for vegetarian diet with puree texture and nectar thick consistency. Review of Resident # 1's progress note dated 08/01/2024 at 2:34 PM reflected the DON wrote Resident # 1's RP came to the facility today upset because Resident # 1 had received meat on her tray. CNA C was in the room feeding Resident # 1 her lunch at the time. Review of Resident # 1's RP grievance dated 07/29/2024 revealed [Resident # 1] had been on vegetarian diet but had been receiving meat on her tray. Review of Resident # 1 's RP grievance dated 08/01/2024 revealed [Resident # 1] received meat on her tray. Review of Resident # 1's printed lunch dietary ticket dated 08/01/2024 reflected in notes (no pureed meat) and give extra servings of pureed vegetables. Interview with the DON on 08/03/2024 at 11:00 AM stated that Resident # 1's RP was upset because Resident # 1 was brought ground chicken and she was a vegetarian. The DON stated Resident # 1 was being fed by CNA C and the RP was in the room when the tray came. The DON stated that Dietary matched the resident's food preferences by the meal ticket. The DON stated that the charge nurses would double check the meal ticket and tray. The DON stated once the tray had been verified the CNA staff would deliver the tray to the resident's room. The DON stated the facility did not have a policy on verification of trays and that was just a process that the facility followed to ensure residents received the correct meal. The DON stated on 08/01/2024 Resident # 1's tray did not get verified by LVN A or RN D because both charge nurses were busy with other facility duties. Interview with Resident # 1's RP on 08/03/2024 at 11:15 AM stated on 08/01 when I was at the facility, I got upset and blew a fuse. Resident # 1's RP stated he told LVN A told that they had poisoned Resident # 1 by feeding her meat and she was a vegetarian. Resident # 1's RP stated CNA C had delivered the tray to the room. Resident # 1's RP stated the facility had called the police on him because he would not calm down. Resident # 1's RP stated he left the facility and came back to the facility on [DATE] (time not recalled) to get Resident #1's belongings and he also took Resident # 1 out of the facility to his home. RP stated he had taken Resident #1 out of the facility due to the police kicking him out. RP stated Resident # 1 would not be returning to the facility due to that incident. Interview with LVN A on 08/03/2024 at 1:15 PM stated during lunch time (exact time not recalled) CNA C brought the tray to Resident #1. LVN A stated he did not verify Resident # 1's tray because he was busy with assisting another resident. LVN A stated he was focused on the issue with the resident and he did not get to check Resident # 1's tray. LVN A stated Resident # 1 's RP was upset that meat was on Resident # 1's tray. The facility process that is followed to make sure residents receive the correct diet, the dietary staff review the special instructions on the bottom of the meal ticket, the charge nurse verifies the meal ticket, and the CNA assigned would deliver the tray to the room. Interview with the Kitchen Manager on 08/03/2024 at 1:43 PM stated LVN A brought to her attention that meat was on Resident # 1's plate. The Kitchen Manager stated that [NAME] B had messed up, and the special instructions of no meat was on the bottom of the meal ticket. The Kitchen Manager stated she discarded the tray and made a new tray for Resident #1. The Kitchen Manager was unable to state why LVN A did not check the tray before CNA C delivered to the room. Interview with [NAME] B on 08/03/2024 at 2:05 PM stated she looked at Resident # 1's meal ticket on 08/01/2024 and it did have no meat on the ticket. [NAME] B stated that she made the plate puree, and she did not know what had happened with Resident # 1 receiving the puree meat on the tray. [NAME] B stated that she was told by the Kitchen Manager that Resident # 1 should not get any meat. Interview with CNA C on 08/03/2024 at 3:30 PM stated she delivered the tray on 08/01/2024 and was going to feed Resident # 1 and Resident # 1's RP told her to leave the tray and that he was going to feed Resident # 1. CNA C stated she never looked at the tray and she did not believe LVN A looked at the tray because he was busy with another resident. CNA C stated that Resident # 1 and Resident # 1's RP stated to her that she was vegetarian. CNA C stated she would not have given Resident # 1 any meat. CNA C stated that someone (no name given) dropped the ball that day and Resident #1's RP did not give her a chance because he had taken over. CNA C stated LVN A and RN D were busy with other facility issues, and she could not tell why the tray was not physically checked prior to her bringing to Resident # 1. Interview with RN D on 08/03/2024 at 3:42 PM stated as far as she understands it was the charge nurse of the resident who would verify the meal tray. RN D stated at around lunch time (exact time unknown) she was busy with sending out a resident to the hospital. RN D stated LVN A was busy with a resident and LVN A never checked Resident # 1 's tray from her understanding. Interview with the ADM on 08/03/2024 at 4:20 PM stated she did not know Resident # 1 had received the wrong diet until Resident # 1's RP had became upset on 08/01/2024. The ADM stated it was expected for residents to receive their food preference choices. Review of Policy Tray Service dated 2018, revealed The facility believes that accurate tray service and adequate portion sizes are essential to the residents' well being and safety. The facility will ensure that diets are served accurately and in the correct portions and that resident's preferences are met.

Based on interviews and record reviews, the facility failed to ensure residents had a right to be free from neglect for 1 (Resident #1) of 6 residents reviewed for neglect. The facility failed to ensure CNA A reported that she observed signs and symptoms of dizziness from Resident #1 before taking her to the shower room on [DATE]. CNA A did not report to anyone what she observed and continued to take Resident #1 to the shower room. While CNA A's back was turned in the shower room to grab something, Resident #1 got up from a shower bench unassisted, fell , and sustained a nondisplaced right inferior pubic ramus fracture and right parietal scalp hematoma with underlying acute traumatic subarachnoid hemorrhage. Resident #1 was sent to the ER and placed on hospice for comfort care. On [DATE], Resident #1 passed away. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:56 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not having change in conditions assessed, falls, injury, decreased quality of life, and/or death. Findings included: Record review of Resident #1's Admission Record, dated [DATE], revealed an [AGE] year-old female who was admitted to the facility on [DATE] and had diagnoses including unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), age-related osteoporosis (a condition in which bones become weak and brittle) without current pathological fracture, and unspecified low back pain. Record review of Resident #1's Quarterly MDS Assessment, dated [DATE], revealed a 3 BIMS score, which indicated she had severe cognitive impairment. Resident #1 also required partial/moderate assistance with showering/bathing herself and supervision or touching assistance with tub-shower transfers. The MDS reflected Resident #1 had no falls since admission. Record review of Resident #1's Care Plan, dated [DATE], revealed Resident #1 was at risk for falls related to confusion, incontinence, and being unaware of safety needs. Resident #1 also had an ADL care performance deficit and required extensive assistance by one staff with showers and supervision assistance by one staff to move between surfaces. Record review of the facility's Incident List, dated [DATE], revealed Resident #1 had a witnessed fall on [DATE] at 6:30 a.m. Record review of the facility's Admission/Discharge Report, from [DATE] through [DATE], revealed Resident #1 discharged to an acute care hospital on [DATE]. Record review of Resident #1's Fall Risk Evaluation, created by RN B on [DATE] at 7:36 a.m., revealed she was categorized as low risk for falls, had no falls in the past three months, had no cognition changes in the last 90 days, displayed cognitive behaviors, had adequate vision, was independent and continent with ambulation and elimination, ambulated without problem and with a device, had a steady balance, no drop in systolic blood pressure (pressure in the arteries when the heart contracts) while lying, sitting, and 1 and 3 minutes after standing, had ,d+[DATE] health diseases that placed her at risk for falls, took ,d+[DATE] high risk medications within the last seven days, and had no changes in medication and dosage in the past five days. Record review of the facility's Incident List, dated [DATE], revealed Resident #1 had a witnessed fall on [DATE] at 6:30 a.m. Record review of the facility's Admission/Discharge Report, from [DATE] through [DATE], revealed Resident #1 discharged to an acute care hospital on [DATE]. Record review of Resident #1's Progress Notes revealed the following: -A note created by RN B on [DATE] at 7:35 a.m., [CNA A] reported to nurse that [Resident #1] had a fall in the shower. Nurse assessed resident and resident is noted to have a hematoma (A pool of mostly clotted blood that forms in an organ, tissue, or body space) to back of the right side of her head. Ice pack applied to head, vitals stable. Resident assisted into a wheelchair by staff. AROM WNL for resident. CNA stated that resident was noted to have some increase confusion while in the shower and became startled and hopped up out of the chair and fell to the floor. [Family member] made aware of incident. ADON and NP made aware. Neuro checks started. -A note created by RN B on [DATE] 8:34 p.m., [Resident #1] sent to [hospital] for evaluation per family request. -A note created by RN B on [DATE] at 8:40 p.m., [Resident #1] admitted to [hospital]. Record review of Resident #1's Pain Summary, dated [DATE], revealed she reported experiencing ,d+[DATE] pain on [DATE] at 7:30 a.m. and ,d+[DATE] pain on [DATE] at 8:57 a.m. Record review of Resident #1's Neurological Evaluation Flow Sheet, started by RN B on [DATE] at 6:30 a.m., revealed monitoring was completed from [DATE] at 6:30 a.m. through [DATE] at 10:30 a.m., there were no changes in condition documented, and the last monitoring check documented on [DATE] at 11:30 a.m. indicated Resident #1 went to the hospital. Record review of Resident #1's Hospital Record, from [DATE] through [DATE], revealed she arrived at the hospital emergency department on [DATE] at 11:42 a.m. Resident #1's chief complaint was a fall and hip and rib pain. Resident #1 was presented to the hospital's ER with her family after a fall. Resident #1's family reported Resident #1 was transferring from a chair the morning of [DATE] when she fell backwards and struck her head and had since been complaining of head, ribcage, and pelvic pain. Resident #1's physical exam at the hospital revealed her head was with a contusion (a bruise) and she exhibited decreased range of motion and tenderness to her right hip. Resident #1's x-rays found she had a nondisplaced right inferior pubic ramus (group of bones that park up part of pelvis) fracture and right parietal scalp hematoma (typically appears as a bump on the head) that underlying was an acute traumatic subarachnoid hemorrhage (the accumulation of blood in the space between the arachnoid membrane and the [NAME] mater around the brain referred to as the subarachnoid space). Extensive conversation between Resident #1's family, Neurosurgery and SICU attending regarding how best to proceed moving forward resulted in Resident #1's family felt that she suffered and had significantly deteriorated over the past two days and decided to pursue comfort care only. Hospice was consulted and Resident #1 was transitioned to inpatient hospice the following day ([DATE]). Resident #1 was discharged to an inpatient hospice medical center on [DATE] with no resolved hospital problems. On [DATE], Resident #1 expired at the inpatient hospice medical center. During an interview on [DATE] at 8:25 a.m., CNA D revealed if she observed a resident had s/s of a change in condition, she would inform a nurse and document what she observed. CNA D stated CNAs were responsible for showering residents. CNA D also stated staff were required to never turn their back on a resident during a shower and to have all shower supplies prepared before taking a resident to the shower room. During an interview on [DATE] at 8:29 a.m., CNA E revealed if she observed a resident had s/s of a change in condition, she would notify a nurse. CNA E stated CNAs were responsible for showering residents. CNA E also stated staff were required to never turn their back on a resident during a shower and to have all shower supplies prepared before taking a resident to the shower room. During an interview on [DATE] at 8:38 a.m., LVN F revealed if a CNA observed a resident had s/s of a change in condition, CNAs were required to notify a nurse. LVN F stated CNAs were responsible for showering residents. LVN F also stated staff were required to never turn their back on a resident during a shower and to have all shower supplies prepared before taking a resident to the shower room. During an interview on [DATE] at 8:45 a.m., LVN G revealed if a CNA observed a resident had s/s of a change in condition, CNAs were required to report the incident to a nurse. LVN G stated CNAs and assigned hospice staff showered residents. LVN G also stated staff were required to never turn their back on a resident during shower and to have all shower supplies prepared before taking a resident to the shower room. During an interview on [DATE] at 9:04 a.m., CNA H revealed if a CNA observed a resident had s/s of a change in condition, CNAs were required to report to the nurse. CNA H stated CNAs showered residents. CNA H also stated staff were required to never turn their back on a resident during shower and to have all shower supplies prepared before taking a resident to the shower room. During an interview on [DATE] at 9:23 a.m., CNA I revealed CNAs showered residents. CNA I stated staff were required to never turn their back on a resident during shower and to have all shower supplies prepared before taking a resident to the shower room. CNA I also stated if a CNA observed a resident had s/s of a change in condition, CNAs required to notify a nurse. During an interview on [DATE] at 10:26 a.m., the FAM revealed Resident #1 was on hospice due to a brain injury and hematoma sustained because of the fall she had on [DATE]. The FAM stated they requested Resident #1 be sent to the hospital. The FAM also stated the hospital x-rays and CT scans found Resident #1 had a recent pelvic fracture and brain bleed. The FAM stated Resident #1 was transferred to the trauma center. The FAM also stated he notified staff on [DATE] about Resident #1's hematoma and dehydration found at the hospital. During an interview on [DATE] at 10:48 a.m., the NP revealed the facility staff informed her that Resident #1 fell during a shower and sustained a hematoma (a pocket of blood) to the head. The NP also stated Resident #1 was not on any anticoagulant medication. NP explained the facility's protocol was to conduct neurological checks and vital sign checks for 72 hours if the resident was not taking any anticoagulant medication at the time of their fall. NP went on the explain there were no changes in Resident #1's condition and no abnormal vitals during the monitoring. NP explained Resident #1 denied any changes in condition or pain, even with the FAM present. NP went on to explain the FAM had her reevaluate Resident #1 when they arrived at the facility three hours after the fall, in which she complained of hip pain. The NP explained she informed the FAM that the facility could get a mobile x-ray to evaluate Resident #1's hip. NP went on to explain the FAM still wanted Resident #1 to go to the hospital. NP stated Resident #1 never had any past falls at the facility. NP also stated a hematoma was a great bodily injury, but she was not sure if Resident #1 sustained it due to her fall or that it was a precondition at her admission to the facility. During an interview on [DATE] at 11:12 a.m., the DON stated Resident #1 had no history of falls at the facility. DON stated Resident #1 was ambulatory and had no s/s of injury from previous falls. The DON stated CNA A showered Resident # 1 on [DATE]. DON stated CNA A told her that she had her back turned-on Resident #1 because she was moving another shower chair when Resident #1 got up unassisted and fell . DON also stated an Agency Hospice CNA was present who might have witnessed Resident #1's fall in the shower room. DON stated she made two attempts to contact the Agency Hospice CNA and was waiting for a returned call. DON also stated she was in-servicing staff on performing showers on residents. During an interview on [DATE] at 12:08 p.m., CNA A revealed Resident #1 used a walker. CNA A stated CNAs showered residents. CNA A explained on [DATE], she observed Resident #1 walking without her walker on [DATE] at 6:30 a.m. CNA A stated she noticed Resident #1 was dizzy and might have been dizzy from walking without a walker. CNA A explained she knew Resident #1 was dizzy because Resident #1's eyes looked dizzy, and Resident #1 looked like she was going to fall when she was walking. CNA A stated she reeducated Resident #1 that she could not walk without her walker, helped Resident #1 back to her room, grabbed Resident #1's walker and new clothes, and thought she should shower Resident #1 because Resident #1 was awake. CNA A also stated she did not report that she observed Resident #1's dizziness to a nurse because RN B did not report to work on time. CNA A explained she did not immediately notify a nurse of Resident #1's dizziness because there was no nurse to report to. CNA A went on to explain the previous shift nurse left and RN B had not arrived yet when she observed Resident #1's dizziness. CNA A stated she did not look for another nurse because she was going to shower Resident #1. CNA A stated residents' health and safety could be affected if CNAs did not notify a nurse that a resident was showing s/s of dizziness. CNA A explained the nurses must know everything anytime a CNA observed a change in condition and CNAs must immediately notify a nurse whenever they observed a change in condition. CNA A explained she took Resident #1 to the shower room and helped Resident #1 into a small chair because Resident #1 could not get into the bigger shower chair. CNA A went on to explain she instructed Resident #1 to wait for her and had Resident #1's clothes off from the wrist down . CNA A stated as she looked the other way to prepare the shower, Resident #1 stood up within seconds, held onto the bigger chair, fell , and the bigger chair fell over her. CNA A stated a male witnessed Resident #1's fall incident. CNA A explained she notified RN B when RN B came into work, asked RN B to come to the shower room, RN B came to the shower room and saw Resident #1 on the ground and bleeding. CNA A stated her and RN B picked up Resident #1 and she observed Resident #1 had blood on her hand and hair. She stated RN B assessed Resident #1 and notified the DON, she brought ice and cleaned the blood from Resident #1's face and hand, and then informed RN B that she observed Resident #1 was dizzy before she took Resident #1 to the shower room. CNA A also stated RN B instructed her not to shower Resident #1. During an interview on [DATE] at 1:30 p.m., RN B revealed on [DATE], CNA A came to her and told her that Resident #1 fell . RN B explained she went into the shower room and observed Resident #1 was on the floor and had blood on her head. RN B stated she got gauze, assessed Resident #1's vitals and neuros, determined everything was okay and that ROM was normal, initiated neurological checks, applied ice to the injured area, placed Resident #1 in a wheelchair, and notified the DON, ADON, FAM and NP . RN B also stated CNA A told her that Resident #1 was sitting on a shower bench in the shower room, grabbed another shower chair, and fell . RN B stated CNA A told her that Resident #1 was confused before she brought Resident #1 to the shower room and stated she believed Resident #1 was confused because she was walking without her walker, which was abnormal for her. RN B also stated CNA A did not report to her that Resident #1 was confused before she took Resident #1 to the shower room. RN B stated she did not ask CNA A why CNA A did not inform her about observing confusion from Resident #1 because she was in middle of assessing and treating Resident #1. RN B stated Resident #1's family visited the facility (could not recall what time) and wanted Resident #1 sent out to the hospital. RN B also stated she did not think to ask CNA A about Resident #1's confusion prior to taking her to the shower room. RN B stated CNAs were supposed to immediately report to the nurse any change in condition . During an interview on [DATE] at 1:53 p.m., the DON revealed she conducted in-services on abuse, neglect, and ADL care related to showers. DON stated there were no in-services initiated on change in condition. DON also stated CNA A was suspended pending investigation until she found out what happened and CNA A was given the right training and reeducation before returning to work. DON stated CNA A told her that she helped Resident #1, knew it was Resident #1's shower day. The DON stated Resident #1 was ambulatory, CNA A gathered Resident #1's supplies, took Resident #1 to the shower room, sat Resident #1 on the shower bench that was against the wall, went to grab an extra shower chair, and noticed Resident #1 fell . DON also stated CNA A told her that Resident #1 seemed off before taking her to the shower room and that Resident #1 was like that sometimes. DON stated CNA A told her that Resident #1 was stable with a walker when walking to the shower room when she asked how Resident #1 was walking. DON also stated when she asked why CNA A believed Resident #1 was off before taking her to the shower room, CNA A told her that Resident #1 was off because Resident #1 was walking without her walker and believed it was abnormal behavior. DON stated CNA A mentioned Resident #1's confusion. DON also stated she asked if Resident #1's confusion was new and CNA A told her that Resident #1's confusion was not new because it sometimes happened. DON stated CNA A did not mention anything about Resident #1 showing s/s of dizziness. DON also stated CNA A did not mention reporting Resident #1's dizziness to a nurse before taking Resident #1 to the shower and did not provide an explanation to her as to why she did not tell a nurse before taking Resident #1 to the shower room when she observed abnormal behavior. DON stated she expected CNAs to notify a charge nurse whenever they suspected or observed s/s of a change in condition. DON also stated residents' health or safety could be affected if CNAs did not notify a nurse of a resident's change in condition. DON explained residents' diagnoses or change in condition could go overlooked if CNAs did not notify nurses about residents' change in condition. During an interview on [DATE] at 2:23 p.m., the ADM revealed she was notified that Resident #1 fell in the shower room, hit her head, and went to the hospital. ADM stated when investigating the incident, CNA A told staff that the shower room was not situated before she brought Resident #1 into the shower room, sat Resident #1 onto a shower bench, and grabbed a shower chair. ADM stated she was taught that shower tools were prepared before bringing a resident into the shower room. ADM also stated she could not recall if CNA A told staff that Resident #1 seemed off before taking Resident #1 to the shower room. ADM stated she recalled CNA A stating Resident #1 seemed off in the shower room. ADM explained CNA A described that Resident #1 was off because Resident #1 was acting differently and did not elaborate more than that to staff. ADM stated she was not sure if CNA A told RN B that she observed Resident #1 was off before taking Resident #1 to the shower room. ADM also stated residents' health and safety could be affected if staff were not reporting incidents within required timeframes and not notifying of residents' changes in condition. During an interview on [DATE] at 3:01 p.m., the DON revealed she checked with HR and did not find anything about CNA A completing training on notifying nurse of changes in condition expectation, training, or requirement. Record review of a voicemail from Resident #1's FAM on [DATE] at 10:46 a.m. revealed Resident #1 passed away in the morning of [DATE] and the death was caused by the brain bleed due to the damage it did from Resident #1's physical and mental state. During an interview on [DATE] at 8:38 a.m., CNA A revealed she could not remember if she were given training on how to shower residents. CNA A explained she was trained by an experienced CNA when she first began her employment. CNA A stated she was taught to have everything ready before bringing residents into the shower room and showering residents. CNA A also stated she was supposed to ask another CNA to grab whatever she forgot in the shower room when she was about to shower a resident and forgot something. CNA A stated she did not ask another CNA to grab the shower chair when she was in the shower room with Resident #1 because the other CNA was outside the shower room, she did not think it was necessary, and she was confident because there was another CNA from hospice in the shower room with her. CNA A also stated she did not ask the hospice CNA to grab the shower chair or monitor Resident #1 while she grabbed a shower chair because the hospice CNA was busy bathing the other resident in the shower room and was not able to help her at the same time. CNA A stated she turned her back on Resident #1 because there were two shower chairs in the shower room and she was trying to grab a shower chair. CNA A explained she left Resident #1 for one second. CNA A stated CNAs could not have their backs turned on a memory care resident in the shower room. CNA A also stated she did not think Resident #1 would stand up unassisted. CNA A stated the other CNA who was supposed to work on the shift did not arrive yet. CNA A explained there were three CNAs who were assigned to work on the day Resident #1 fell . CNA A stated RN B told her that she could bathe residents. CNA A stated RN B arrived at the facility at the time when Resident #1 fell . CNA A also stated RN B was not there when she took Resident #1 to the shower room. CNA A stated she was required to shower residents. CNA A also stated residents' health and safety could be affected if a CNA had their back turned on a resident and a resident got up unassisted and fell . During an interview on [DATE] at 9:09 a.m., the DON revealed the facility did not have any ADL policies specific to CNAs showering residents. DON stated the facility followed the ADA's recommendations and reasonably accommodate what they could do as a facility for the residents. During an interview on [DATE] at 9:17 a.m., RN B revealed CNA A showered Resident #1. RN B stated CNA A was assigned to care for the residents in the memory care unit who could walk, which included giving residents showers. RN B also stated she was given in-services on the fall protocol two weeks ago by the ADON. RN B stated the in-services did not address ADL care related to showers. RN B also stated CNAs were expected to press the call light for help if they forget to bring something in the shower room and about to shower resident in the shower room. RN B stated CNAs should get all shower equipment together before taking a resident to the shower room. RN B also stated she could not recall when she had clocked in on [DATE]. RN B stated when she arrived, CNA A was already in the shower room with Resident #1. RN B also stated CNA A did not receive her responsibilities from her before she arrived at the facility. RN B also stated CNA A had been told that she was required to provide care to residents who walked, which included Resident #1. RN B stated residents' health and safety could be affected if a CNA had their back turned and a resident got up unassisted and fell because residents were already in the shower room and residents could end up hurting themselves. RN B also stated CNAs should be keeping their eyes on residents at all times. During an interview on [DATE] at 9:47 a.m., the DON revealed the facility tried to reach out to the Agency Hospice CNA who was in the shower room with CNA A on [DATE]. DON explained she contacted the hospice company the Agency Hospice CNA worked for to see if they could reach him. DON stated she was informed that the agency hospice the CNA was on vacation. An attempt to call the Agency Hospice CNA was made on [DATE] at 9:53 a.m. A voicemail and call back number were left for the aide. The Agency Hospice CNA did not return the call. During an interview on [DATE] at 10:20 a.m., the DON revealed the facility did not have a specific training check off list for CNAs giving showers. An attempt to call CNA C was made on [DATE] at 10:28 a.m. A voicemail and call back number were left for the aide. During an interview on [DATE] at 10:39 a.m., CNA J revealed she was given orientation training on who and when to report a change in condition to. CNA J stated she did not receive an in-service on who and when to report a change in condition . CNA J also stated if she observed a change in condition, she was trained to ensure resident safety and report to a nurse. CNA J stated if her charge nurse were unavailable, she would find another nurse. CNA J also stated she was not given orientation training and recent in-services on ADL care related to how to shower residents. CNA J stated CNAs were required to have everything in place before taking a resident to the shower room. CNA J also stated if she forgot something and was about to give a resident a shower in the shower room, she would ask another CNA to grab what she forgot. CNA J stated CNAs were required to never turn their backs on a resident. During an interview on [DATE] at 10:46 a.m., CNA K revealed she was given orientation training on who and when to report a change in condition to and ADL care related to how to shower residents. CNA K stated she was in-serviced on falls yesterday ([DATE]) by the ADON. CNA K also stated she was not given a recent in-service on ADL care related to how to give showers. CNA K stated CNAs were required to have everything in place before taking a resident to the shower room. CNA K also stated if she forgot something and was about to give a resident a shower in the shower room, she would ask another CNA to grab what she forgot. CNA K stated CNAs were required to never turn their backs on a resident. CNA K also stated if she observed a change in condition, she was trained to report to a nurse. CNA K stated if the charge nurse were unavailable, she would find another nurse. During an interview on [DATE] at 10:52 a.m., CNA L revealed she was given orientation training on who and when to report change in condition to. CNA L stated she was not given recent in-services on who and when to report change in condition. CNA L also stated if she observed a change in condition, she was trained to report to a nurse. CNA L stated if the charge nurse she reported to was not on duty yet, she would find another supervisor. CNA L also stated she was not given orientation training on ADL care related to how to give showers. CNA L stated she was given a recent in-service on ADL care related to how to give showers. CNA L also stated CNAs were required to have everything in place before taking a resident to the shower room. CNA L stated if she forgot something and was about to give a resident a shower in the shower room, she would pull the emergency call light, cover up the resident and get the resident out of the shower room or ask another CNA to get what she forgot. CNA L also stated CNAs were required to never turn their backs on or leave a resident. During an interview on [DATE] at 11:38 a.m., the DON revealed she tried to give CNA A easier residents so she did not have to help with ADLs. DON defined easier as residents who were more independent with ADL care. DON stated she did not know who assigned CNA A to give Resident #1 a shower. DON stated RN B was drawing blood possibly during the time CNA A observed dizziness. DON also stated she in-serviced staff on showers and discussed how to prepare all shower items before taking a resident to the shower room on [DATE]. DON stated newly employed CNAs were paired with an experienced CNA who demonstrated to them how to perform duties. DON also stated she also discussed reporting change in condition during the in-service initiated on [DATE]. DON stated if CNAs noticed anything different or abnormal, CNAs were required and trained to notify a nurse or supervisor. DON also stated CNAs were expected to prepare all shower items before taking resident to shower room. DON stated CNAs could use the shower call light if they forgot something and were about to shower residents in the shower room. DON also stated CNAs were not allowed to have their backs turned on residents in the memory care unit while in the shower room. DON stated she added a reporting change in condition in-service. DON also stated CNAs were taught to find a nurse and notify them of any change in condition observed. DON stated the in-servicing was ongoing. DON stated Resident #1 did not have any dizzy behaviors prior to the fall. DON also stated she did not believe Resident #1's medication contributed to the dizziness observed by CNA A. Record review of the facility staff timesheets, dated [DATE], revealed staff worked in the memory care unit during the following shifts: -RN B [DATE] 6:22 a.m. - [DATE] 10:19 p.m. -CNA C [DATE] 6:53 a.m. - [DATE] 2:39 p.m. and [DATE] 3:24 p.m. - [DATE] 6:48 p.m. -CNA A [DATE] 6:12 a.m. - [DATE] 2:08 p.m. Record review of CNA A's proficiencies upon hire and annually and clinical proficiencies required upon hire and annually revealed no documented evidence of training given and completed related to falls, abuse, neglect, and change in condition. Record review of the facility's orientation, [DATE], revealed staff were trained on resident abuse/neglect and mistreatment, resident rights, customer satisfaction, medical records, dietary service, emergency preparedness, infection control, physical environment, and Nurse/CNA orientation checklists that covered hand hygiene, incontinent care, transfers, infection control, and vitals. Record review of the facility's self-report, received by the State Agency on [DATE], revealed on [DATE] at 6:30 a.m., Resident #1 was in the shower room with CNA A. CNA A sat Resident #1 on a shower bench to prepare the shower stall. When Resident #1 fell when she got up unassisted. The ADM first learned of the incident on [DATE] at approximately 7:00 a.m. RN B immediately assessed Resident #1. The NP reassessed Resident #1 on [DATE] around 9:00 a.m. There was a hematoma noted to Resident #1's right back area of her head. Ice was applied and neurological monitoring was started. Upon assessment, Resident #1 denied headaches or dizziness and did not vomit. Resident #1 did report right hip and groin pain. The facility staff notified Resident #1's family, physician, and the ADON who notified the ADM and DON, and Regional Nurse. Resident #1's family was present during the NP's visit and requested Resident #1 be sent to the hospital. The facility staff sent Resident #1 to the hospital for further evaluation. X-rays were completed in the hospital and noted Resident #1 had a brain bleed. On [DATE] at 5:30 a.m., Resident #1's family spoke with the facility staff and reported Resident #1's hospital scans revealed she had a brain bleed, old rib fractures they attributed to a fall prior to admission, six vertebrae fractures that were osteoporosis related and a broken pubic bone that was unknown if it was acute with the fall or not. Resident #1 was placed on hospice in the hospital on [DATE] and possibly had a stroke that could have caused the fall. CNA A was suspended until further investigation was completed. In-services on abuse and neglect, falls, and reporting were conducted. Record review of the facility's in-services revealed on [DATE], staff were educated on shower safety and taught to gather all supplies, ensure the shower room was ready prior to taking residents into the shower room, and to immediately report any suspicions of abuse/neglect to the ADM. Attached to the in-service was a copy of the State Agency's reporting guidelines and the facility's Assessing Falls and Their Causes policy and procedure revised in [DATE]. Record review of the facility's Abuse Prevention Program policy and procedure, revised [DATE], revealed the following, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and

Based on observation, interviews and record reviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental and psychosocial well-being for 1 (CNA A) of 9 CNAs reviewed for competent nursing care. The facility failed to ensure CNA A was proficient in reporting residents' change in condition and resident shower safety. CNA A did not report that she observed Resident #1 having s/s of dizziness and did not have all shower supplies prepared before taking Resident #1 to the shower room. CNA A took Resident #1 to the shower room, turned her back to grab something, Resident #1 got up from the shower bench unassisted and fell in the shower room. Resident #1 was sent to the ER, found to have sustained a nondisplaced right inferior pubic ramus fracture and right parietal scalp hematoma with underlying acute traumatic subarachnoid hemorrhage, and placed on hospice for comfort care. On [DATE], Resident #1 passed away. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:56 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not having change in conditions assessed, falls, injury, decreased quality of life, and/or death. Findings included: Record review of Resident #1's Admission Record, dated [DATE], revealed an [AGE] year-old female who was admitted to the facility on [DATE] and had diagnoses including unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), age-related osteoporosis (a condition in which bones become weak and brittle) without current pathological fracture, and unspecified low back pain. Record review of Resident #1's Quarterly MDS Assessment, dated [DATE], revealed a 3 BIMS score, which indicated she had severe cognitive impairment. Resident #1 also required partial/moderate assistance with showering/bathing herself and supervision or touching assistance with tub-shower transfers. Resident #1 had no falls since admission. Record review of Resident #1's Care Plan, dated [DATE], revealed Resident #1 at risk for falls related confusion, incontinence, unaware of safety needs. Resident #1 also had an ADL care performance deficit and required extensive assistance by one staff with showers and supervision assistance by one staff to move between surfaces. Record review of Resident #1's Fall Risk Evaluation, created by RN B on [DATE] at 7:36 a.m., revealed she was categorized as low risk for falls, had no falls in the past three months, had no cognition changes in the last 90 days, displayed cognitive behaviors, had adequate vision, was independent and continent with ambulation and elimination, ambulated without problem and with a device, had steady balance, no drop in systolic blood pressure while lying, sitting, and 1 and 3 minutes after standing, had ,d+[DATE] health diseases that placed her at risk for falls, took ,d+[DATE] high risk medications within the last seven days, and had no changes in medication and dosage in the past five days. Record review of Resident #1's Pain Summary, dated [DATE], revealed she reported experiencing ,d+[DATE] pain on [DATE] at 7:30 a.m. and ,d+[DATE] pain on [DATE] at 8:57 a.m. Record review of Resident #1's Neurological Evaluation Flow Sheet, started by RN B on [DATE] at 6:30 a.m., revealed monitoring was completed from [DATE] at 6:30 a.m. through [DATE] at 10:30 a.m., there were no changes in condition documented, and the last monitoring check documented on [DATE] at 11:30 a.m. indicated Resident #1 went to the hospital. Record review of Resident #1's Progress Notes revealed the following: -A note created by RN B on [DATE] at 7:35 a.m., [CNA A] reported to nurse that [Resident #1] had a fall in the shower. Nurse assessed resident and resident is noted to have a hematoma to back of the right side of her. Ice pack applied to head, vitals stable. Resident assisted into a wheelchair by staff. AROM WNL for resident. CNA stated that resident was noted to have some increase confusion while in the shower and became startled and hopped up out of the chair and fell to the floor. Son made aware of incident. ADON and NP made aware. Neuro checks started. -A note created by RN B on [DATE] 8:34 p.m., [Resident #1] sent to [hospital] for evaluation per family request. -A note created by RN B on [DATE] at 8:40 p.m., [Resident #1] admitted to [hospital]. During an interview on [DATE] at 8:25 a.m., CNA D revealed if she noticed a resident had a change in condition, she would inform a nurse and document her observations. CNA D stated she would also never turn her back on a resident in the shower room during a shower. CNA D also stated she would have all the shower supplies prepared before taking residents to the shower room. During an interview on [DATE] at 8:29 a.m., CNA E revealed if she noticed a resident had a change in condition, she would notify a nurse. CNA E stated she would also never turn her back on a resident in the shower room during a shower. CNA E also stated she would have all the shower supplies prepared before taking residents to the shower room. During an interview on [DATE] at 8:38 a.m., LVN F revealed if a CNA noticed a resident had a change in condition, CNAs were expected to report the incident to a nurse. LVN F stated CNAs were to never turn their back on a resident in the shower room during a shower. LVN F also stated CNAs were required to have all shower supplies prepared before taking residents to the shower room. During an interview on [DATE] at 8:45 a.m., LVN G revealed if a CNA noticed a resident had a change in condition, CNAs were expected to report the incident to a nurse. LVN G stated CNAs were to never turn their back on a resident in the shower room during a shower. LVN G also stated CNAs were required to have all shower supplies prepared before taking residents to the shower room. During an interview on [DATE] at 9:04 a.m., CNA H revealed if he noticed a resident had a change in condition, he would report the incident to a nurse. CNA H stated he would also never turn his back on a resident in the shower room during a shower. CNA H also stated he would have all the shower supplies prepared before taking residents to the shower room. During an interview on [DATE] at 9:23 a.m., CNA I revealed if she noticed a resident had a change in condition, she would help the resident and notify a nurse. CNA I stated she would also never turn her back on a resident in the shower room during a shower. CNA I also stated she would have all the shower supplies prepared before taking residents to the shower room. During an interview on [DATE] at 10:26 a.m., FAM revealed Resident #1 was placed on hospice care due to a brain injury and hematoma sustained due to her fall at the facility. FAM stated they requested the facility staff to transfer Resident #1 to the hospital. FAM also stated Resident #1 was then transferred to the trauma center. FAM stated he notified the facility staff on [DATE] about Resident #1's hematoma found at the hospital. During an interview on [DATE] at 10:48 a.m., NP revealed the facility staff informed her that Resident #1 fell during a shower and sustained a hematoma, which she defined was a pocket of blood to her head. NP stated Resident #1 was not taking any anticoagulants, which she defined as blood thinning medication. NP also stated FAM wanted Resident #1 to go to the hospital. NP stated Resident #1 did not have any falls at the facility in the past. NP also stated a hematoma was a great bodily injury, but she was not sure if the hematoma Resident #1 sustained was due to her fall or a precondition. During an interview on [DATE] at 11:12 a.m., DON revealed CNA A showered Resident #1. DON stated a brain bleed constituted as a serious bodily injury. DON also stated Resident #1 had no history of falls at the facility, was ambulatory, and had no s/s of injury from past falls. DON stated CNA A told staff that she had her back turned-on Resident #1 because she was moving another shower chair when Resident #1 got up unassisted and fell . DON also stated Agency Hospice CNA was in the shower room and may have witnessed Resident #1's fall, she made two attempts to contact Agency Hospice CNA, and still waiting for Agency Hospice CNA to return her calls. DON stated she was in-servicing staff on performing showers on residents. During an interview on [DATE] at 12:08 p.m., CNA A revealed Resident #1 used a walker, was on the right side of the hallway, and in the memory care unit. CNA A stated CNAs showered residents. CNA A also stated on [DATE] at 6:30 a.m., she observed Resident #1 was walking without a walker, helped walk Resident #1 back to her room, grabbed Resident #1's walker and new clothes from her room, and thought to shower Resident #1 because Resident #1 was awake. CNA A also stated she observed Resident #1 had s/s of dizziness and thought that might have been why she was walking without a walker. CNA A stated she knew Resident #1 was dizzy because Resident #1's eyes looked like she was dizzy and when walking looked like she was going to fall. CNA A also stated the nurse must know everything anytime a CNA observed a change in condition. CNA A stated a CNA must immediately notify a nurse whenever they observe a change in condition. CNA A also stated she did not report dizziness to the nurse because there was no nurse at the time because the nurse did not report to work on time. CNA A stated she did not look for another nurse because she was going to shower Resident #1. CNA A stated she notified RN B that Resident #1 was dizzy when RN B started her work shift, which was during the time she took Resident #1 to the shower room. CNA A stated residents' health and safety could be affected if CNA did not notify a nurse that residents were showing s/s of dizziness. CNA A stated there was a bigger chair in the room, Resident #1 could not sit on the bigger chair, she put Resident #1 in the small shower chair, she instructed Resident #1 to wait for her, and had Resident #1's clothes off from the wrist down. CNA A also stated as she looked away from Resident #1, Resident #1 stood up within seconds, held the bigger chair, fell down, and the bigger chair fell over her. CNA A stated a male had saw the incident in the shower room. CNA A also stated she notified RN B, she asked RN B to come, RN B came to the shower room, and saw Resident #1 on the ground and bleeding on her hand and hair, helped her pick up Resident #1, and assessed Resident #1 and notified the DON. CNA A stated she was not working at the facility at the time of the interview because the facility staff did not want to give her work hours or put her on the schedule and she was suspended pending an investigation. During an interview on [DATE] at 1:30 p.m., RN B revealed CNA A came to her and stated Resident #1 fell in the shower room. RN B stated she went into the shower room and observed Resident #1 on the floor and had blood on her head. RN B also stated CNA A told her that Resident #1 was sitting on shower bench, grabbed a shower chair, and fell in the shower room. RN B stated CNA A told her that Resident #1 was confused before she brought Resident #1 to the shower room and that she believed Resident #1 was confused because she was walking without her walker, which was abnormal behavior for her. RN B also stated CNA A did not tell her that Resident #1 was confused before taking her to the shower room. RN B stated she did not ask CNA A why CNA A did not inform her about Resident #1's confusion because she was in middle of assessing and treating Resident #1 after the fall. RN B also stated a CNA was supposed to immediately report to the nurse if they observe any change in condition. During an interview on [DATE] at 1:53 p.m., DON revealed she conducted in-services on abuse, neglect, and ADL care related to showers with the staff after Resident #1's fall. DON stated she did not initiate in-services on change in condition. DON also stated she did not initiate change in condition in-services because she did not believe Resident #1 had a change in condition at the time. DON explained CNA A told her that on [DATE], she knew it was Resident #1's shower day, Resident #1 was ambulatory, and helped Resident #1. DON also stated CNA A told her that she gathered Resident #1's shower supplies, took Resident #1 to the shower room, sat Resident #1 on the shower bench that was against the wall, went to grab an extra shower chair, and noticed Resident #1 fell . DON stated CNA A also told her that Resident #1 seemed off before taking her to shower room and that Resident #1 acted in that manner sometimes. DON also stated CNA A told her that Resident #1 was stable with a walker when walking to the shower room when she asked how Resident #1 was walking. DON stated CNA A told her that Resident #1 was off because Resident #1 was walking without her walker and believed it was abnormal behavior when she asked CNA A why CNA A believed Resident #1 was off before taking her to the shower room. DON also stated CNA A mentioned Resident #1 had some confusion. DON stated she asked CNA A if Resident #1's confusion was new and CNA A told her that it was not new because it sometimes happened with Resident #1. DON stated CNA A did not mention anything to her about Resident #1 showing s/s of dizziness. DON also stated CNA A also did not mention anything about reporting to a nurse before taking Resident #1 to the shower room and did not provide her with an explanation as to why she did not tell a nurse before taking Resident #1 to the shower room when she observed Resident #1's behavior. DON stated she expected CNAs to notify a charge nurse whenever they suspected or observed s/s of change in condition. DON also stated residents' health or safety could be affected if CNAs did not notify a nurse of a change in condition. DON explained residents' diagnoses or change in condition could go overlooked if CNAs did not notify a nurse. DON stated CNA A was suspended pending investigation until they found out what happened and CNA A had right training and reeducation before returning to work. During an interview on [DATE] at 2:23 p.m., ADM revealed she was notified that Resident #1 fell in the shower room, hit her head, and went to the hospital. ADM stated when investigating the incident, CNA A told staff that the shower room was not situated before bringing Resident #1 into the shower room, sat Resident #1 on a shower bench, and went to grab a shower chair in the shower room. ADM also stated staff were taught that shower supplies were prepared before bringing any resident to the shower room. ADM stated she could not recall if CNA A told staff that Resident #1 seemed off before taking Resident #1 to the shower room. ADM also stated she recalled CNA A stating Resident #1 seemed off in the shower room. ADM stated CNA A described Resident #1 was acting differently and did not describe how Resident #1 was acting differently to the staff. ADM also stated she was not sure if CNA A told a nurse before taking Resident #1 to the shower room about Resident #1 seeming off. ADM stated residents' health and safety could be affected if staff were not notifying residents' changes in condition. During an interview on [DATE] at 3:01 p.m., DON revealed she checked with HR and did not find any expectation, training, or requirement related to CNAs notifying nurses of s/s of change in condition. A voicemail from Resident #1's FAM on [DATE] at 10:46 a.m. revealed Resident #1 passed away in the morning of [DATE] and the death was caused by the brain bleed due to the damage it did from Resident #1's physical and mental state. During an interview on [DATE] at 8:38 a.m., CNA A revealed she could not remember if she were given training on how to shower residents. CNA A explained when she started as a CNA, she was trained by an experienced CNA. CNA A stated she was taught to have all shower supplies ready before bringing residents in the shower room to shower them. CNA A also stated CNAs were supposed to ask another CNA to grab whatever they forgot in the shower room if they are about to shower a resident and forget something. CNA A explained she did not ask another CNA to grab the shower chair when she was in the shower room with Resident #1 and needed it because the other CNA was outside the shower room, she did not think it was necessary to ask, and she was confident because there was an Agency Hospice CNA in the shower room with her. CNA A went on to explain she did not ask the Agency Hospice CNA to help her grab the shower chair or monitor Resident #1 while she grabbed the shower chair because the Agency Hospice CNA was busy bathing another resident and she believed he was unable to help her at the same time. CNA A stated she turned her back on Resident #1 because she was grabbing one of the two shower chairs in the shower room. CNA A also stated she left Resident #1 for one second. CNA A also stated CNAs could not have their back turned on a memory care resident in the shower room. CNA A explained she left Resident #1 for one second because she did not think Resident #1 would stand up unassisted from the shower bench. CNA A stated she was required to shower residents. CNA A stated RN B was not there when she took Resident #1 to the shower room. CNA A stated residents' health and safety could be affected if a CNA had their back turned and a resident got up unassisted and fell . During an interview on [DATE] at 9:09 a.m., DON revealed the facility did not have a policy on ADL care related to showering residents. DON explained the facility followed ADA's recommendations and reasonably accommodate what they can do as a facility for the residents. DON stated CNA A's training orientation was completed in 2010. During an interview on [DATE] at 9:17 a.m., RN B revealed she was given in-services on fall protocol a two weeks ago by the ADON. RN B also stated she was not given an in-service on ADL care related to showering residents. RN B also stated CNAs should get all the shower equipment together before taking a resident to the shower room. RN B stated she expected CNAs to press the call light for help if they forgot to get something and were about to shower a resident in the shower room. RN B stated she could not recall when she had clocked into work on [DATE]. RN B also stated when she arrived to work her shift, CNA A was already in the shower room with Resident #1 and already providing care to Resident #1. RN B stated CNA A did not receive responsibilities from her before she arrived to work her shift. RN B explained CNA A had been told since beginning to provide care to residents who could walk, which included Resident #1. RN B stated CNAs should be keeping eyes on residents at all times. RN B stated residents' health and safety could be affected if a CNA had their back turned on a resident and the resident got up unassisted and fell because the resident was already in the shower room and the resident could end up hurting themselves. During an interview on [DATE] at 9:47 a.m., DON revealed the facility tried to contact the Agency Hospice CNA, who was in the shower room with CNA A on [DATE]. DON explained she contacted the Hospice Company to see if they could reach the Agency Hospice CNA and was notified that he was on vacation. An attempt to call Agency Hospice CNA was made on [DATE] at 9:53 a.m. Left voicemail and call back number. Agency Hospice CNA did not return the call. During an interview on [DATE] at 10:20 a.m., DON revealed the facility did not have a specific training check off list for CNAs giving showers. An attempt to call CNA C was made on [DATE] at 10:28 a.m. Left voicemail and call back number. During an interview on [DATE] at 10:39 a.m., CNA J revealed she was given orientation training on who and when to report change in condition. CNA J stated she did not receive an in-service on who and when to report a change in condition. CNA J also stated if she observed a change in condition, she was trained to ensure resident safety and report to a nurse. CNA J stated if her charge nurse were unavailable, she would find another nurse. CNA J also stated she was not given orientation training and recent in-services on ADL care related to how to shower residents. CNA J stated CNAs were required to have everything in place before taking a resident to the shower room. CNA J also stated if she forgot something and was about to give a resident a shower in the shower room, she would ask another CNA to grab what she forgot. CNA J stated CNAs were required to never turn their backs on a resident. During an interview on [DATE] at 10:46 a.m., CNA K revealed she was given orientation training on who and when to report change in condition and ADL care related to how to shower residents. CNA K stated she was in-serviced on falls yesterday ([DATE]) by the ADON. CNA K also stated she was not given a recent in-service on ADL care related to how to give showers. CNA K stated CNAs were required to have everything in place before taking a resident to the shower room. CNA K also stated if she forgot something and was about to give a resident a shower in the shower room, she would ask another CNA to grab what she forgot. CNA K stated CNAs were required to never turn their backs on a resident. CNA K also stated if she observed a change in condition, she was trained to report to a nurse. CNA K stated if the charge nurse were unavailable, she would find another nurse. During an interview on [DATE] at 10:52 a.m., CNA L revealed she was given orientation training on who and when to report change in condition. CNA L stated she was not given recent in-services on who and when to report change in condition. CNA L also stated if she observed a change in condition, she was trained to report to a nurse. CNA L stated if the charge nurse she reported to was not on duty yet, she would find another supervisor. CNA L also stated she was not given orientation training on ADL care related to how to give showers. CNA L stated she was given a recent in-service on ADL care related to how to give showers. CNA L also stated CNAs were required to have everything in place before taking a resident to the shower room. CNA L stated if she forgot something and was about to give a resident a shower in the shower room, she would pull the emergency call light, cover up the resident and get the resident out of the shower room or ask another CNA to get what she forgot. CNA L also stated CNAs were required to never turn their backs on or leave a resident. During an interview on [DATE] at 11:38 a.m., DON revealed she tried to give CNA A easier residents so she did not have to help with ADLs. DON defined easier as residents who were more independent with ADL care. DON stated she did not know who assigned CNA A to give Resident #1 a shower. DON explained RN B was drawing blood possibly during the time CNA A observed Resident #1's dizziness. DON also stated she in-serviced staff on showers and discussed how to prepare all shower items before taking a resident to the shower room on [DATE]. DON stated newly employed CNAs were paired with an experienced CNA who demonstrated to them how to perform job duties. DON also stated she also discussed reporting residents' change in condition during the in-service initiated on [DATE]. DON stated if CNAs noticed anything different or abnormal, CNAs were required and trained to notify a nurse or supervisor. DON also stated CNAs were expected to prepare all shower items before taking resident to shower room. DON stated CNAs could use shower call light if they forgot something and were about to shower residents in the shower room. DON also stated CNAs were not allowed to have their backs turned on residents in the memory care unit while in the shower room. DON stated she added a reporting change in condition in-service. DON also stated CNAs were taught to find a nurse and notify them of any change in condition observed. DON stated the in-servicing was ongoing. DON stated she did not observe any dizzy behaviors prior to Resident #1's fall. DON also stated she did not believe Resident #1's medication contributed to the dizziness observed by CNA A. Record review of the facility staff timesheets, dated [DATE], revealed staff worked in the memory care unit during the following shifts: -RN B [DATE] 6:22 a.m. - [DATE] 10:19 p.m. -CNA C [DATE] 6:53 a.m. - [DATE] 2:39 p.m. and [DATE] 3:24 p.m. - [DATE] 6:48 p.m. -CNA A [DATE] 6:12 a.m. - [DATE] 2:08 p.m. Record review of CNA A's proficiencies upon hire and annually and clinical proficiencies required upon hire and annually revealed no training given and completed related to falls, abuse, neglect, and change in condition. Record review of the facility's orientation, [DATE], revealed staff were trained on resident abuse/neglect and mistreatment, resident rights, customer satisfaction, medical records, dietary service, emergency preparedness, infection control, physical environment, and Nurse/CNA orientation checklists that covered hand hygiene, incontinent care, transfers, infection control, and vitals. Record review of Resident #1's Hospital Record, from [DATE] through [DATE], revealed she arrived at the hospital emergency department on [DATE] at 11:42 a.m. Resident #1's chief complaint was fall and hip and rib pain. Resident #1 was presented to the hospital's ER with her family after a fall. Resident #1's family reported Resident #1 was transferring from a chair the morning of [DATE] when she fell backwards and struck her head and had since been complaining of head, ribcage, and pelvic pain. Resident #1's physical exam at the hospital revealed her head was with a contusion (a bruise) and she exhibited decreased range of motion and tenderness to her right hip. Resident #1's x-rays found she had a nondisplaced right inferior pubic ramus fracture and right parietal scalp hematoma that underlying was an acute traumatic subarachnoid hemorrhage (the accumulation of blood in the space between the arachnoid membrane and the [NAME] mater around the brain referred to as the subarachnoid space). Extensive conversation between Resident #1's family, Neurosurgery and SICU attending regarding how best to proceed moving forward resulted in Resident #1's family felt that she suffered and had significantly deteriorated over the past two days and decided to pursue comfort care only. Hospice was consulted and Resident #1 was transitioned to inpatient hospice the following day ([DATE]). Resident #1 was discharged to an inpatient hospice medical center on [DATE] with no resolved hospital problems. On [DATE], Resident #1 expired at the inpatient hospice medical center. Record review of the facility's self-report, received by the State Agency on [DATE], revealed on [DATE] at 6:30 a.m., Resident #1 was in the shower room with CNA A. CNA A sat Resident #1 on a shower bench to prepare the shower stall. When Resident #1 fell when she got up unassisted. The ADM first learned of the incident on [DATE] at approximately 7:00 a.m. RN B immediately assess Resident #1. NP reassessed Resident #1 on [DATE] around 9:00 a.m. There was a hematoma noted to Resident #1's right back of head. Ice was applied and neurological monitoring was started. Upon assessment, Resident #1 denied headaches or dizziness and did not vomit. Resident #1 did report right hip and groin pain. The facility staff notified Resident #1's family, physician, ADON who notified the ADM and DON, and Regional Nurse. Resident #1's family was present during NP's visit and requested Resident #1 be sent to the hospital. The facility staff sent Resident #1 to the hospital for further evaluation. X-rays were completed in the hospital and noted Resident #1 had a brain bleed. On [DATE] at 5:30 a.m., Resident #1's family spoke with the facility staff and reported Resident #1's hospital scans revealed she had a brain bleed, old rib fractures they attribute to were sustained due to a fall prior to admission, six vertebrae fractures that were osteoporosis related and a broken pubic bone that was unknown if it was acute with the fall or not, Resident #1 was placed on hospice in the hospital on [DATE] and possibly had a stroke that could have caused the fall. CNA A was suspended until further investigation was completed. In-services on abuse and neglect, falls, and reporting were conducted. Record review of the facility's Incident List, dated [DATE], revealed Resident #1 had a witnessed fall on [DATE] at 6:30 a.m. Record review of the facility's Admission/Discharge Report, from [DATE] through [DATE], revealed Resident #1 discharged to an acute care hospital on [DATE]. Record review of the facility's in-services revealed on [DATE], staff were educated on shower safety and taught to gather all supplies, ensure the shower room was ready prior to taking residents into the shower room, and to immediately report any suspicions of abuse/neglect to the ADM. Attached to the in-service was a copy of the State Agency's reporting guidelines and the facility's Assessing Falls and Their Causes policy and procedure revised in [DATE]. Record review of the facility's Change in a Resident's Condition or Status policy and procedure, revised February 2021, revealed the following, Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident. b. discovery of injuries of an unknown source. c. adverse reaction to medication. d. significant change in the resident's physical/emotional/mental condition. e. need to alter the resident's medical treatment significantly. f. refusal of treatment or medications two (2) or more consecutive times). g. need to transfer the resident to a hospital/treatment center. h. discharge without proper medical authority; and/or i. specific instruction to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). b. impacts more than one area of the resident's health status. c. requires interdisciplinary review and/or revision to the care plan; and d. ultimately is based on the judgment of the clinical team and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. The policy did not indicate CNA's responsibilities for who, what, when where and how to notify if they observe a resident had a change in condition or status. Record review of the facility's ADL's Supporting policy and procedure, revised [DATE], revealed the following, Residents will provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unabl [TRUNCATED]

Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Residents #1 and #2) of 6 reviewed for neglect and injuries of unknown origin. 1. The facility failed to report to SA within the required time frame of Resident #1's fall that resulted in a brain bleed and broken public bone. On [DATE], Resident #1's family reported to staff that Resident #1 sustained a brain bleed and broken pubic bone from her fall on [DATE]. 2. The facility failed to report to SA within the required time frame of Resident #2's injury of unknown source. On [DATE] at 1:30 a.m., staff observed Resident #2 had a hematoma to the left forehead, a skin tear to the left lower extremity and a swollen left wrist. This failure could place residents at risk of abuse, neglect, pain, and diminished quality of life. Findings included: 1. Record review of Resident #1's Admission Record, dated [DATE], revealed an [AGE] year-old female who was admitted to the facility on [DATE] and had diagnoses including unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), age-related osteoporosis (a condition in which bones become weak and brittle) without current pathological fracture, and unspecified low back pain. Record review of Resident #1's Quarterly MDS Assessment, dated [DATE], revealed a 3 BIMS score, which indicated she had severe cognitive impairment. Resident #1 also required partial/moderate assistance with showering/bathing herself and supervision or touching assistance with tub-shower transfers. Resident #1 had no falls since admission. Record review of Resident #1's Care Plan, dated [DATE], revealed Resident #1 at risk for falls related confusion, incontinence, unaware of safety needs. Resident #1 also had an ADL care performance deficit and required extensive assistance by one staff with showers and supervision assistance by one staff to move between surfaces. Record review of Resident #1's Progress Notes revealed the following: -A note created by RN B on [DATE] at 7:35 a.m., [CNA A] reported to nurse that [Resident #1] had a fall in the shower. Nurse assessed resident and resident is noted to have a hematoma to back of the right side of her. Ice pack applied to head, vitals stable. Resident assisted into a wheelchair by staff. AROM WNL for resident. CNA stated that resident was noted to have some increase confusion while in the shower and became startled and hopped up out of the chair and fell to the floor. Son made aware of incident. ADON and NP made aware. Neuro checks started. -A note created by RN B on [DATE] 8:34 p.m., [Resident #1] sent to [hospital] for evaluation per family request. -A note created by RN B on [DATE] at 8:40 p.m., [Resident #1] admitted to [hospital ]. Record review of Resident #1's Hospital Record, from [DATE] through [DATE], revealed she arrived at the hospital emergency department on [DATE] at 11:42 a.m. Resident #1's chief complaint was fall and hip and rib pain. Resident #1 was presented to the hospital's ER with her family after a fall. Resident #1's family reported Resident #1 was transferring from a chair the morning of [DATE] when she fell backwards and struck her head and had since been complaining of head, ribcage, and pelvic pain. Resident #1's physical exam at the hospital revealed her head was with a contusion (a bruise) and she exhibited decreased range of motion and tenderness to her right hip. Resident #1's x-rays found she had a nondisplaced right inferior pubic ramus fracture and right parietal scalp hematoma that underlying was an acute traumatic subarachnoid hemorrhage (the accumulation of blood in the space between the arachnoid membrane and the [NAME] mater around the brain referred to as the subarachnoid space). Extensive conversation between Resident #1's family, Neurosurgery and SICU attending regarding how best to proceed moving forward resulted in Resident #1's family felt that she suffered and had significantly deteriorated over the past two days and decided to pursue comfort care only. Hospice was consulted and Resident #1 was transitioned to inpatient hospice the following day ([DATE]). Resident #1 was discharged to an inpatient hospice medical center on [DATE] with no resolved hospital problems. On [DATE], Resident #1 expired at the inpatient hospice medical center. Record review of the facility's self-report, received by the SA on [DATE] at 8:11 a.m., revealed on [DATE] at 6:30 a.m., Resident #1 was in the shower room with CNA A. CNA A sat Resident #1 on a shower bench to prepare the shower stall. When Resident #1 fell when she got up unassisted. The ADM first learned of the incident on [DATE] at approximately 7:00 a.m. RN B immediately assess Resident #1. NP reassessed Resident #1 on [DATE] around 9:00 a.m. There was a hematoma noted to Resident #1's right back of head. Ice was applied and neurological monitoring was started. Upon assessment, Resident #1 denied headaches or dizziness and did not vomit. Resident #1 did report right hip and groin pain. The facility staff notified Resident #1's family, physician, ADON who notified the ADM and DON, and Regional Nurse. Resident #1's family was present during NP's visit and requested Resident #1 be sent to the hospital. The facility staff sent Resident #1 to the hospital for further evaluation. X-rays were completed in the hospital and noted Resident #1 had a brain bleed. On [DATE] at 5:30 a.m., Resident #1's family spoke with the facility staff and reported Resident #1's hospital scans revealed she had a brain bleed, old rib fractures they attribute to were sustained due to a fall prior to admission, six vertebrae fractures that were osteoporosis related and a broken pubic bone that was unknown if it was acute with the fall or not, Resident #1 was placed on hospice in the hospital on [DATE] and possibly had a stroke that could have caused the fall. CNA A was suspended until further investigation was completed. In-services on abuse and neglect, falls, and reporting were conducted. Record review of the facility's self-report email to SA revealed the facility staff submitted Resident #1's report on [DATE] at 9:18 a.m. 2. Record review of Resident #2's Admission Record, dated [DATE], revealed an [AGE] year-old female who was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, unspecified fracture of the lower end of the left radius (one of two bones in your forearm), chronic pain syndrome, and restlessness and agitation. Record review of Resident #2's Comprehensive MDS Assessment, dated [DATE], revealed a 4 BIMS score, which indicated she had severe cognitive impairment. The MDS reflected Resident #2 had no falls since admission. Record review of Resident #2's Care Plan, dated [DATE], revealed she was at high risk for falls related to impaired cognitions. Resident #1 also had an ADL care performance deficit. Record review of Resident #2's Progress Notes revealed the following: -A note created by LVN O on [DATE] at 3:43 a.m., Resident found lying in bed upon assessment discovered resident with a knot on left side of her head golf-ball size. Nurse did head to toe assessment and found resident left wrist to be sore, swollen, and painful to touch. Notified on call who ordered resident sent to ER for evaluation and treatment. Transported by ambulance to [hospital]. Accompany by EMT. Notified RP and ADON. Record review of the facility's self-report, received by the SA on [DATE] at 3:14 p.m., revealed on [DATE] at 1:30 a.m., Resident #2 fell in her room, there were no witnesses, Resident #2 crawled back in bed by herself, and LVN O noticed a hematoma on Resident #2's head when she turned on the lights during rounds and that Resident #2's left wrist was slightly swollen and sore. LVN O conducted a head-to-toe assessment, took vital signs, found neuros were within normal limits, Resident #2 had a hematoma to the left forehead, a skin tear to the left lower extremity and a swollen left wrist that ended up being fractured. Resident #2 told the staff she thought she fell and would be physically able to get herself up. LVN O applied ice to Resident #2's wrist and forehead before sending her to the hospital on [DATE] at 3:43 a.m. Cat scans were done at the hospital and came back within normal limits. A wrist splint and sling were applied to Resident #2's fractured left wrist. Safe surveys were performed and found all residents feel safe and do not have a problem asking staff for help. Resident #2's roommate was bedbound and no other residents were up wandering at that time. No injuries on other residents observed. Staff confirmed wrist fracture as investigative findings. During an interview on [DATE] at 9:46 a.m., the DON revealed the facility followed the SA's provider letter for reporting timeframes and guidelines. The DON stated her and the ADM reported alleged violations to SA. During an interview on [DATE] at 10:26 a.m., Resident #1's FAM revealed they notified the facility staff on [DATE] about Resident #1's hematoma found at the hospital due to her fall on [DATE]. During an interview on [DATE] at 11:12 a.m., the DON revealed a brain bleed constituted as a serious bodily injury . DON stated facility staff followed reporting guidelines for reporting to SA within 2 or 24 hours. DON also stated she reported to SA within 2 hours of Resident #1's FAM's notification to them of Resident #1's brain bleed. DON stated she was unable to determine at the time of the interview as to what time on [DATE] that LVN O made and reported her observation of Resident #2's swollen wrist and hematoma. DON also stated Resident #2 went to the hospital on [DATE] for injury of unknown origin and returned later that day. DON stated the facility staff notified her on [DATE] before sending Resident #2 to the hospital because of the swollen wrist and bump on her head. DON also stated she did not know why she did not notify SA within 2 hours of being notified of Resident #2's suspected injury of unknown origin and Resident #1's fall that resulted in great bodily injury. The residents' health and safety could be affected if staff were not reporting within required timeframes . During an interview on [DATE] at 2:23 p.m., the ADM revealed she was not aware that injury of unknown origin was to be reported within 2 hours. The ADM stated the residents' health and safety could be affected if staff were not reporting within required timeframes, especially for abuse incidents. During an interview on [DATE] at 3:01 p.m., the DON revealed she was notified of Resident #2's incident on [DATE] at 3:02 a.m. Record review of the facility's admission/transfer/discharge report, [DATE]-[DATE], revealed Resident #1 was discharged to the hospital on [DATE]. Resident #2 was not listed on the report. Record review of the facility's incident log, [DATE]-[DATE], revealed Resident #1's witnessed fall occurred on [DATE] at 6:30 a.m. and Resident #2's unwitnessed fall occurred on [DATE] at 3:14 a.m. Record review of the facility's Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating policy and procedure, revised [DATE], revealed the following, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. Record review of the facility's State Agency's Provider Letter, issued [DATE], revealed a nurse facility must report to the State Agency the following types of incidents, in accordance with applicable state and federal requirements: Neglect. Timeframes for reporting neglect incidents that result in serious bodily injury and injuries of unknown source are immediately, but not later than two hours after the incident occurs or is suspected. Timeframes for reporting an injury that does not result in serious bodily injury and involve neglect are immediately but not later than 24 hours after the incident occurs or is suspected. State Agency rules define neglect as, The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. Federal Agency defines neglect as, The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. To determine whether neglect may have occurred, a nurse facility must decide if an injury, emotional harm, pain or death of a resident was due to the facility's failure to provide goods or services to a resident. An injury is defined as an injury of unknown source when both of the following conditions are met: -The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and -The injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one point in time or the incidence of injuries over time. Record review of the facility's Abuse Prevention Program policy and procedure, revised [DATE], revealed the following, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. As part of the resident abuse prevention, the administration will: 7. Investigate and report any allegations of abuse within time frames as required by federal requirements.

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 the 69 residents and 33 staff members in the facility that contracted the COVID-19 virus. The facility failed follow recommendations provided by the CDC regarding infection control measures to prevent the spread of the coronavirus in the facility that included: A. There was a barrier to separate the COVID-19 designated wing from the rest facility. B. Proper storage of PPE and biohazard bags on the COVID-19 unit. C. On the COVID-19 unit, doors to be closed and the proper wearing of PPE for the residents. D. Social distancing of residents on the secure unit. E. Sanitation of equipment in between residents. F. Staff knowledgeable of which residents had tested positive for COVID-19. G. Failed to ensure all staff members had not worked at another COVID-19 facility. This resulted in the deaths 16 residents who contracted COVID-19. An Immediate Jeopardy (IJ) was identified on 04/25/2020. While the IJ was lowered on 4/30/2020, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. The facility failed to shield residents who reside in the secure unit from exposures to the COVID-19 virus which placed residents and staff at a greater risk of contracting the COVID-19 virus by failing to follow the recommendations from Center Disease and Control by: H. cohorting of residents testing positive for the coronavirus (COVID), keeping doors of positive residents closed to contain the spread of infection, and cohorting of staff to ensure the staff that provided care for the positive residents did not also provide care to the residents without the coronavirus. An Immediate Jeopardy (IJ) was identified on 05/14/2020. While the IJ was lowered on 5/17/2020, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern. Findings Include: A. Observation on 4/25/2020 at 3:50 p.m., revealed double doors were open from the front lobby to the station C and another set of double doors open which leads from station C the main dining room and kitchen. In an interview on 4/27/2020 at 2:30 p.m., via telephone, DSHS Epidemiologist, stated he had recommendations of: - for the facility to rework the direction in which staff members come into station C and exit station C. Epidemiologist stated the staff will have to exit the building and doff PPE in a tent to avoid cross contamination from walking through the hallways exiting the building from the front. - Epidemiologist stated the facility had a plan for tray carts to be delivered at the tunnel area, of the barrier that was being installed, and staff to place the trays on a cart that was being kept in the unit. Once the meal was completed then staff would place the trays on a table outside of the unit so that kitchen staff would be able to pick up the trays. According to the Centers for Disease controls' Interim Infection Prevention and Control Recommendation for Patients with Suspected or Confirmed Coronavirus Disease 2019 states that when long term care facilities have symptomatic or confirmed COVID-19 the resident should be on a unit with the door closed and a barrier should be a barrier in place to separate the residents on a designate COVID-19 unit. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.htm; https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html B. Observation on 4/25/2020 at 4:00 p.m., Yellow disposable gowns were available in the resident's rooms and hanging on the walls. However, gowns were observed to be hanging on the same hook or bundled up together on the tables. Observation on 4/25/2020 at 4:00 p.m., revealed no biohazard bags in each resident's room who were confirmed to have COVID-19. Observation on 4/26/2020 at 10:00 a.m., Yellow disposable gowns were available in all of the resident's rooms; however, the gowns were observed to be bundled together either on hooks or on a table. In an interview on 4/26/2020 at 11:00 a.m., CNA D and CNA E stated they did not know who was COVID positive and negative. CNA E stated she was not sure why she needed to know this information as she cares for each resident the same way by wearing a reusable yellow gown into each room Observation on 4/26/2020 at 11:00 a.m., no biohazard bags in each resident's room who was confirmed to have COVID-19. In an interview on 4/26/2020 at 12:15 a.m., ADON C stated each resident is treated the same and a yellow gown (which is kept in the room) is worn each time a facility staff member enters room to provide care. In an interview on 4/27/2020 at 12:15 p.m. CNA F stated she was not aware of who was positive or negative. CNA F stated when they go into rooms they are to place the yellow gown on prior to entering the room. In an interview on 4/25/2020 at 4:30 p.m., DON stated they in each resident room they have put into place a hook system for the yellow gowns. DON stated that for each room the staff are to don and doff the yellow gown, in the resident room, and hang up the gown to be reused. In an interview on 4/27/2020 at 2:30 p.m., via telephone., DSHS Epidemiologist, stated the facility had their staff wear a blue surgical gown and then had yellow gowns hanging up in the resident's room. Epidemiologist stated he did not recommend this practice with the yellow gowns. He stated staff should be using a new yellow gown per resident and per encounter because of the risk of cross contamination would be high with the way they were doing it. He stated the facility at this time had 8 residents who were negative, and facility is waiting for the residents to have another negative result. He stated there should not be any negative residents on the COVID-19 unit. According to the Centers for disease Control guidance on contact and droplet precautions dated 2019 states that when caring for a patient with COVID-19 staff should wear a new gown each time they enter the room and properly discard the gown before leaving the room. Disposable gowns should be discarded after each use. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.htm According to the CDC only residents with the same pathogens should be housed in the same room. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.htm According to the CDC dedicated equipment should be used when caring for patient known or suspected of having COVID-19. All multi use equipment used for patient care should be cleansed according to the manufactures instructions and facility policies. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.htm According to the CDC the doors used to house residents suspected or confirmed to have COVID-19 should be kept closed except when entering and exiting. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.htm C . Observation on 4/25/2020 at 4:00 p.m., revealed Resident #1, confirmed positive for COVID-19, walking in the hallway of Station C while wearing a mask. Observation revealed Resident #2, Resident #3, Resident #4 sitting next to the nursing station, who were confirmed positive for COVID-19, and these residents were not wearing a mask. Further observations of Station C revealed residents' doors were opened while residents were in their rooms. Observation on 4/26/20 at 10:00 a.m., revealed three residents who have tested for COVID-19 are found sitting in the common residential area as well as the group dining room (Resident #2, Resident #3, and Resident #4). Observation revealed resident's door observed to be open. Observation on 4/25/20 at 6:15p.m., revealed three residents who tested positive for COVID 19, Resident #2, Resident #3, and Resident #4 in the hallways and sitting in the common residential area without a mask on. Observation did not reveal facility staff attempting to redirect these residents to return to their rooms and or put on a mask. Observation on 4/27/2020 at 11:00 a.m., revealed many of the resident's rooms were left open and Resident #2 and Resident #3 were observed in the common area by nursing station not wearing a mask. Observation on 4/27/2020 at 2:00 p.m., revealed Resident #5, who had originally tested negative for COVID-19, was in the hallway without a mask in her wheelchair. Observation revealed Resident #3 in the lobby as well, who had tested Positive for COVID-19. Resident #5 or Resident #3 were not redirected by staff to return to their rooms during this observation. In an interview on 4/29/2020 at 10:38 a.m., DSHS epidemiologist stated the facility should keep residents who have tested negative and resident who have tested positive in their rooms, as much as possible, masked if out of their rooms to reduce the potential exposure. In an interview on 4/29/2020 at 4:29 p.m., DSHS Epidemiologist stated the resident doors needed to remain shut, continue keeping residents, who are resided on the COVID unit, that are pending results and confirmed positive in their rooms as much as possible, masked if they are out of their rooms to reduce the potential exposure as much as possible According to the Centers for Disease controls' Interim Infection Prevention and Control Recommendation for Patients with Suspected or Confirmed Coronavirus Disease 2019 states that when long term care facilities have symptomatic or confirmed COVID-19 the resident should be on a unit with the door closed and a barrier should be a barrier in place to separate the residents on a designate COVID-19 unit. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.htm; https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html According to the CDC residents should wear a face mask whenever they leave their rooms, including when residents leave the facility unless they have trouble breathing, unconscious, incapacitated, or they are unable to remove the mask by themselves. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html D. An observation on 4/25/2020 of the dinner time meal at 5:42 p.m. on the secure unit, revealed several tables of residents eating while not observing social distancing guidelines. The layout observed was as follows: - Table #1: two residents seated at the table facing each other. Both residents were within arms' length of each other. - Table #2: five residents seated at the table, facing each other. All five residents were within an arm's length apart from each other. - Table #3: seven residents seated at the table, facing each other. The seven residents were within arms' length of each other. - Table #4: two residents seated at the table facing each other. Both residents were within arms' length of each other. In an interview on 4/25/2020 at 5:45 p.m., LVN H stated that this is how each of the meals in the secure unit was conducted of how the population is in the secure unit. In an interview on 4/25/2020 6:12 p.m., DON stated the residents eat in their rooms for meals. However, that the secure unit was eating in the dining room during their normal time because this population would walk around. DON stated at this time not all of the secure unit tests have come back as negative. Review of CDC guidance reflected Healthcare personnel (HCP) working in memory care units in long-term care facilities including nursing homes, skilled nursing facilities, and assisted living facilities should follow the IPC guidance for those specific settings, which are considered supplemental guidance to the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.In addition to the current IPC guidance for long-term care facilities, nursing homes and assisted living facilities providing memory care should consider the following: Routines are very important for residents with dementia. Try to keep their environment and routines as consistent as possible while still reminding and assisting with frequent hand hygiene social distancing and use of cloth covering (if tolerated). Cloth face coverings should not be used for anyone who has trouble breathing, or is unconscious, incapacitated, or otherwise unable to remove the mask without assistance. Dedicate personnel to work only on memory care units when possible and try to keep staffing consistent. Limit personnel on the unit to only those essential for care. Continue to provide structured activities, which may need to occur in the resident's room or be scheduled at staggered times throughout the day to maintain social distancing. Provide safe ways for residents to continue to be active, such as personnel walking with individual residents around the unit or outside. Limit the number of residents or space residents at least 6 feet apart as much as feasible when in a common area, and gently redirect residents who are ambulatory and are in close proximity to other residents or personnel. https://www.cdc.gov/coronavirus/2019-ncov/hcp/memory-care.html E. Observation on 4/25/2020 at 4:30 p.m., revealed CMA I checked Resident #6's blood pressure with wrist cuff marked with CMA I's name. Observation did not reveal sanitation of the blood pressure cuff. Observation on 4/25/2020 at 5:10 p.m., CMA I took Resident #7's blood pressure with the same cuff as Resident #6 without sanitizing the blood pressure cuff. In an interview on 4/25/2020 at 5:15 p.m., CMA I stated the blood pressure cuff is her personal property. She stated she had not sanitized the blood pressure cuff and was unaware that she was supposed to do so in between residents. In an interview on 4/25/2020 at 5:50 p.m., DON stated it was her expectations for staff to sanitize equipment between the residents. In an interview on 4/27/2020 at 12:30 p.m., CMA J stated that she has been trained to sanitize the blood pressure cuff in between each of the residents. In an observation on 4/27/2020 at 12:21 p.m., revealed CMA J checking blood pressures on Station C, the assigned COVID-19 wing, with a wheeled blood pressure unit. Continuous observation revealed: - CMA J entered Resident #8, who was confirmed positive for COVID-19, and checked the residents blood pressure. After the blood pressure was check CMA J exited Resident #8's room. No sanitation of the blood pressure unit was observed. - CMA J Green entered Resident #9's room, with the same blood pressure cuff and checked Resident #9's blood pressure. Review of facility policy dated October 2018, titled Cleaning and Disinfection of Resident Care Items and equipment reflected resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Non-critical items are those that come in contact with intact skin but not mucous membranes. Non critical resident care items include bedpans, blood pressure cuffs. Reusable items are cleaned and disinfected between residents. Durable medical equipment must be cleaned and disinfected before reuse by another resident. F. In an interview on 4/25/2020 at 3:50 p.m., DON stated they had their first staff member received positive test results for COVID-19 on 4/23/2020 and her primary work assignment was on Station C. DON stated on 4/23/2020 she has 5 additional staff members from station C call in sick. DON stated she had worked with the local health department and was able to get the whole facility tested . DON stated the local health department started to focus on resident on station C because that appeared to have the most residents coming up positive for COVID-19. DON stated since most of the residents were coming up positive on the C wing they have designated this their COVID-19 unit. In an interview on 4/25/2020 at 4:30 p.m., LVN C stated she was not sure which residents were COVID-19 positive or COVID-19 negative due to resident results just came in and how could she possibly know. In an interview on 4/25/2020 at 530 p.m., ADON B stated she was told by the management that she had to work on the C-wing which is not her normal wing. ADON B stated she was unsure of which residents were COVID-19 positive and COVID-19 pending. In an interview on 4/25/2020 at 6:00 p.m., LVN C stated she was not aware which residents were positive and negative for COVID-19 so I treat them all the same. In an interview on 4/25/2020 at 8:00 p.m., DON stated that she did not expect staff to know who was COVID positive and negative because she just got the results in and was working on notifying the family. In an interview on 4/26/20 at 11:30 a.m., LVN C state she still was not sure who was COVID positive and negative but that she was treating each patient the same. In an interview on 4/27/2020 at 3:16 p.m., DON stated they have assigned one CNA to the residents who are negative for COVID-19 and pending the results of the re-swabbing. DON stated once the facility received a second negative result they will move the residents to an observation wing for 14 days. According to the CDC guidance regarding COVID-19 outbreaks in a facility recommends that signage should be present at the entrance of the COVID-19 unit which informs staff they must wear eye protection, and an N95 mask when entering the COVID-19 unit. Gowns and gloves should be added when entering residents' rooms. https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html G. Review of CMA G personnel file reflected her application was completed on 12/29/2019. Review of employment history revealed CMA identified Facility B as a current place of employment. Interview on 4/25/2020 at 5:00 p.m. CMA G stated she works at this facility as well as facility B. Observation on 4/25/2020 at 5:00 p.m. revealed CMA G medication aide going into residents' room without donning a yellow gown each time to pass medication to a new resident. In an interview on 4/25/2020 at 8:33 p.m., DON stated CMA G had not disclosed she was working at another facility. According to Texas Health and Human Services COVID-19 response for nursing facilities having a nursing facility staff member who works at more than one nursing facility is more likely to become exposed to COVID-19 virus and will likely expose other residents and staff in more than one nursing facility making it difficult to control the spread of the COVID-19 virus. To prevent transmission nursing facilities should use separate staffing teams fhttps://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/provider-portal/long-term-care/nf/covid-response-nursing-facilities.pdf Review of facility policy dated March 2020, titled Coronavirus Disease (COVID- 19) Prevention and Control. Policy reflected facility leadership and clinical team are implementing all reasonable measures to protect the health and safety of residents and tam during the current outbreak of coronavirus disease. The response to the current outbreak of coronavirus disease is based on the most current recommendations from health policy officials, state agencies and the federal government. Policy reflected current CDC guidelines will be followed for infection prevention and control of resident diagnosed with [REDACTED]. According to the CDC when a resident with new onset symptoms or confirmed COVID-19 should be placed in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV2 testing. Cohorting residents on the same unit based on symptoms alone could result in an inadvertent COVID-19 infection. Symptomatic residents should be housed separately if possible. If two residents are housed together care should be to ensure infection prevention and control measures are taken to reduce the risk of cross-contamination. Resident with COVID-19 and those who are showing symptoms of COVID-19 should not be housed together. https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html The Administrator was notified on 4/25/2020 at 8:14 p.m. of Immediate Jeopardy due to the above failure. The IJ template was signed on 4/25/2020. The following Plan of Removal was submitted by the Administrator on 04/26/2020, at 12:53 a.m. and was accepted by the Survey Team at 1:09 a.m. on 4/26/2020. The facility's plan of removal was as follows: - Environmental Services is working to secure a barrier system for installation at entrance to C Hall. Installed by 4/28/2020. Administrator will ensure this will occur. QAPI Committee will monitor and meet monthly and/or as needed. - Separate hooks to accommodate resident specific gown have been installed for all dually occupied rooms and labeled A or B. All direct care staff members are being in services regarding proper storage of gowns when not in use. Installed by 4/26/2020. QAPI committee will monitor and meet monthly and/or as needed. - All resident rooms doors have been closed as feasible; any residents refusing to allow room door to be closed is being instructed to remain in their room. Staff will monitor for compliance. Resident that are unwilling or unable to comply with process will be placed in a location to allow for social distancing, while allowing for ongoing monitoring. Staff is being in-serviced regarding proper use of masks. Masks are to be work at all times while in the facility. A surgical mask overlay will be worn while working with COVID-19 patients and will be labeled with individual staff members name. Surgical mask is used as an overlay and it will be disposed of at the end of the shift. Inservice initiated on 4/25/2020 to be completed on 4/28/2020. DON ensure that this will occur. QAPI committee will monitor and meet monthly and/or as needed. - Biohazard bags have been placed in all resident rooms and utility closets on the identified unit. Installed by 4/25/2020. DON will ensure this will occur. QAPI committee will monitor and meet monthly and/or as needed. - Resident records have been tagged to indicate COVID-19 status in the electronic medical record. A red colored dot system has been deployed with marking next to each COVID-19 positive resident's name at the entrance to their respective room while maintaining confidentiality. All staff members are being in-serviced with identifiers. Installed by 4/25/2020. Inservice started on 4/25/2020 and to be completed on 4/28/2020. DON will ensure this will occur. QAPI committee will monitor and meet monthly and/or as needed. - All staff members have completed questionnaires regarding employment at other facilities and have been informed that they can not work at other facilities concurrently. The staff member that has been identified has been suspended until further notice. All staff will be in serviced that they acknowledge not working at more than one facility. Inservice started on 4/25/2020 and to be completed on 4/28/2020. DON will ensure this will occur. QAPI committee will monitor and meet monthly and/or as needed. - Secure unit present additional challenges due to the nature of the population; efforts to feed residents in their rooms are not always successful, though will be attempted. Alternatively, the flor on the dining room is being taped at interval no closer than 6 feet apart to allow for appropriate spacing of overbed tables that will allow for social distancing during the meals. Two meal services will be done to meet the standard of no greater than 10 residents gathered in room at one time. Tables have been rearranged to accommodate 6 feet distancing. Taped to be installed on 4/25/2020. Administrator will ensure this will occur. QAPI committee will monitor and meet monthly and/or as needed. ADON will monitor that residents are encouraged to eat in rooms. QAPI committee will monitor and meet monthly and/or as needed. - All staff are being in-serviced on sanitizing equipment in between residents. Inservice initiated on 4/25/2020 and to be completed on 4/28/2020. QAPI committee will monitor and meet monthly and/or as needed. - Positive and negative residents will be isolated per result status. Completed on 4/26/2020. DON will ensure this will occur. QAPI committee will monitor and meet monthly and/or as needed. The Plan of Removal was monitored by the following: Review of In-service dated 4/25/2020 titled COVID-19 reflected resident records have been tagged to indicated COVID-19 status in the electronic medical record. A red colored dot system has been deployed with marking next to each COVID-19 positive resident's name at the entrance to their respective room while maintaining confidentiality. Separate hooks to accommodate resident specific gowns have been installed for all dually occupied rooms and labeled A or B. All direct care staff members are being in-serviced regarding proper storage of gowns when not in use. Review of In-services dated 4/25/2020 titled Staffing reflected all staff are required to notify Trinity ADON/DON od positions worked at any other facility. At this time staff are not allowed to work at more than one facility at a time. Staff must report if they have been exposed to a COVID-19 positive person. Signing this Inservice confirmed that you are not currently working at any other facility/job at this time. Review of signatures on in services were verified on staff roaster. Review of In-service dated 4/25/2020 titled Comprehensive assessments reflected nurses are responsible for completing comprehensive assessments on all COVID-19 positive residents and to also notify an RN and or NP of any changes. Review of In-service dated 4/25/2020 titled Cleaning reflected all equipment must be sanitized between use on each resident. This includes blood pressure cuffs, thermometer, pulse ox, wrist cuff, glucose machine. Anything that can be used on more than one resident. Observation on 4/26/2020 at 10:00 a.m., revealed no barrier in place to separate station C from the rest of the facility. Observation revealed there was not signage to indicate Station C was a COVID-19 unit and the resident were under droplet precautions. Observation on 4/27/2020 at 11:00 a.m., revealed a barrier was being constructed but was not completed. The double doors which lead to Station C were closed and signs were posted to indicate the need to apply PPE before entering the unit. Observation on 4/28/2020 at 2:24 p.m., Revealed barrier was in place for Station C. Observation on 4/28/2020 at 2:29 p.m., revealed bio hazard boxes at the end of each hall of Station C. The administrator was informed on 4/30/2020 at 5:00 p.m. the Immediate Jeopardy was removed, and that the facility remained out of compliance at a severity of actual harm and a scope identified as pattern. H. Review of Resident #26's facesheet reflected resident was an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 26's facesheet reflected COVID-19 [DIAGNOSES REDACTED]. Review of Resident #26's most recent MDS, quarterly, dated 4/21/2020 reflected Resident #26 received a 1 on her BIMS assessment which reflected a significant cognitive impairment. Review of Resident #26 progress notes dated 5/2/2020 reflected the resident was swabbed for a 3rd time and results were positive for COVID-19. Review of Resident #23's facesheet reflected Resident #23 was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #23's most recent MDS, quarterly, dated 2/6/2020 reflected resident received a 99 on her BIMS assessment due to not being able to complete the assessment. Review of Resident #10's facesheet reflected resident was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's most recent MDS, quarterly, dated 4/10/2020 reflected resident was not able to complete the BIMS assessment which reflected a cognitive impairment. Review of Resident #10's progress notes dated 5/3/2020 reflected responsible party notified of positive COVID-19 test results. Review of email, provided by the Administrator, dated 5/13/2020, revealed Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16 were positive for COVID -19. Review of the email revealed resident who needed to be retested reflected Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, and Resident #25. Observation on 5/13/2020 at 10:30 a.m., revealed on the memory care unit all of the residents room doors were opened. Observation on 5/13/2020 at 10:30 a.m., revealed, in the memory care unit, wearing white suites with hoods, face shields, and gloves. Observation on 5/13/2020 at 2:15 p.m., revealed Resident #23 (Pending COVID-19 retest) and Resident #26, who was confirmed positive were in the same room sleeping. Observation on 5/13/2020 at 2:30 p.m., with the ADON A revealed Resident #23, COVID-19 test was pending, was in the room with Resident #26, who was confirmed COVID-19 positive. Observation on 5/13/2020 at 6:00 p.m., revealed Resident #10, who is confirmed positive for COVID-19, was observed to wonder into room [ROOM NUMBER] and then room [ROOM NUMBER], these residents were pending COVID-19 test results. Further observation revealed Resident #10 walking down the hall to the dining room and picked up a cup from another resident's tray. Observation did not reveal staff intervention until resident picked up the cup. Observation on 5/15/2020 at 10:30 a.m., revealed residents, who had confirmed COVID-19 results, name plate marked with a red sticker. Resident with Confirmed COVID-19 results were roomed at the beginning of the hall in the memory care unit. Observation on 5/15/2020 at 10:30 a.m., revealed House Keeper cleaning Resident #24's room, who was pending COVID-19 results. Observation revealed House Keeper was wearing white suite with a hood, face shield and gloves. In an interview on 5/11/2020 at 4:43 p.m., DON stated when they had resident test positive on Unit B the facility was advised, by Health Department to lock down the unit and that is what the facility did. DON stated this unit has resident who have wondering behaviors and can not be moved off the unit. In an interview on 5/12/2020 at 9:39 a.m., via phone, DSHS Epidemiologist stated when he spoke about his team, and they are not recommending for facilities to (TRUNCATED)

Based on observation, interview and record review the facility failed to develop and implement written policy and procedures that prohibit neglect of residents for one (1)of eight (8) residents reviewed for neglect. The facility failed to thoroughly investigate, report to the Administrator and the State Agency and protect other female residents when Resident #16, who had a reported history of inappropriate sexual behavior, and lived on the secured unit, was not identified, assessed, care plan and interventions were not developed to prevent the resident from inappropriate sexual contact, touching Resident #19 as well as other unknown females. This deficient practice resulted in an Immediate Jeopardy (IJ) on 10/25/2012. While the IJ was removed on 10/26/2012, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm with a Scope of Pattern that is not IJ. This deficient practice placed 13 female residents who lived on the secured unit at risk of becoming victims of inappropriate sexual behavior that could cause mental, physical, and/or psychosocial harm. Findings include: Review of the facility undated Abuse/Neglect Policy reflected: " The resident has the right to be free from verbal, sexual physical or mental abuse, corporal punishment, and/or involuntary seclusion and/or injury from an unknown source. In the event of an evidence or cause to believe that a resident has suffered any of the above abuses, the employee, visitor, or family members are required to report all allegations, suspicions, or incidents to the administrator of the facility or the State officials posted in the facility. Upon report of any allegations or violations the Administer of his/her designated representative will thoroughly investigate the situation in accordance with Texas law. " Review of Preventing and Reporting Patient Abuse and Neglect dated 8/2010 reflected that " the company will not permit Patients to be subjected to abuse by anyone, including Associates, other patients. Consultants, volunteers, staff or personnel of other agencies serving the patient, family members, legal guardians, sponsors, friends, or other individuals. The company will follow state law (Senate Bill 9) concerning alleged abuse. " " Neglect: Failure to provide goods and services necessary to avoid harm, mental anguish or mental illness. " " Reporting abuse, neglect and mistreatment guidelines and investigation procedure for patients: Any facility staff member who has cause to believe that the physical or mental health or welfare of a patient has been, or may be, adversely affected by abuse, neglect or exploitation caused by another person is to report the abuse, neglect or exploitation immediately to his/her manager and the facility abuse/neglect coordinator. " Neglect: The facility must determine if any injury harm or death of a patient was due to facility failure to provide services, treatment, or care to a patient. Review of undated Rights of Nursing Home Facility Residents reflected residents have the right " to be free from abuse, neglect and exploitation. " During an interview on 10/24/2012 at 7:06 PM, Resident #16 ' s Responsible Party (RP) stated that he had received a phone call from a nurse at the facility on 10/19/2012, indicating that Resident #16 had demonstrated some " inappropriate sexual behaviors. " The RP did not know the name of the nurse who contacted him. The RP stated that when he asked for clarification on the behaviors, he was told that Resident #16 placed his hand down the pants and touched the breast of " multiple " female residents. The RP stated that he was told two females were involved and was only given the first name of one of the female residents. The RP stated Resident #16 " had a history of [REDACTED].#16 had a similar incident of " groping " an unknown female resident at the same facility. The RP stated in March, 2012 he was asked to come to the facility and fill out a consent for treatment for [REDACTED].#16's behaviors would subside. The RP stated the facility had not mentioned the consent form again until the phone call on 10/19/2012. Furthermore, the RP stated that a " couple years ago " , Resident #16, shortly after being admitted , was found in his room with an unknown female resident, and both residents were naked. The RP could not recall the name of the female resident that Resident # 16 was found naked with. The RP stated that the female resident had to be moved off the secured unit at that time to separate Resident #16 from her. The RP was initially reluctant to offer the information due to the belief that Resident #16 would be asked to leave the facility and stated "I don't know what to do with him." Observation on 10/23/2012 between 8:35 AM and 9:00 AM revealed Resident # 16 repetitively exiting and entering the door that leads to the secured courtyard. Observation on 10/24/2012 at 10:00 AM and 10/25/2012 at 12:30 PM revealed Resident # 16 repetitively exiting and entering the door that leads to the secured courtyard. An attempt was made to interview Resident # 16 on 10/25/2012 at 1:00 PM. Resident # 16 was unable to answer simple questions, and would only respond inappropriately with "ah huh". Review of Resident #16 ' s Face Sheet reflected that he was an [AGE] year old male that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #16 ' s Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected that Resident #16 had a Brief Interview for Mental Status (BIMS) score of three (3), indicating Resident #16 had severe cognitive impairment. The behavior section on the MDS only reflected that Resident #16 exhibited wandering behaviors. Review of the Comprehensive Care Plan on 10/23/2012 revealed there was no plan of care for Resident # 16's inappropriate sexual behavior. Review on 10/24/2012 revealed there was a plan of care that had been added with a problem onset date of 10/19/2012 that reflected "Resident exhibits sexually inappropriate behaviors. Resident started on [MEDICATION NAME]." (a medication to decrease the resident's libido, sexual drive or desire for sexual activity). Review of the Nurse's Notes from 02/01/2012 through 10/19/2012, did not reflect any documented inappropriate sexual behaviors for Resident #16. The Nurse s Notes dated 10/19/2012 reflected that Resident #16 " received new orders which was [MEDICATION NAME] 20 milligrams (mg) every (q) morning (AM) diagnosis (dx) sexual behavior." The Nurse's Notes reflected that Licensed Vocational Nurse (LVN) J wrote the progress note and that LVN J notified the RP concerning the incident. Review of the Behavior Tracking Form dated 11/2011 reflected that in the past year, since 11/28/11, there were only two (2) behaviors documented (11/28/11 and 10/3/12) and neither were for sexually inappropriate behavior. There were no documented incidents of inappropriate sexual behavior on the Behavior Monitoring Sheet. Review of the Incident/Accident Reports from 05/01/2012 through 10/26/2012 did not reflect any documented incidents of inappropriate sexual behavior between Resident # 16 and other female residents. The survey team requested the Administrator to provide incident/accident reports and investigations from 09/01/2011 through the present. In an interview on 10/22/2012, the Administrator stated she would provide the incident reports however would not provide investigations of incidents to the survey team. Review of the Subjective, Objective, Assessment and Plan (SOAP) Note dated 10/19/2012 reflected that the PPA was asked to see Resident #16 for "agitation and sexual behavior." The note did not reflect what sexual behavior Resident #16 had been exhibiting. The assessment reflected that Resident #16 had "advanced dementia with agitation and sexual aggression." The plan reflected that the sexual behavior was new and would be treated with medication ([MEDICATION NAME]). Review of Telephone Physician order [REDACTED]. During an interview on 10/25/2012 the Psychiatric Physician Assistant (PPA) stated that on 10/19/2012 during his regular visit at the facility, a nurse requested him to see Resident # 16 due to his inappropriate sexual behaviors and agitation. The PPA could not tell the survey team what nurse had requested him to see Resident # 16 but stated it was relayed to him that the resident's behavior had become an urgent matter that needed to be addressed. The PPA stated he saw Resident # 16 but did not perform an Initial Psychiatric Evaluation. The PPA stated [MEDICATION NAME] was ordered for Resident # 16.The PPA stated he could not remember what inappropriate sexual behaviors the resident was exhibiting that the staff told him about. The PPA stated he would not have prescribed [MEDICATION NAME] for the sole purpose of kissing on the check or caressing a shoulder. The PPA stated that he was told Resident #16 had formed an emotional attachment to a female resident (Resident # 19) and the incident of inappropriate sexual behavior did not include her. The PPA stated he normally "relies" on the information that is given to him by the nurses and does not usually review the documentation in the chart. In an interview on 10/24/2012 at 3:00 PM CNA N stated she had seen Resident # 16 rub on Resident # 19's back and leg, from the knee upwards, in the courtyard, sometime last week. CNA N stated she told the LVN G when the event occurred and separated the residents but did not remember putting the information in the tracking system for behaviors. CNA N stated she was instructed to separate the two residents but did not feel the behaviors were inappropriate. CNA N stated neither residents had cognitive skills to make a decision regarding sexual actions. In an interview on 10/24/2012 at 3:50 PM, LVN G stated she had observed incidents where Resident # 16 had been sexually inappropriate with Resident # 19. When asked, LVN G stated she had observed Resident # 16 kissing and rubbing Resident # 19's arm. LVN G stated she did not know when the incident occurred but thought it was last month sometime. LVN G stated Resident # 16 and Resident # 19 always go out into the courtyard, unsupervised, but are called back in if observation is made of inappropriate sexual behavior. LVN G stated inappropriate touching is considered abuse but did not remember reporting Resident # 19's actions to the Abuse Coordinator, DON, or RP. In an interview on 10/26/2012 at 9:15 AM LVN K stated she was the nurse on duty from 6:00 AM to 2:00 PM on 10/19/2012, the day the PPA was requested to see Resident # 16, but stated she did not make the request. LVN K stated she had not seen Resident # 16 exhibiting inappropriate sexual behavior, but she had been advised by other staff members that Resident # 16 had been found with his hand up the blouse of an unknown female resident. In an interview on 10/24/2012 at 2:50 PM Certified Nurse Aide (CNA) M stated when she observed Resident # 16 touching and/or kissing a female resident, it is her responsibility to separate the two residents. CNA M stated Resident # 16 is found touching and kissing Resident # 19 periodically and the last incident she observed happened a couple of weeks ago. CNA M stated she separated the two residents because LVN J requested she do so. When asked, CNA M could not give specific dates or times of incidents she had observed Resident # 16 inappropriately touching a female resident. CNA M stated facility policy required her to enter the inappropriate sexual behavior into the care tracking system but could not remember if she made the entry the day of the incident that happened a couple of weeks ago. CNA M stated she did not feel the incidents of Resident # 16's inappropriate sexual behavior with Resident # 19 was considered abusive; however, CNA M stated neither residents had cognitive skills to make a decision regarding sexual actions. During an interview on 10/23/2012 at 5:59 PM LVN J stated that she received the physician's orders [REDACTED].# 16, she was not the staff member that made the request. LVN J stated she did not know what happened to initiate a request for the PPA to see Resident # 16. LVN J stated that Resident #16 kisses and rubs on the arm of Resident #19 in the courtyard. LVN J stated she did remember Resident # 16 having a relationship with another woman but could not give the details, including the name, of the other woman. LVN J stated Resident # 16 was separated from the female resident. LVN J was requested by the survey team to give specific dates and times Resident # 16 had to be separated from other female residents, including Resident # 19, the LVN could not give that information. LVN J stated she did not feel Resident # 19 or # 16 was in danger but neither resident are cognitively aware enough to express sexual consent. Review of the Social Services MDS assessment dated [DATE] did not reflect any behaviors other than wandering for Resident #16. Further review reflected there were no Social Service MDS Assessment related to Resident # 16's sexual behaviors. In an interview on 10/24/2012 at 10:00 AM the MDS Coordinator stated the plan of care for Resident # 16's inappropriate sexual behaviors dated 10/19/2012 was originated on 10/23/2012. The MDS Coordinator stated there was not a plan of care for Resident # 16's inappropriate sexual behaviors until 10/23/2012. In an interview on 10/24/2012 at 5:05 PM, LVN I stated Resident # 16 hugs, rubs and kisses Resident # 19. LVN I stated when she observes incidents where Resident # 19 is rubbing, hugging or kissing Resident # 16 she redirects both residents because they are not cognitively aware enough to make a decision to engage in sexual acts. LVN I stated there is no policy or protocol in place to report public sexual acts to the Administrative staff and she is using her nursing judgment when she separates the two residents. In an interview on 10/24/2012 at 3:20 PM, CNA O stated he had seen Resident # 16 rubbing Resident # 19. CNA O stated he told the nurse because he felt it was odd. CNA O stated he did not separate the two residents and stated he did not know if the nurse did or not. When asked, CNA O could not give specific dates or times of incidents with Resident # 16. During an interview on 10/25/2012 at 9:30 AM the Director of Nursing (DON) stated that she was still getting to know Resident # 16 as she had begun working for the facility on 09/17/2012. The DON stated she did not know Resident # 16's background or behaviors. When asked how information and incidents that occur within the facility are passed along to the her and other Administrative staff, the DON stated she received a 24 hour report every morning, Monday through Friday, and that report is reviewed in the morning team meetings. The DON stated she received the 24 hour report for 10/19/2012 on 10/22/2012. The DON retrieved the 24 hour report for 10/19/2012, reviewed it, then stated Resident #16 was placed on [MEDICATION NAME] for inappropriate sexual behavior. The DON stated she did not clarify what the sexual behavior was that Resident #16 required medication to treat but was told Resident # 16 sits with a female resident and has been seen "patting" and "rubbing up and down the arm" of that female resident. The DON stated she did not remember if she advised the Social Worker (SW) to interview Resident # 16. The DON stated she does not sit and watch all day long to see if Resident # 16 was stroking the breast of female residents but that had not been relayed to her. The DON stated, although Resident # 16 was placed on [MEDICATION NAME] for inappropriate sexual behavior, it is in her professional opinion that " patting" and "rubbing" behavior described to her was not a behavior that warranted medication. The DON stated it was her expectation that an incident report be completed by nursing staff if an inappropriate sexual behavior is exhibited by any resident. She would use the incident reports to track and trend behaviors but had not been given an incident report for Resident # 16's inappropriate sexual behaviors. The DON also stated any inappropriate sexual behaviors should be entered into the nurse's notes and the behavior monitoring tracking system. The DON stated the Interdisciplinary Team (IDT)should investigate the reason behind an inappropriate sexual behavior but she did not know if Resident # 16's behavior had not been investigated. In an interview on 10/26/2012 at 10:00 AM, SW Q stated Assistant Director of Nurses (ADON) B came to her on 10/22/2012 and requested a Psychiatric Evaluation for Resident # 16 (3 days after a prescription for [MEDICATION NAME] was written for the resident). SW Q stated she did not see Resident # 16, nor look into the inappropriate sexual behaviors, but only notified Psychiatric Services to complete an evaluation. In an interview on 10/26/2012 9:15 AM the Vice President of Clinical Services, Vice President of Operations and Regional Nurse Consultant advised the team the Administrator had been told to step away from the survey because, whether by accident or on purpose, she had interfered with the survey process. In an interview on 10/26/2012 at 9:20 AM the Medical Director (MD), who is also designated as Resident # 16's Primary Care Physician (PCP) stated he was aware Resident # 16 had a girlfriend, but was not aware that other female residents were involved with the resident's inappropriate sexual behavior. The MD stated it was his expectation of staff to document all sexual behaviors and of course, the Administrative staff should be notified through the chain of command. The MD stated if the behavior was deemed to be unusual and/or violent, an incident report should be completed and given to the appropriate personnel of the facility, and further investigation should be conducted. The MD stated re-direction was the usual method used to intervene with inappropriate sexual behavior exhibited by residents and further stated it was difficult to have one-on-one supervision for an extended period of time. The MD stated it was the facility policy that an order had to be signed by the PCP before Psychiatric Services are performed. Review of Resident # 19's Face Sheet reflected an [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident # 19 had [DIAGNOSES REDACTED]. Review of Resident # 19's Annual MDS assessment dated [DATE] reflected, per staff interview, the resident scored a 03 for cognitive skills for daily decision making. A score of 03 indicated Resident # 19 had a severe cognitive impairment and never/rarely made decisions. Resident # 19's MDS Assessment reflected the resident exhibited wandering behaviors, but no sexual inappropriate behaviors were indicated. Review of Resident # 19's Comprehensive Care Plan reflected no plan of care for inappropriate sexual behaviors before 10/25/2012 Further review of Resident # 19's clinical record reflected there was no evidence the resident's RP had been notified and consented to Resident 19's inappropriate sexual behaviors with Resident # 16. Review of the Nurse's Notes dated 10/21/2012 at 5:00 PM reflected that a visitor reported that Resident #16 was "kissing a woman in the courtyard." The note reflected that the incident was reported to the nurse on duty and redirection was used to separate the two residents. Review of 24 hour report dated 10/21/2012 reflected Resident #16 was placed "on [MEDICATION NAME] 20mg q AM (every morning) - DX: Sexual behavior." Review of the Telephone Physician order [REDACTED].#16. Review of Resident # 16's medical chart reflected as of 10/26/2012 there was no documentation of a psychiatric evaluation. On 10/25/2012 at 10:05 AM the Administrator, Regional Nurse Consultant and Director of Nurses were informed that an IJ and SQC existed. On 10/26/12 at 3:43 PM, the Administrator provided the surveyor with a written plan of removal, which was accepted and reflected the following: Area Requiring Attention: Neglect: lack of supervision of a cognitive impaired resident with sexual inappropriate behavior. Corrective Action Taken: Psychology evaluation and services ongoing for Resident # 16. New medication, [MEDICATION NAME], ordered for Resident # 16 to decrease behaviors. One to one supervision of resident until behaviors subside and medication at therapeutic level as evidenced by staff observations of absence of inappropriate sexual behaviors. In-Service of all staff on abuse/neglect definitions and reporting. In-Service all staff on incident reporting/identification and reporting of sexual behaviors and notification of DON. All identified residents with sexual behaviors will be monitored for exacerbation of symptoms and managed through psychiatric services and IDT. All exacerbation of sexual behaviors will be reported to DON, placed on increased supervision as appropriate at onset of behavior until intervention is effective, referred to psychiatric services for evaluation and treatment of [REDACTED]. Any resident who exhibits sexually inappropriate behaviors towards another resident or staff member will have an incident report generated and internal investigation completed. To include assessment by licensed nurse, family and physician notified of incident and resident will be monitored for emotional distress and care plan updated. Incident will be reported to the appropriate agency (police department, DADS, ombudsman). DON or designee will conduct a meeting to review residents identified as having sexually inappropriate behaviors to monitor and review interventions and treatment. Results of meeting will be reported to QAA committee to include medical director for follow up by DON/designee for any further recommendations, weekly times 3 weeks, then monthly times 3 months and as needed thereafter. The survey team confirmed the facility had begun to carry out the Plan of Removal as follows: Observation made on 10/25/2012 at 1:00 PM revealed Resident # 16 had been placed on one-on-one supervision. Record review of the in-service sign-in sheets reflected approximately 75% of facility staff had been in-serviced. Interviews with staff on 10/26/2012 between 4:00 PM and 5:00 PM revealed the in-service regarding Abuse/Neglect, what to report, who to report and when to complete an incident report had been provided to the staff on duty. The facility provided a list of residents identified as having sexual behaviors and care plans and interventions had been put into place for those residents. While the IJ was removed on 10/26/12 at 5:00 PM, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility did not have time to monitor the Plan of Removal for effectiveness or to train all staff. Review of the facility CMS Form 802 revealed 13 cognitively impaired female residents lived on the secured unit.

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit neglect for one (1) of eight (8) residents reviewed for neglect when: Resident #16, who had a reported history of inappropriate sexual behavior, and lived on the secured unit, was not identified, assessed, care plan and interventions were not developed to prevent the resident from inappropriate sexual contact, touching Resident #19 as well as other unknown females. This deficient practice resulted in an Immediate Jeopardy (IJ) on 10/25/2012. While the IJ was removed on 10/26/2012, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm with a Scope of Pattern that is not IJ. This deficient practice placed 13 female residents who lived on the secured unit at risk of becoming victims of inappropriate sexual behavior that could cause mental, physical, and/or psychosocial harm. Findings include: During an interview on 10/24/2012 at 7:06 PM, Resident #16 ' s Responsible Party (RP) stated that he had received a phone call from a nurse at the facility on 10/19/2012, indicating that Resident #16 had demonstrated some " inappropriate sexual behaviors. " The RP did not know the name of the nurse who contacted him. The RP stated that when he asked for clarification on the behaviors, he was told that Resident #16 placed his hand down the pants and touched the breast of " multiple " female residents. The RP stated that he was told two females were involved and was only given the first name of one of the female residents. The RP stated Resident #16 " had a history of [REDACTED].#16 had a similar incident of " groping " an unknown female resident at the same facility. The RP stated in March, 2012 he was asked to come to the facility and fill out a consent for treatment for [REDACTED].#16's behaviors would subside. The RP stated the facility had not mentioned the consent form again until the phone call on 10/19/2012. Furthermore, the RP stated that a " couple years ago " , Resident #16, shortly after being admitted , was found in his room with an unknown female resident, and both residents were naked. The RP could not recall the name of the female resident that Resident # 16 was found naked with. The RP stated that the female resident had to be moved off the secured unit at that time to separate Resident #16 from her. The RP was initially reluctant to offer the information due to the belief that Resident #16 would be asked to leave the facility and stated "I don't know what to do with him." Observation on 10/23/2012 between 8:35 AM and 9:00 AM revealed Resident # 16 repetitively exiting and entering the door that leads to the secured courtyard. Observation on 10/24/2012 at 10:00 AM and 10/25/2012 at 12:30 PM revealed Resident # 16 repetitively exiting and entering the door that leads to the secured courtyard. An attempt was made to interview Resident # 16 on 10/25/2012 at 1:00 PM. Resident # 16 was unable to answer simple questions, and would only respond inappropriately with "ah huh". Review of Resident #16 ' s Face Sheet reflected that he was an [AGE] year old male that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #16 ' s Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected that Resident #16 had a Brief Interview for Mental Status (BIMS) score of three (3), indicating Resident #16 had severe cognitive impairment. The behavior section on the MDS only reflected that Resident #16 exhibited wandering behaviors. Review of the Comprehensive Care Plan on 10/23/2012 revealed there was no plan of care for Resident # 16's inappropriate sexual behavior. Review on 10/24/2012 revealed there was a plan of care that had been added with a problem onset date of 10/19/2012 that reflected "Resident exhibits sexually inappropriate behaviors. Resident started on [MEDICATION NAME]." (a medication to decrease the resident's libido, sexual drive or desire for sexual activity). Review of the Nurse's Notes from 02/01/2012 through 10/19/2012, did not reflect any documented inappropriate sexual behaviors for Resident #16. The Nurse s Notes dated 10/19/2012 reflected that Resident #16 " received new orders which was [MEDICATION NAME] 20 milligrams (mg) every (q) morning (AM) diagnosis (dx) sexual behavior." The Nurse's Notes reflected that Licensed Vocational Nurse (LVN) J wrote the progress note and that LVN J notified the RP concerning the incident. Review of the Behavior Tracking Form dated 11/2011 reflected that in the past year, since 11/28/11, there were only two (2) behaviors documented (11/28/11 and 10/3/12) and neither were for sexually inappropriate behavior. There were no documented incidents of inappropriate sexual behavior on the Behavior Monitoring Sheet. Review of the Incident/Accident Reports from 05/01/2012 through 10/26/2012 did not reflect any documented incidents of inappropriate sexual behavior between Resident # 16 and other female residents. The survey team requested the Administrator to provide incident/accident reports and investigations from 09/01/2011 through the present. In an interview on 10/22/2012, the Administrator stated she would provide the incident reports however would not provide investigations of incidents to the survey team. Review of the Subjective, Objective, Assessment and Plan (SOAP) Note dated 10/19/2012 reflected that the PPA was asked to see Resident #16 for "agitation and sexual behavior." The note did not reflect what sexual behavior Resident #16 had been exhibiting. The assessment reflected that Resident #16 had "advanced dementia with agitation and sexual aggression." The plan reflected that the sexual behavior was new and would be treated with medication ([MEDICATION NAME]). Review of Telephone Physician order [REDACTED]. During an interview on 10/25/2012 the Psychiatric Physician Assistant (PPA) stated that on 10/19/2012 during his regular visit at the facility, a nurse requested him to see Resident # 16 due to his inappropriate sexual behaviors and agitation. The PPA could not tell the survey team what nurse had requested him to see Resident # 16 but stated it was relayed to him that the resident's behavior had become an urgent matter that needed to be addressed. The PPA stated he saw Resident # 16 but did not perform an Initial Psychiatric Evaluation. The PPA stated [MEDICATION NAME] was ordered for Resident # 16.The PPA stated he could not remember what inappropriate sexual behaviors the resident was exhibiting that the staff told him about. The PPA stated he would not have prescribed [MEDICATION NAME] for the sole purpose of kissing on the check or caressing a shoulder. The PPA stated that he was told Resident #16 had formed an emotional attachment to a female resident (Resident # 19) and the incident of inappropriate sexual behavior did not include her. The PPA stated he normally "relies" on the information that is given to him by the nurses and does not usually review the documentation in the chart. In an interview on 10/24/2012 at 3:00 PM CNA N stated she had seen Resident # 16 rub on Resident # 19's back and leg, from the knee upwards, in the courtyard, sometime last week. CNA N stated she told the LVN G when the event occurred and separated the residents but did not remember putting the information in the tracking system for behaviors. CNA N stated she was instructed to separate the two residents but did not feel the behaviors were inappropriate. CNA N stated neither residents had cognitive skills to make a decision regarding sexual actions. In an interview on 10/24/2012 at 3:50 PM, LVN G stated she had observed incidents where Resident # 16 had been sexually inappropriate with Resident # 19. When asked, LVN G stated she had observed Resident # 16 kissing and rubbing Resident # 19's arm. LVN G stated she did not know when the incident occurred but thought it was last month sometime. LVN G stated Resident # 16 and Resident # 19 always go out into the courtyard, unsupervised, but are called back in if observation is made of inappropriate sexual behavior. LVN G stated inappropriate touching is considered abuse but did not remember reporting Resident # 19's actions to the Abuse Coordinator, DON, or RP. In an interview on 10/26/2012 at 9:15 AM LVN K stated she was the nurse on duty from 6:00 AM to 2:00 PM on 10/19/2012, the day the PPA was requested to see Resident # 16, but stated she did not make the request. LVN K stated she had not seen Resident # 16 exhibiting inappropriate sexual behavior, but she had been advised by other staff members that Resident # 16 had been found with his hand up the blouse of an unknown female resident. In an interview on 10/24/2012 at 2:50 PM Certified Nurse Aide (CNA) M stated when she observed Resident # 16 touching and/or kissing a female resident, it is her responsibility to separate the two residents. CNA M stated Resident # 16 is found touching and kissing Resident # 19 periodically and the last incident she observed happened a couple of weeks ago. CNA M stated she separated the two residents because LVN J requested she do so. When asked, CNA M could not give specific dates or times of incidents she had observed Resident # 16 inappropriately touching a female resident. CNA M stated facility policy required her to enter the inappropriate sexual behavior into the care tracking system but could not remember if she made the entry the day of the incident that happened a couple of weeks ago. CNA M stated she did not feel the incidents of Resident # 16's inappropriate sexual behavior with Resident # 19 was considered abusive; however, CNA M stated neither residents had cognitive skills to make a decision regarding sexual actions. During an interview on 10/23/2012 at 5:59 PM LVN J stated that she received the physician's orders [REDACTED].# 16, she was not the staff member that made the request. LVN J stated she did not know what happened to initiate a request for the PPA to see Resident # 16. LVN J stated that Resident #16 kisses and rubs on the arm of Resident #19 in the courtyard. LVN J stated she did remember Resident # 16 having a relationship with another woman but could not give the details, including the name, of the other woman. LVN J stated Resident # 16 was separated from the female resident. LVN J was requested by the survey team to give specific dates and times Resident # 16 had to be separated from other female residents, including Resident # 19, the LVN could not give that information. LVN J stated she did not feel Resident # 19 or # 16 was in danger but neither resident are cognitively aware enough to express sexual consent. Review of the Social Services MDS assessment dated [DATE] did not reflect any behaviors other than wandering for Resident #16. Further review reflected there were no Social Service MDS Assessment related to Resident # 16's sexual behaviors. In an interview on 10/24/2012 at 10:00 AM the MDS Coordinator stated the plan of care for Resident # 16's inappropriate sexual behaviors dated 10/19/2012 was originated on 10/23/2012. The MDS Coordinator stated there was not a plan of care for Resident # 16's inappropriate sexual behaviors until 10/23/2012. In an interview on 10/24/2012 at 5:05 PM, LVN I stated Resident # 16 hugs, rubs and kisses Resident # 19. LVN I stated when she observes incidents where Resident # 19 is rubbing, hugging or kissing Resident # 16 she redirects both residents because they are not cognitively aware enough to make a decision to engage in sexual acts. LVN I stated there is no policy or protocol in place to report public sexual acts to the Administrative staff and she is using her nursing judgment when she separates the two residents. In an interview on 10/24/2012 at 3:20 PM, CNA O stated he had seen Resident # 16 rubbing Resident # 19. CNA O stated he told the nurse because he felt it was odd. CNA O stated he did not separate the two residents and stated he did not know if the nurse did or not. When asked, CNA O could not give specific dates or times of incidents with Resident # 16. During an interview on 10/25/2012 at 9:30 AM the Director of Nursing (DON) stated that she was still getting to know Resident # 16 as she had begun working for the facility on 09/17/2012. The DON stated she did not know Resident # 16's background or behaviors. When asked how information and incidents that occur within the facility are passed along to the her and other Administrative staff, the DON stated she received a 24 hour report every morning, Monday through Friday, and that report is reviewed in the morning team meetings. The DON stated she received the 24 hour report for 10/19/2012 on 10/22/2012. The DON retrieved the 24 hour report for 10/19/2012, reviewed it, then stated Resident #16 was placed on [MEDICATION NAME] for inappropriate sexual behavior. The DON stated she did not clarify what the sexual behavior was that Resident #16 required medication to treat but was told Resident # 16 sits with a female resident and has been seen "patting" and "rubbing up and down the arm" of that female resident. The DON stated she did not remember if she advised the Social Worker (SW) to interview Resident # 16. The DON stated she does not sit and watch all day long to see if Resident # 16 was stroking the breast of female residents but that had not been relayed to her. The DON stated, although Resident # 16 was placed on [MEDICATION NAME] for inappropriate sexual behavior, it is in her professional opinion that " patting" and "rubbing" behavior described to her was not a behavior that warranted medication. The DON stated it was her expectation that an incident report be completed by nursing staff if an inappropriate sexual behavior is exhibited by any resident. She would use the incident reports to track and trend behaviors but had not been given an incident report for Resident # 16's inappropriate sexual behaviors. The DON also stated any inappropriate sexual behaviors should be entered into the nurse's notes and the behavior monitoring tracking system. The DON stated the Interdisciplinary Team (IDT)should investigate the reason behind an inappropriate sexual behavior but she did not know if Resident # 16's behavior had not been investigated. In an interview on 10/26/2012 at 10:00 AM, SW Q stated Assistant Director of Nurses (ADON) B came to her on 10/22/2012 and requested a Psychiatric Evaluation for Resident # 16 (3 days after a prescription for [MEDICATION NAME] was written for the resident). SW Q stated she did not see Resident # 16, nor look into the inappropriate sexual behaviors, but only notified Psychiatric Services to complete an evaluation. In an interview on 10/26/2012 9:15 AM the Vice President of Clinical Services, Vice President of Operations and Regional Nurse Consultant advised the team the Administrator had been told to step away from the survey because, whether by accident or on purpose, she had interfered with the survey process. In an interview on 10/26/2012 at 9:20 AM the Medical Director (MD), who is also designated as Resident # 16's Primary Care Physician (PCP) stated he was aware Resident # 16 had a girlfriend, but was not aware that other female residents were involved with the resident's inappropriate sexual behavior. The MD stated it was his expectation of staff to document all sexual behaviors and of course, the Administrative staff should be notified through the chain of command. The MD stated if the behavior was deemed to be unusual and/or violent, an incident report should be completed and given to the appropriate personnel of the facility, and further investigation should be conducted. The MD stated re-direction was the usual method used to intervene with inappropriate sexual behavior exhibited by residents and further stated it was difficult to have one-on-one supervision for an extended period of time. The MD stated it was the facility policy that an order had to be signed by the PCP before Psychiatric Services are performed. Review of Resident # 19's Face Sheet reflected an [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident # 19 had [DIAGNOSES REDACTED]. Review of Resident # 19's Annual MDS assessment dated [DATE] reflected, per staff interview, the resident scored a 03 for cognitive skills for daily decision making. A score of 03 indicated Resident # 19 had a severe cognitive impairment and never/rarely made decisions. Resident # 19's MDS Assessment reflected the resident exhibited wandering behaviors, but no sexual inappropriate behaviors were indicated. Review of Resident # 19's Comprehensive Care Plan reflected no plan of care for inappropriate sexual behaviors before 10/25/2012 Further review of Resident # 19's clinical record reflected there was no evidence the resident's RP had been notified and consented to Resident 19's inappropriate sexual behaviors with Resident # 16. Review of the Nurse's Notes dated 10/21/2012 at 5:00 PM reflected that a visitor reported that Resident #16 was "kissing a woman in the courtyard." The note reflected that the incident was reported to the nurse on duty and redirection was used to separate the two residents. Review of 24 hour report dated 10/21/2012 reflected Resident #16 was placed "on [MEDICATION NAME] 20mg q AM (every morning) - DX: Sexual behavior." Review of the Telephone Physician order [REDACTED].#16. Review of Resident # 16's medical chart reflected as of 10/26/2012 there was no documentation of a psychiatric evaluation. Review of the facility undated Abuse/Neglect Policy reflected: " The resident has the right to be free from verbal, sexual physical or mental abuse, corporal punishment, and/or involuntary seclusion and/or injury from an unknown source. In the event of an evidence or cause to believe that a resident has suffered any of the above abuses, the employee, visitor, or family members are required to report all allegations, suspicions, or incidents to the administrator of the facility or the State officials posted in the facility. Upon report of any allegations or violations the Administer of his/her designated representative will thoroughly investigate the situation in accordance with Texas law. " Review of Preventing and Reporting Patient Abuse and Neglect dated 8/2010 reflected that " the company will not permit Patients to be subjected to abuse by anyone, including Associates, other patients. Consultants, volunteers, staff or personnel of other agencies serving the patient, family members, legal guardians, sponsors, friends, or other individuals. The company will follow state law (Senate Bill 9) concerning alleged abuse. " " Neglect: Failure to provide goods and services necessary to avoid harm, mental anguish or mental illness. " " Reporting abuse, neglect and mistreatment guidelines and investigation procedure for patients: Any facility staff member who has cause to believe that the physical or mental health or welfare of a patient has been, or may be, adversely affected by abuse, neglect or exploitation caused by another person is to report the abuse, neglect or exploitation immediately to his/her manager and the facility abuse/neglect coordinator. " Neglect: The facility must determine if any injury harm or death of a patient was due to facility failure to provide services, treatment, or care to a patient. Review of undated Rights of Nursing Home Facility Residents reflected residents have the right " to be free from abuse, neglect and exploitation. " On 10/25/2012 at 10:05 AM the Administrator, Regional Nurse Consultant and Director of Nurses were informed that an IJ and SQC existed. On 10/26/12 at 3:43 PM, the Administrator provided the surveyor with a written plan of removal, which was accepted and reflected the following: Area Requiring Attention: Neglect: lack of supervision of a cognitive impaired resident with sexual inappropriate behavior. Corrective Action Taken: Psychology evaluation and services ongoing for Resident # 16. New medication, [MEDICATION NAME], ordered for Resident # 16 to decrease behaviors. One to one supervision of resident until behaviors subside and medication at therapeutic level as evidenced by staff observations of absence of inappropriate sexual behaviors. In-Service of all staff on abuse/neglect definitions and reporting. In-Service all staff on incident reporting/identification and reporting of sexual behaviors and notification of DON. All identified residents with sexual behaviors will be monitored for exacerbation of symptoms and managed through psychiatric services and IDT. All exacerbation of sexual behaviors will be reported to DON, placed on increased supervision as appropriate at onset of behavior until intervention is effective, referred to psychiatric services for evaluation and treatment of [REDACTED]. Any resident who exhibits sexually inappropriate behaviors towards another resident or staff member will have an incident report generated and internal investigation completed. To include assessment by licensed nurse, family and physician notified of incident and resident will be monitored for emotional distress and care plan updated. Incident will be reported to the appropriate agency (police department, DADS, ombudsman). DON or designee will conduct a meeting to review residents identified as having sexually inappropriate behaviors to monitor and review interventions and treatment. Results of meeting will be reported to QAA committee to include medical director for follow up by DON/designee for any further recommendations, weekly times 3 weeks, then monthly times 3 months and as needed thereafter. The survey team confirmed the facility had begun to carry out the Plan of Removal as follows: Observation made on 10/25/2012 at 1:00 PM revealed Resident # 16 had been placed on one-on-one supervision. Record review of the in-service sign-in sheets reflected approximately 75% of facility staff had been in-serviced. Interviews with staff on 10/26/2012 between 4:00 PM and 5:00 PM revealed the in-service regarding Abuse/Neglect, what to report, who to report and when to complete an incident report had been provided to the staff on duty. The facility provided a list of residents identified as having sexual behaviors and care plans and interventions had been put into place for those residents. While the IJ was removed on 10/26/12 at 5:00 PM, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility did not have time to monitor the Plan of Removal for effectiveness or to train all staff. Review of the facility CMS Form 802 revealed 13 cognitively impaired female residents lived on the secured unit.