Every finding on record at Van Healthcare

Based on interview and record review, the facility failed to ensure each resident had the right to be free from misappropriation of property, and exploitation for 1 of 5 residents (Resident #1) reviewed for misappropriation of property.The facility failed to prevent the misappropriation of Resident #1's checkbook on 06/09/2026. The noncompliance was identified as PNC. The noncompliance began on 06/25/2026 and ended on 06/27/2026. The facility had corrected the noncompliance before the investigation began on 07/09/2026.This failure could place residents at risk for misappropriation of their personal property. Findings included: Record review of Resident #1's face sheet dated 07/09/2026 indicated Resident #1 was an [AGE] year-old female admitted on [DATE]. Resident #1 had diagnoses including epilepsy (a brain disease where nerve cells don't signal properly, which causes seizures), psychosis, anxiety, hallucinations, high blood pressure and a fractured right humerus.Record review of Resident #1's admission MDS assessment dated [DATE] indicated Resident #1 had clear speech, was understood and could understand others. She had a BIMS score of 10 indicating moderate cognitive impairment. Resident #1 required substantial to partial assistance with all ADLs and was incontinent of bowel and bladder.Record review of the facility's Provider Investigation Report dated 06/30/2026 indicated, officers with the local police department contacted the administrator to inform the facility CNA A had allegedly stolen a checkbook belonging to Resident #1 and attempted to cash several checks. Resident #1 had no money lost from her checking account because the bank denied payment on the checks. The CNA was an employee of a healthcare staffing company and only worked one shift from 10:00 PM-6:00 AM on 06/09/2026. Resident #1 was unaware the checkbook was missing. The resident's family member was notified and said they were the one that had notified the police department of the theft.During an interview on 07/09/2026 at 8:40 PM, the Administrator said the facility had been working closely with the local police department because they were actively trying to apprehend CNA A. He said the CNA had other warrants for his arrest for similar incidents at other facilities. He said the police department came to the facility on [DATE] to inform them of the theft of the checkbook. He said the police wanted everything to be kept quiet and did not want the facility to report or alert the staffing agency. He said he told them he was required to notify the state of the incident but would try to keep it very quiet and information away from general staff and residents. He said he did some general interviews with residents to determine if they had any missing items and he said none of the residents had anything missing. He said residents said they felt safe at the facility. He said staff were given a general inservice on abuse, neglect, exploitation, reporting guidelines and misappropriation of property. He said he did not disclose any specifics to staff but was a general inservice that was usually held twice a year. During an interview on 07/09/2026 at 9:20 AM, Resident #1 was in her room and said she was treated really well by the staff and she received assistance when she needed it. She said she had her checkbook stolen but did not know when it happened but her family member reported it to her. She said she was aware the police knew who did it. She said she felt safe at the facility but realized she might need to be more cautious now.During an interview on 07/09/2026 at 10:15 AM, CNA B said she had received an inservice recently on abuse, neglect, and exploitation. She said they were told the abuse coordinator was the administrator. She said she understood the reporting procedures. She said Resident #1 had told her she had something missing but did not tell her what it was.During an interview on 07/09/2026 at 11:30 AM, LVN C said they had a recent inservice on abuse, neglect, and exploitation. She said the Administrator was the abuse coordinator. She said no residents had reported anything missing. She said she would report a missing item if they could not find it. She said items they looked for were not taken or missing just misplaced,During an interview on 07/09/2026 at 11:40 AM, MA D said she had a recent inservice on abuse, neglect, and exploitation and the Administrator was the abuse coordinator. She said no residents have reported any issues or missing items. During an interview on 07/09/2026 at 11:42 AM, DA/LA E said they had explained the types of abuse and about exploitation and to report to the Administrator as the abuse coordinator. She said no residents had reported missing items.During an interview on 07/09/2026 at 11:44 AM, DA/LA F said they had explained the types of abuse and about exploitation and the Administrator was the abuse coordinator and things are reported to him. She said no residents had reported missing items.During an interview on 07/09/2026 at 11:45 AM, the DM said they had a recent inservice on abuse, neglect, and exploitation. She said her laundry personnel were very familiar with the residents' clothes and rarely do they have any reported missing. She said usually something would be in their closet and they just could not see it. She said if they cannot find the missing item she would report it to the Administrator so he can replace the item.During an interview on 07/09/2026 at 11:55 AM, CNA G said she had a recent inservice on abuse, neglect and exploitation. She said the Administrator was the abuse coordinator and any issues with abuse or exploitation should be reported to him immediately. She said no one had reported anything missing on her end of the hall. During an interview on 07/09/2026 at 12:50 PM, Detective H said the police department started the case on 06/26/2026 when a family member reported the checkbook stolen from a resident at the facility. He said a warrant had been issued on 07/06/2026 for CNA A. He said they had not been able to find him at home because he had moved and they did not want to go to an incorrect location and scare him off. He said the facility had been working with the police department to keep everything quiet and post another shift vacancy hoping he would sign up to work another shift and the police could arrest him at the facility when he came to work. He said the police department had a video from a check cashing establishment where he had attempted to cash a check on Resident #1's account for $3,500.00. He said the check cashing establishment called a phone number and was routed to the resident's family member who told them the check was fraudulent and they did not cash it. He said CNA A left the establishment but he had his face on video and the company had his identification. He said the CNA had been successful at 2 local banks with checks for $1,500.00 each but the resident's bank did not pay those checks. He said the resident did not lose any money from her account. He said he did not interview any staff or residents at the facility because he was trying to keep everything quiet and only spoke with the Administrator, DON and ADON. He said the CNA had 2 more warrants in 2 other counties for similar offenses. He said he would not give the video or information to the state until he was able to apprehend the suspect and then he would give all the information and reports requested. The case number was 26-00228.During an interview on 07/09/2026 at 1:15 PM the Administrator said the ADON had been the charge nurse on 06/09/2026 when CNA A worked his one shift. He said the nurses worked 12 hour shifts and the CNAs worked 8 hour shifts.During an interview on 07/09/2026 at 1:17 PM the ADON said she was the charge nurse on the night shift on 06/09/2026 when CNA A worked his shift. She said CNA A worked halls C and D and the other CNA worked halls A and B. She said CNA A did not act oddly or strangely. She said no residents complained of any issues with the CNA. She said she had plenty of residents who would speak out if they were upset about something. She said he made his rounds and did his job very well. She said he was very good and did everything he was supposed to do and no residents had complained that things had been left undone or not finished. She said he was clean shaven and neat in appearance and did not do anything that would have called attention to himself. She said there were no indications he was up to something. She said he did sneak around or spend extra time in the residents' rooms. She said no one complained of anyone going through their things or their drawers or cabinets. The ADON said she had sent him a text on 07/08/2026 requesting him to contact her if he was interested in some more shifts at the facility but had not received any response. She said the current staffing agency had dropped him from all shifts and was only letting him pick up the facility's posting.A review of the state reporting website indicated CNA A had been referred for similar allegations of misappropriation at another facility.The facility took the following actions to correct the non-compliance:Conducted safe surveys with alert and oriented residents regarding whether they had any missing items and whether they felt safe at the facility. The interviews revealed no residents complained of resident abuse/neglect or misappropriation. There were no negatives results from the interviews. Conducted an all-staff training on abuse, neglect, exploitation, reporting guidelines, and misappropriation of property. Staff interviewed reported having received the training and knew topics that were presented and what to do.Record review of the facility's undated policy Prevention and Reporting of Suspected Resident Abuse and Neglect indicated, the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .Record review of facility incident/accident reports for the past three (3) months revealed no concerns in the area(s) of Resident Abuse; Resident Neglect; Misappropriation of property. Appropriate facility responses and investigations were done as necessary. Incident report for Misappropriation of property was addressed with appropriate facility response and investigationRecord review of facility complaints for the past three (3) months revealed no concerns in the area(s) of Resident Abuse; Misappropriation of property; or Resident Neglect.The noncompliance was identified as PNC. The noncompliance began on 06/25/2026 and ended on 06/27/2026. The facility had corrected the noncompliance before the investigation began on 07/09/2026.

Based on observations, interviews, 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 2 of 4 residents (Residents #7 and #32) reviewed who required Enhanced Barrier Precautions. The facility failed to ensure Enhanced Barrier Precautions signage was posted on the entry doors for Resident's #7 and Resident #32. This failure had the potential to expose residents, staff, and visitors to the transmission of infectious organisms.Finding included: A review of a face sheet dated January 13, 2026 indicated Resident #7 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included aortic (value) stenosis (the aortic valve narrow or stiffens and restricts blood flow), benign prostatic hyperplasia ( non-cancerous enlargement of the prostate gland), orthostatic hypotension(decrease in systolic blood, and diastolic blood pressure), gastro-esophageal reflux disease (GERD), hyperlipidemia ( increase in lipids in your bloodstream), hypertension, syncope (fainting), and urinary tract infection. A review of an admission MDS dated [DATE] reflected Resident's #7 had a BIMS score of 11 indicating his cognition was moderately impaired. A review of Resident #7's physician orders form dated 1/14/2026 reflected: Enhanced Barrier precautions for high contact care related to history of multidrug-resistant organism (MDRO) and an indwelling device, Gloves and gowns prior to high contact care which includes dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting toileting. PPE may be discarded in regular trash every shift related to Benign prostatic hyperplasia with lower urinary tract symptoms. Order/start date 12/29/2025.A review of Resident #7's physician orders form dated 1/14/2026 reflected: May insert 16 French 5 cc foley catheter as needed related to Benign Prostatic Hyperplasia without lower urinary tract symptoms. Order /start date 12/24/2025. A review of Resident #7's Care Plans last reviewed and completed dated 12/30/2025 reflected: Resident's #7 and family had elected Hospice Care: Focus, placement of indwelling catheter date initiated 12/30/2025. A review of Resident #7's Care Plans last reviewed and completed dated 12/30/2025 reflected: No implementation of Enhanced Barrier Precautions for high contact care related to history of multidrug-resistant organism (MDRO) and an indwelling catheter device. Observation and interview on 1/12/2026 at 10:46 AM revealed Resident #7 in bed, awake and watching TV; alert and oriented. The resident was clean, dry, and well-groomed. Resident #7 reported staff assisted with transfers and ADLs. The foley catheter was observed draining to gravity below bladder with privacy cover in place; urine was clear/yellow in color. Observation revealed the resident did not have EBP signage posted at the point of entry, and no instructions for required personal protective equipment were observed.A review of a face sheet dated January 14, 2026, indicated Resident #32 was a [AGE] year-old-male who admitted to the facility on [DATE] with diagnoses which included cerebral ischemic attack( OR stroke: when a blood clot blocks blood flow to the brain), type 2 diabetes mellitus, polymyositis with myopathy (chronic inflammation, pain and weakness in skeletal muscles), syncope (fainting), dysphagia ( difficulty swallowing), vascular dementia, neuromuscular dysfunction of bladder, depression, muscle wasting and atrophy, hypothyroidism, sarcopenia (loss of skeletal muscle mass, strength and function), presence of cardiac pacemaker, poly-osteoarthritis, atrioventricular block, dementia, hypertension, and esophagitis ( inflammation of the esophagus).A review of an admission MDS dated [DATE] reflected Resident #32 had a BIMS score of 14 indicating his cognition was cognitively intact. A review of Resident #32's physician orders form dated 1/14/2026 reflected: Enhanced Barrier Precautions for high contact care related to history of MDRO and / indwelling device, Gloves and gowns prior to high contact care which includes dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting toileting. PPE may be discarded in regular trash every shift. Order/start date 09/17/2025. A review of Resident #32's physician orders form dated 1/14/2026 reflected: If the resident develop retention replace 16 French foley catheter and phone urology with volume from catheter placement. Order dated 07/11/2025. May re-insert 16 French 5 cc foley catheter as needed related to retention. Order date 07/21/2025. A review of Resident #32's Care Plans last reviewed and completed dated 12/10/2025 reflected: The resident had an indwelling catheter. At risk for UTI, complications Neurogenic bladder. Dated initiated 08/06/2025. Intervention: Catheter care per facility policy and physician orders as needed. Assess reports of abnormal urine- sediment, odor, color, amount. Report to MD as needed. A review of Resident #32's Care Plans last reviewed and completed dated 12/10/2025 reflected: No implementation of Enhanced Barrier Precautions for high contact care related to history of MDRO and an indwelling catheter device. Observation and interview on 1/12/2026 at 11:37 AM revealed Resident #32 in bed, awake, alert, and watching TV. The resident was clean, dry and well-groomed. The foley catheter was observed draining to gravity below bladder with privacy cover in place; urine was clear/amber in color. Resident #32 stated he was doing fine, denied current UTI symptoms, and reported a UTI a few months ago. Resident #32 stated staff provided catheter care per orders. Observation revealed the resident did not have EBP signage posted at the point of entry, and no instructions for required personal protective equipment were observed. During an interview on 1/13/2026 at 11:00 AM., CNA A said she had worked for the facility for 2 years and had been educated on EBP. She accurately described EBP protocols for high contact residents with indwelling catheters and located the PPE supplies. The CNA stated she was unaware why Resident #32 did not have an EBP signage posted on the door, but acknowledged the resident had a foley catheter and stated she would put on the PPE located in the room during ADL's and Foley care. During an interview on 1/13/2026 at 11:15 AM., CNA B stated she had worked for the facility for 8 years and had received education EBP. She stated that she was also unaware of why the EBP signage was not posted on Resident #7's and #32's doors. But it was acknowledged the residents had a foley catheter and stated she would [NAME] (to put on) the PPE located in the room during ADL's care and Foley care. During an interview on 1/13/2026 at 11:30AM, LVN C said she was the charge nurse on the units and trained staff putting on PPE supplies. She accurately described EBP protocols for high contact care involving residents with indwelling catheters, including donning (to put on) PPE during dressing, bathing/showering, transferring, hygiene care, linens changes, briefs changes, and toileting assistance. During an interview with LVN C, observations of Resident #7, and Resident #32 rooms, who required Enhanced Barrier Precautions (EBP), revealed the EBP signage was not posted at the point of entry, and no instructions for required personal protective equipment were observed. LVN C stated she was unaware why EBP signage was not posted and stated she would immediately place the EBP's signage on both residents' doors. A review of facility's ( Section 12-infection Control ) Standard Precautions Policy, (Section 12- infection Control) Policy: Enhanced Barrier Precautions (EBP) are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MSROs to staff hands and clothing. A review of facility's (Section 12- Handwashing) Policy: Handwashing hand washing is regarded by this facility as the single most important means of preventing the spread of infections.

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 2 medication carts ((Cart A/B halls and Cart C/D halls) reviewed for pharmacy services. The facility failed to ensure the nursing staff responsible for the safekeeping of narcotics performed and documented the performance of change of shift narcotic counts on multiple shifts and days for Medication Cart A/B halls and Cart C/D halls. This failure could place residents at risk for loss of medications and possible drug diversion.Findings included: A review of the 01/01-13/2026 narcotic count signature sheets for the Medication Aide cart for Halls A and B on 01/13/2026 at 02:30 PM reflected 21 missing signatures indicating change of shift narcotic counts had not been routinely performed by on-coming and off-going medication aides. Further review indicated change of shift narcotic counts had not been done for 21 of 37 change of shifts dated 01/01-13/2026. A review of the 01/01-13/2026 narcotic count signature sheets for the Medication Aide cart for Halls C and D on 01/13/2026 at 02:30 PM reflected 26 missing signatures indicating change of shift narcotic counts had not been routinely performed by on-coming and off-going medication aides. Further review indicated change of shift narcotic counts had not been done for 26 of 37 change of shifts dated 01/01-13/2026. A review of the December 2025 narcotic count signature sheets for the Medication Aide cart for Halls A and B reflected 24 missing signatures indicating change of shift counts had not been routinely performed by on-coming and off-going medication aides. Further review indicated change of shift narcotic counts had not been done for 24 of 93 change of shifts dated 12/01-31/2025. During an interview with MA-E on 01/13/2026 at 02:56 PM, she said narcotic counts were to be done at every change of shift. She said the Medication Aide at the end of his/her shift was supposed to count the narcotics in the cart with the Medication Aide at the start of the next shift. She said the purpose of counting the narcotics in the carts was to ensure the number of narcotics in the cart was accurately reflected by the count. MA-E said both Medication Aides involved in the change of shift were to sign the narcotic count sheet to indicate the count had been done. She said the missing signatures looked like the narcotic counts had not been done. MA-E said the narcotic counts were done but sometimes the medication aides forgot to sign the sheets. During an interview with MA-D on 01/14/2026 at 09:25 AM, she said she had been told about the concern for the narcotic counts. She said she always counted the narcotics at the beginning and end of her shifts but sometimes forgot to sign the sheets. She said if she did not sign the narcotic count sheet after performing a narcotic count, then she had no proof that she had counted the narcotics at the beginning nor at the end of her shift. MA-D said narcotic medications could come up missing or lost and she could be suspect for the missing drugs. MA-D said narcotic counts and signing the narcotic count sheets were crucial for showing accountability for the safekeeping of narcotics. During an interview with the DON on 01/14/2026 at 10:40 AM, she said the Medication Aides were responsible for maintaining the security of the narcotics in their carts. She said narcotic counts were to be performed on each cart at change of shift and was to be completed by the on-coming and off-going Medication Aides. She said they were to sign the narcotic count sheets after completing the narcotic counts to indicate the narcotic counts were done and the count was accurate. She said failure to sign the narcotic count sheets could lead to missing drugs that could not be accounted for. The DON said she and the ADON were responsible for ensuring the change of shift narcotic counts were being completed and signed for. During an interview with the ADON on 01/14/2026 at 10:45 AM, she said she and the DON shared duties and both were responsible for ensuring narcotic counts were being completed at change of shift. A review of the facility's undated policy titled Shift Change and Medication Cart Responsibility indicated the following: It is the policy of this facility to ensure the transition from one shift to the next is appropriate, ensure proper handling of all medications and minimize risk.Procedure:1.At the end of each shift, the outgoing shift is to count all narcotics with the oncoming shift (per policy)2.Whoever accepts the keys and verifies the narcotic counts are accurate is assuming responsibility for the medication cart until the above point )#1) occurs again.

Based on observations, interviews, and record review, the facility failed to develop and implement comprehensive care plans with measurable objectives and timeframes to address resident's medical, nursing, and required enhanced barrier precautions needs for 2 of 4 residents reviewed. The facility failed to ensure that Resident #7's and Resident #32's care plans reflected focus instructions on Enhanced Barrier Precautions for high contact care related to history of MDRO and / indwelling device. The facility fails to ensure that Resident #7's care plans reflected focused interventions for indwelling catheter care in accordance with facility policy and physician orders. This failure could place residents at risk of not receiving care and services to meet individualized medical and nursing needs. Finding included: A review of a face sheet dated 01/13/2026 indicated Resident #7 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included aortic (value) stenosis (the aortic valve narrow or stiffens and restricts blood flow), benign prostatic hyperplasia ( non-cancerous enlargement of the prostate gland), orthostatic hypotension(decrease in systolic blood, and diastolic blood pressure ), gastro-esophageal reflux disease (GERD), hyperlipidemia ( increase in lipids in your bloodstream), hypertension, syncope (fainting), and urinary tract infection. A review of an admission MDS dated [DATE] reflected Resident's #7 had a BIMS score of 11 indicating his cognition was moderately impaired. A review of Resident's #7's physician orders form dated 1/14/2026 reflected: Enhanced Barrier Precautions for high contact care related to history of MDRO and / indwelling device, Gloves and gowns prior to high contact care which includes dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting toileting. PPE may be discarded in regular trash every shift related to Benign prostatic hyperplasia with lower urinary tract symptoms. Order/start date 12/29/2025. A review of Resident's #7 physician orders form dated 1/14/2026 reflected: May insert 16 French 5 cc foley catheter as needed related to Benign Prostatic Hyperplasia without lower urinary tract symptoms. Order /start date 12/24/2025. A review of Resident's #7 Care Plans last reviewed and completed dated 12/30/2025 reflected: Resident's #7 and family had elected Hospice Care: Focus, placement of indwelling catheter date initiated 12/30/2025. Resident #7's care plans did not reflect focused interventions for indwelling catheter care in accordance with facility policy and physician orders. A review of Resident's #7 Care Plans last reviewed and completed dated 12/30/2025 did not reflect implementation of Enhanced Barrier Precautions for high-contact care related to a history of MDRO and an indwelling catheter. Observation and interview of Resident #7 on 1/12/2026 at 1046 AM revealed Resident #7 was in bed, awake and watching TV; alert and oriented. Resident was clean, dry, and well-groomed. Resident #7 reported staff assisted with transfers and ADLs. Foley catheter noted to gravity with covered bag and urine was clear. Resident #7 denied UTI symptoms and reported history of bladder issues. A review of a face sheet dated 1/14, 2026, indicated Resident #32 was a [AGE] year-old-male who admitted to the facility on [DATE] with diagnoses which included cerebral ischemic attack( OR stroke: when a blood clot blocks blood flow to the brain), type 2 diabetes mellitus, polymyositis with myopathy (chronic inflammation, pain and weakness in skeletal muscles), syncope (fainting), dysphagia ( difficulty swallowing), vascular dementia, neuromuscular dysfunction of bladder, depression, muscle wasting and atrophy, hypothyroidism, sarcopenia (loss of skeletal muscle mass, strength and function), presence of cardiac pacemaker, poly-osteoarthritis, atrioventricular block, dementia, hypertension, and esophagitis ( inflammation of the esophagus). A review of an admission MDS dated [DATE] reflected Resident #32 had a BIMS score of 14 indicating his cognition was cognitively intact. A review of Resident's #32 physician orders form dated 1/14/2026 reflected: Enhanced Barrier Precautions for high contact care related to history of MDRO and / indwelling device, Gloves and gowns prior to high contact care which includes dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting toileting. PPE may be discarded in regular trash every shift. Order/start date 09/17/2025. A review of Resident's #32 physician orders form dated 1/14/2026 reflected: If the resident develop retention replace 16 French foley catheter and phone urology with volume from catheter placement. Order dated 07/11/2025. May re-insert 16 French 5 cc foley catheter as needed related to retention. Order date 07/21/2025. A review of Resident's #32 Care Plans last reviewed and completed dated 12/10/2025 reflected: The resident had an indwelling catheter. At risk for UTI, complications Neurogenic bladder. Dated initiated 08/06/2025. Intervention: Catheter care per facility policy and physician orders as needed. Assess reports of abnormal urine- sediment, odor, color, amount. Report to MD as needed. A review of Resident's #32 Care Plans last reviewed and completed dated 12/10/2025 did not reflect implementation of Enhanced Barrier Precautions for high-contact care related to a history of MDRO and an indwelling catheter. Observation and interview on 1/12/2026 at 11:37 AM revealed Resident #32 were in bed, awake, alert, and watching TV. The resident was clean, dry and well-groomed. The foley catheter observed draining to gravity below bladder with privacy cover in place; urine was clear/amber in color. Resident #32 stated he was doing fine, denied current UTI symptoms, and reported a UTI a few months ago. Resident #32 stated staff provided catheter care per orders. During an interview on 1/14/2026 at 1:52 PM., the MDS nurse said she was an LVN, and she was responsible for updating and keeping the MDS indicators updated. She further stated the initiation of the comprehensive care plan was the responsibility of the DON who was an RN. During an interview on 1/14/2026 at 2:00 PM., the ADON said she was an LVN, and the care plans were the responsibility of the MDS Nurse and the DON who was an RN. During an interview on 1/14/2026 at 2:15 PM. the DON said she was the RN, and she was responsible for initiating and updating the comprehensive care plans. The DON stated she had been updating care plans as incidents happen and tried to cover incidents in daily staff meetings. However, she said she planned on changing her method of updating the care plans. A Review of the facility's policy (section 18 - Minimum Data Set (MDS) titled Comprehensive Care Plans The comprehensive, person-centered care plans reflect currently recognized standards of practice for problem areas and conditions.

Based on interview and record review, the facility failed to ensure individuals with a diagnosis of mental illness were provided an accurate Preadmission Screening and Resident Review (PASARR) Level 1 Screening for 1 of 3 residents reviewed for PASARR (Resident #8). The facility failed to ensure that Resident #8 had an accurate PASARR Level 1 Screening indicating a diagnosis of mental illness after newly evident diagnosis dated 05/31/2019. This failure could place residents at risk of not receiving needed assessments (PASARR Evaluation), individualized care, and specialized services to meet their needs. The findings included: Record review of undated face sheet, obtained 01/14/2026, indicated Resident #8 was a [AGE] year-old female admitted to the facility on [DATE] and had a diagnosis of Major Depressive Disorder, Recurrent and Moderate (a psychiatric diagnosis characterized by persistent sadness, anxiety, apathy, irritability, or emotional numbness). Record review of the most recent Quarterly MDS dated [DATE] indicated Resident #8 had a BIMS score of 0 indicating severe cognitive impairment. The MDS section for active diagnosis indicated that Resident #8 had the psychiatric/mood disorders of depression. Section B0100 indicated that Resident #8 had unclear speech, was sometimes understood, and sometimes understood others. Record review of Resident #8's admitting PASARR Level 1 Screening completed 03/01/2019 indicated in section C0100 this resident did not have evidence of a mental illness. Record review of psychoactive medication consent dated 03/16/2019 for Resident #8 included a signed consent for Lexapro (an antidepressant that primarily treats depression and anxiety by increasing serotonin levels in the brain) to treat the diagnosis of depression. Record review of physician's progress note dated 05/31/2019 indicated that Resident #8 had obtained the diagnosis of Major Depressive Disorder, Recurrent and Moderate. Record review of the Quarterly MDS dated [DATE] first indicated Resident #8 had a diagnosis of depression. During an interview on 01/14/2026 at 10:15 AM, the MDS Nurse stated she was responsible for ensuring residents had an accurate PASARR Level 1 Screening. The MDS Nurse stated that residents were only able to be evaluated for services if the PASARR Level 1 Screening was accurate. The MDS Nurse stated that Resident #8 should have had an updated PASARR Level 1 Screening at the time of the diagnosis of Major Depressive Disorder, Recurrent and Moderate. During an interview on 01/14/2026 at 10:26 AM, the ADM stated he was not aware of the procedure for PASARR Level 1 Screening for a resident with a newly evident diagnosis of mental illness. During a joint interview on 01/14/2026 at 11:10 AM, the ADON and DON stated they were not aware of the procedure for PASARR Level 1 Screening for a resident with a newly evident diagnosis of mental illness. A review of an undated facility policy titled Preadmission Screening and Resident Review indicated the following: It is the policy of this facility to ensure the all residents are screen and appropriately addressed via the PASRR process as outlines by regulations. The results of this process will be used to develop, review, and revise the residents care plan.

Based on observation, interview, and record review, the facility failed to post their most recent survey of the facility in an area of the facility accessible to residents, and family members and legal representatives of residents, in 1 of 1 survey binder. The facility failed ensure the most recent standard survey dated 10/23/2024 was readily available within the survey binder. This failure could place residents at risk for not having access to current information regarding the facility's compliance with federal and state regulations, limiting their ability to make informed decisions and exercise their rights. Findings included: An observation on 01/12/2026 at 1:23 PM indicated that the survey binder posted within the facility did not include the results from the most recent standard survey completed 10/23/2024. The survey binder did include the results from standard surveys dated 09/13/2023 and 08/10/2022. During an interview on 01/12/2026 at 1:26 PM, the ADM stated he had recently printed out the most recent standard survey but failed to place it in the survey binder. The ADM stated that if the most recent standard survey results were not placed in the survey binder that would mean that the residents were unable to review them. The ADM stated that he understood that it was the residents' right to review survey results. During a confidential group interview on 01/13/2026 at 11:00 AM, 8 residents confirmed that they did not have access to the most recent standard survey results and that they wanted to review them. Record review of an undated facility policy titled Required Facility Postings indicated the following: The Resident has the right to: (1) Examine the results of the most recent survey of the facility conducted by federal or state surveyors and any plan of correction in effect with respect to the facility. The facility must make the results available for examination in a place readily accessible to residents, and must post a notice of their availability.

Based on observation, interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of 3 of 4 residents reviewed for pharmacy services (Residents #16, #24, #26). The facility failed to ensure medications were available in the form ordered by the physician for Residents #16 and #24. The facility failed to ensure a physician's order to discontinue an oral diabetic medication and replace it with another medication was carried out resulting in the discontinued medication being given for 3 (three) months after it was discontinued, and the replacement medication not being initiated for Resident #16. The facility failed to ensure LVN D administered insulin to Resident #26 in a safe, therapeutic manner. These failures could place residents at risk for not receiving the intended therapeutic response of prescribed medications and not having accurate records of medication administration which could result in diminished health and well-being. Findings included: 1.A review of Resident #16's face sheet indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included dementia, cerebral infarction (stroke), and Diabetes Mellitus (a long-tern condition in which the body has trouble controlling blood sugar and using it for energy). During an observation of medication administration and interview on 10/22/2024 at 08:20 AM, MA H was observed to administer 1 (one) tablet of Vitamin D3 2000mg to Resident #16. MA H said the physician's order was for 2 tablets of Vitamin D3 1000mg. MA H said he did not have any Vitamin D3 1000mg tablets and said the 1 tablet of Vitamin D3 2000mg was the same thing. MA H did not consult the charge nurse about not having the prescribed 1000mg Vitamin D3 tablets nor did he seek the nurse's guidance for determining the number of tablets to give of the substituted medication. During this same observation of medication administration, MA H said he did not have the physician ordered Glipizide 2.5mg tablets (for treatment of Diabetes). He told LVN D who said she would look for the medication. The ADON came to the medication cart and pulled out a card of Glyburide 2.5mg tablets. MA H said the order was for Glipizide. The ADON put the Glyburide tablets back in the cart and said she would notify the pharmacy. Shortly after, the ADON returned to the cart and said the order for Glyburide was discontinued on 07/19/2024 and a new order for Glipizide was written the same day. The ADON said pharmacy would deliver the Glipizide that evening. A review of Resident #16's October 2024 physician orders indicated an order dated 06/19/2024 for Resident #16 to be given 2 (two) Vitamin D3 25mcg (1000 UT) capsules one time a day. The same physician orders also indicated an order dated 07/19/2024 to discontinue Glyburide 2.5 mg 1 tablet daily and start Glipizide 2.5mg 1 tablet daily. A review of the October 2024 MAR indicated Resident #16 was to receive Glipizide 2.5mg 1 tablet daily. A review of the MARs from 07/20/2024 through 10/21/2024 indicated Resident had received Glipizide 2.5mg daily. A review of Resident #16's medication labeled Glyburide 2,5mg tablets was noted filled by the pharmacy on 09/27/2024 and had 15 tablets missing from the card. A review indicated the following: *07/20/2024 a card containing 30 tablets each of Glyburide 2.5mg was delivered to the facility. *08/29/2024 a card containing 30 tablets each of Glyburide 2.5mg was delivered to the facility. *09/27/2024 a card containing 25 tablets of Glyburide 2.5mg was delivered to the facility. *09/30/2024- 5 tablets of Glyburide 2.5mg was delivered on 09/30/2024. Further review revealed there was no evidence the medication, Glipizide 2.5mg tablets, had ever been delivered to the facility. 2.A review of Resident #24's face sheet indicated he was [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included myasthenia gravis (a weakness and fatigue of muscles under voluntary control), sciatica (pain radiating along the sciatic nerve which runs down one or both legs from the lower back), vertebral low back pain, and chronic pain syndrome. During an observation of medication administration and interview on 10/22/2024 at 08:40 AM, MA H was observed to administer 1 (one) tablet of Vitamin C 500mg to Resident #24. MA H said the physician's order was for 2 (two) tablets of Vitamin C 250mg. MA H said he did not have any Vitamin C 250mg tablets and said the 1 (one)tablet of Vitamin C 500mg was the same thing and proceeded to administer the 1 (one) tablet of vitamin C. MA H did not consult the charge nurse about not having the prescribed 250mg Vitamin C tablets nor did he seek the nurse's guidance for determining the number of tablets to give of the substituted medication. During this same observation of medication administration, MA H said the physician's order was for 2 capsules of Gabapentin 100mg but the label on the bottle containing Gabapentin 100mg capsules said give 1 tablet. He asked the charge nurse, LVN D, about the conflicting labels. LVN D located a card of Gabapentin 100mg capsules with a label that matched the physician's order for 2 capsules to be given. MA H said he did not know if Resident #24 had been getting 1 (one) or 2 (two) capsules. A review of Resident #24's October 2024 physician's orders and MAR indicated an order dated 08/07/2024 to administer 2 Vitamin C 250mg tablets once a day. The same physician orders indicated an order dated 09/20/2024 for Resident #24 to be given 2 (two) Gabapentin 100mg capsules 3 (three) times daily. 3. A review of Resident #26's face sheet indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus. During an observation of Resident #26's insulin administration on 10/22/2024 at 11:30 AM, LVN D was observed to administer a subcutaneous injection of 15 units of insulin to Resident #26's right upper abdominal quadrant. Resident #26 was overheard to ask LVN D if she was going to rub it. LVN D replied she was and proceeded to massage the injection site. During an interview with LVN D on 10/22/2024 at 11:50 AM, LVN said massaging the site of an insulin injection was proper technique, then said, she was not supposed to massage the site of an insulin injection but because Resident #24 asked her to, she did. During an interview with the DON on 10/23/2024 at 01:45 PM, he said medication aides were not supposed to calculate drug dosages. He said MA H should not have made the decision to give different vitamins of different strengths without discussing it with the charge nurse and having the charge nurse determine the amount of each vitamin to give to meet the physician's order. The DON said Resident #24 probably brought the bottle of gabapentin capsules from home when he admitted to the facility and the bottle should not have been in the cart. He said someone should have noticed the discrepancy between the drugs, Glipizide and Glyburide. The DON said massaging the site of an insulin injection was not proper technique. The DON said he expected the medication aides to let the nurse know when medications were not available or when orders needed clarification. He said he expected medication aides to follow the rules of medication administration to ensure residents receive the right medication and he expected nurses to use proper technique when administering injections. A review of the facility's policy titled Pharmacy Services indicated the following: The facility will provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of the residents. Medications must be ordered and reordered on a timely basis so that no resident misses a dose. The facility will ensure drug administration processes are followed to ensure that: drugs to be administered are checked against the physician's orders. A review of the Texas Administrative Code:Title 26: Part 1: Chapter 557: Rule 557.105 indicated the following: A medication aide permitted under this chapter may not: (5) calculate residents' or client's medication dosages for administration . A review of the facility's policy titled Subcutaneous Injection Administration indicated the following: Procedure: 19. Cover site (injection) site with alcohol wipe. Massage site gently to distribute drug and facilitate absorption, except when giving heparin or insulin. A review of Lippincott's 2004Atlas of Medication Administration indicated the following: .For a subcutaneous injection, the site is gently massaged after the medication has been given, except in the case of heparin and insulin because massaging the site can increase the rate of absorption of these agents.

Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 5 Residents (Residents #3, #7, #21) reviewed for medical records accuracy. The facility failed to ensure Resident #3's physician orders included orders for dialysis and the care of the dialysis access device. The facility failed to ensure Resident #7's physician orders included clear and precise instructions for the administration of an antidepressant medication. The facility failed to insure Resident #21's physician orders included the amount of an ordered liquid nutritional supplement to be given. These deficient practices could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. Findings included: 1.A review of Resident #3's face sheet dated 10/25/2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease (a condition in which the kidneys lose the ability to remove wastes and balance fluids) and Dependence on Renal Dialysis (a person requires regular dialysis to remove excess water and wastes to sustain their life). A review of Resident #3's quarterly MDS assessment (Section O:J1) dated 08/17/2024 indicated she had received dialysis during the observation period. The same MDS noted Resident #3 to have a BIMS score of 15 indicating her cognition was intact. A review of Resident #3's care plan dated 10/22/2024 indicated she was receiving dialysis and included interventions to address it. A review of Resident #3's physician orders indicated there were no orders for dialysis treatment nor a protective dressing to the shunt site. During an observation and interview with Resident #3 on 10/21/2024 at 10:30 AM, she said she went to dialysis 3 (three) days a week. While she was speaking, resident #3 pulled up the sleeve on her left arm and pointed to the dialysis shunt (access device) site area. The shunt site was clean and dry. There was no dressing or band aide covering the site. Resident #3 said the dialysis center puts a dressing on the site after the dialysis is complete. She said the dressing usually comes off by itself or becomes loose and she removes it. She said the facility did not put any covering over the site. During an interview on 10/23/2024 at 01:00 PM, LVN D said Resident #3 went to the dialysis center on Tuesday, Thursday, and Saturday every week. She said she would verify orders for dialysis and care of the shunt site by reviewing the physician's orders. LVN D said she could not find any orders for dialysis nor shunt site care. A review of the facility's policy titled Dialysis indicated the following: 1.Review and confirm the physician's order for dialysis. 7.The (access) site will be assessed .every shift. 10.If the dressing should become wet or be removed, put a clean band aid over the site 2.A review of Resident #7's face sheet dated 10/22/2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included Anxiety, unspecified somatoform disorder (extreme focus on physical symptoms such as pain, weakness, shortness of breath), schizoaffective disorder, bipolar type, and schizoaffective disorder, depressive type (major mood disorder , either depression or mania, that occur at the same time as symptoms of schizophrenia are present). A review of Resident #7's admission MDS assessment dated [DATE] noted Resident #7 had a BIMS score of 10 indicating her cognition was moderately impaired. The same MDS indicated Resident #7 had received antidepressant medication during the observation period. A review of Resident #7's physician orders indicated the following: *Dated 04/22/2022 Venlafaxine 150mg to be given once a day with 75mg to equal 225mg. *Dated 07/27/2024 Effexor 150mg to be given once a day (Venlafaxine is the generic form of Effexor). A review of a PMHNP (Psychiatric Mental Health Nurse Practitioner) record for Resident #7 dated 07/19/2024 noted a plan to increase Effexor to 150mg daily. The same record noted Resident #7 was currently receiving Venlafaxine (Effexor) 75 mg with 150mg to equal 225mg. A review of a PMHNP record dated 07/23/2024 noted Resident #7's current medications included Venlafaxine 75mg 1 (one) time a day with 150mg to equal 225mg and Effexor 150mg 1 (one) time a day. The same record included notation saying Effexor had been increased to 150mg a day on 07/19/2024. A review of the October 2024 MAR for Resident #7 indicated the following: * 1 (one) capsule of Venlafaxine 150mg to be administered with 75mg to equal 225mg every day. * Effexor (venlafaxine) 150 mg to be administered one time a day. Further review of the October 2024 MAR indicated both orders had been signed by staff, indicating Resident #7 had received 375mg of Venlafaxine every day since 07/27/2024. Observation of the medication cart on 10/23/2024 at 2:05 PM noted Resident #7 had 2 (two) medication cards containing Venlafaxine. * Card 1-Venlafaxine capsule 75mg: Give 1 (one) capsule by mouth once daily with 150mg for total dose of 225mg per day. * Card 2-Venlafaxine 150mg: Give 1 (one) capsule daily with 75mg for total dose of 225mg per day. During an interview with Resident #7 on 10/22/2024 at 10:15 AM, she did not know what medications she took or why. Resident was noted to be calm and showed no signs of mental upset. During an interview with the ADON, DON, and RN G present on 10/23/2024 at 02:10 PM, the ADON said she understood Resident # 3 was supposed to be given a total of Venlafaxine 375mg daily. The DON said he understood Resident #3 was to receive 225mg of Venlafaxine daily. He said the orders should have been written so that whoever was administering meds would know to give a 150mg capsule and a 75mg capsule and there would be a space to sign for the administration of each capsule. He said he did not know why the PMHNP would document to increase the dose of Venlafaxine to 150mg when Resident #7 was receiving 225mg of Venlafaxine at the time she prescribed the increase. RN G said the orders were not clear and should be clarified. During an interview with the DON on 10/23/2024 at 02:35 PM, he said he found where Resident's order for 75mg Venlafaxine was discontinued on 02/22/2024 and the order for Venlafaxine 150mg daily continued. He said the instructions to give with 75mg to equal 225mg should have been removed from the instructions. He said the PMHNP would be at the facility shortly and he would ask about the noted instructions to increase the Effexor dose to 150mg daily. The DON also said part of the confusion could be due to the use of the generic drug name used in some orders and the brand name used in other orders even though both names refer to the same drug. During an interview with the PMHNP on 10/23/2024 at 03:10 PM, the PMHNP said she increased the Venlafaxine dose by an additional 150 mg to total 300mg daily. The DON was overheard to ask the PMHNP if it would be better to write the order to give 2 Venlafaxine 150mg capsules at which the PMHNP said that was ok. The PMHP said the pharmacist should have addressed this. During an interview on 10/23/2024 at 04:05 PM, the DON said he did not know why the issue with the Venlafaxine orders had not been addressed. He said he did not know why the card of Venlafaxine 75mg capsules were not removed from the cart when it was discontinued. He said he did not know why the discrepancies between the PMHNP records, physician orders, MAR records, and labels on the medication containers had not been noticed and addressed. The DON said there was a risk of overdosing and/or underdosing of medication due to unclear orders. He said he expected the nurses and med aides to notify him of all unclear orders. 3.A review of Resident #21's face sheet dated 10/22/2024 indicated she was a [AGE] year-oldfemale who admitted to the facility on ,d+[DATE] with diagnoses which included dementia and protein calorie malnutrition. A review of Resident #21's MDS dated [DATE] noted her to be rarely understood by others. A review of Resident#21's care plan dated October 2024 indicated she was at risk for weight changes and malnutrition. A review of Resident #21's weight records from April 2024 through October 2024 indicated Resident #21 had a mild weight loss of approximately 4.5 pounds over the last 6 months. A review of the physician's orders dated 10/22/2024 indicated Resident #21 was to receive Med Pass 2.0 (a liquid nutritional supplement that provides 120 calories and 5 grams of protein in each 2 oz. serving) 2 (two) times daily for weight loss. The order did not specify the amount of the supplement to be given with each administration. A review of the October 2024 MAR indicated Resident #21 was provided Med Pass 2.0 twice daily. There was no documentation to reflect how much supplement was provided nor how much Resident #21 consumed. During an interview on 10/23/2024 at 02:20 PM, MA J accessed Resident #21's MAR and said the order did not say how much Med Pass 2.0 to give Resident #21. MA J said whenever she saw Med Pass 2.0 on the MAR, she gave about half of a disposable cup she was holding in her hand. The cup was a 6oz cup. She said she had not consulted the charge nurse nor the DON about the incomplete order. She said Med Pass 2.0 was given to residents who were losing weight. During an interview with the DON on 10/23/2024 at 04:00 PM, he said he was not aware the order for Med Pass 2.0 did not specify the amount to be given. He said he expected the medication aides to notify the charge nurse, ADON, or himself when orders needed clarification. A review of the facility's policy titled Pharmacy Services indicated the following: The facility will provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of the residents. The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.The pharmacist must report any irregularities to the medical director, attending physician and the director of nursing .

Based observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #29) reviewed for infection control. The facility failed to keep the urine drainage bag off the floor. This failure could place residents at risk of cross-contamination and development of infections. Finding include: During observation on 10/21/2024 at 11:27AM, Resident #29's urine catheter bag was hung on the trash can beside his bed. The bottom of the urine catheter bag was observed to be laying on the floor. During observation on 10/23/2024 at 2:29PM, Resident #29 urine catheter bag was hung on a trash can beside his bed. The bottom of the urine catheter bag was observed to be laying on the floor. During an interview on 10/23/2024 at 2:36PM, CNA-E said, the urine catheter bag was hung wrong and it should not be touching the floor. She said it should not be hung from the trash can, it should be hung from the bed and should be below Resident #29 feet. CNA-E said the urine catheter bag should have been place in a covering bag. During an interview and observation with the DON on 10/23/2024 at 2:40PM, the DON said the urine catheter bag should have been placed in a covering bag. He said he did not know why the urine catheter bag was not in a covering bag. He said the facility just purchased new covering bags. Record review of an undated policy titled, Anchoring - Catheter Bags, indicated: To ensure that all catheter bags are anchored appropriately, they do not touch the ground .

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for adequate supervision. The facility failed to ensure hospice staff were informed of Resident #1's need for a cup with a lid and supervision when provided coffee. The facility failed to ensure facility staff were aware of Resident #1's need for a cup with a lid when provided coffee. The facility failed to have a method or form of communication to ensure all staff were aware of Resident #1's need for a cup with a lid and supervision when provided coffee. The facility failed to ensure Resident #1's meal ticket was updated to indicate the need for a cup with a lid for hot liquids. The facility failed to complete a new Hot Liquid Assessment after the hot coffee spill on 12/12/2023. These failures could place residents at risk for injury or decline in health. Findings included: During an observation and interview on 12/23/2023 at 07:50 AM, Resident # 1 was observed to be lying in bed with the head of the bed elevated to approximately 90 degrees. Resident #1 was observed to be eating her breakfast independently. Drinks on the tray included cranberry juice and water. There was no coffee. When asked if she wanted coffee, resident said she did not want coffee right now. Resident was observed to drink the juice without any difficulty. A meal ticket on her tray with her name on it indicated resident #1 required no special considerations or devices. Record review of a face sheet dated 12/23/2023 indicated Resident #1 to be a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease (a group of conditions that affect blood flow and blood vessels in the brain), cognitive impairment, chronic obstructive pulmonary disease, and breast cancer. Record review of a MDS dated [DATE] indicated Resident #1 to be rarely/never understood on her BIMS assessment. The same MDS indicated resident required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs, or other non-weight-bearing assistance) with eating. Record review of a Hot Liquid assessment dated [DATE] and completed by the DON, indicated Resident #1 was not able to hold hot liquids in a cup or bowl without difficulty, had tremors to upper body area, needed assistance with eating, and tremors were worse some days more than others. The interventions section of the Hot Liquid Assessment indicated Resident #1 was safe to drink hot liquids without assistance using a cup with a lid. The latter part of this section indicated resident required assistance while drinking hot liquids from a cup with a lid. Record review of a care plan initiated on 02/24/2022 indicated Resident #1 required set-up help, supervision, verbal cueing, and physical assistance as needed with eating. The care plan did not include any directions for a cup with lid (sippy cup) for hot liquids. Record review of nurses' notes written by LVN E and dated 12/12/2023 at 11:54 AM indicated the Hospice Chaplain gave Resident #1 a cup of coffee and a few minutes later, Resident #1 spilled the coffee onto her left leg. The notes indicated facility staff responded immediately, took Resident #1 to her room, removed her pants, and applied cool compress to the left thigh. The area was described as a red streak down the left thigh with no blistering and no reported pain. Review of nurses' notes written by LVN C and dated 12/13/2023 at 08:34 AM indicated a description of the left thigh as having a pale pink, thin line with no blistering and no reported pain. A record review of the Hospice Notebook for Resident #1 did not indicate a care plan nor any instructions in regard to Resident #1's care. There was no indication of Resident #1's need for supervision nor a cup with a lid for drinking hot liquids. During an interview with Non-Certified Aide A on 12/23/2023 at 08:20 AM, she said the staff knew who to give cups with lids to because it was on the residents' meal tray tickets. Aide A said coffee comes out in a carafe with the meal trays and the staff delivering the trays refer to the meal ticket for instructions on preferred drinks and assistive devices. She said the facility used sippy cups (a 2-handled cup with a lid that has a spout to sip from)) for residents who were at risk to spill their drinks. She did not know how hospice staff or visitors would know if a resident required assistive devices for drinking coffee. During an interview with Non-certified Aide B at 08:35 AM, she said the meal tickets come out with the trays. She said the meal tickets tell the staff what the resident is supposed to have with their meals. She said Resident #1 did not need anything special to drink her coffee but since she spilled coffee on herself a couple of weeks ago, someone watches her when she is drinking coffee. During observation and interview on 12/23/2023 at 09:30 AM, LVN C, was observed to assist Resident #1 to turn toward her ride side to expose the resident's left thigh. LVN C pointed to the area where coffee spilled onto the resident's thigh. No evidence of a burn, red, or open areas were noted. A faint, light tan line approximately 3.0x0.3 cm was noted to the left, lateral distal thigh. Resident denied any pain when area was touched by LVN C. LVN C said the area had not required any treatment nor had Resident #1 required any pain medication because of the coffee spill. During an interview with LVN C on 12/23/2023 at 09:40 AM, she said hospice staff use electronic devices to refer to for resident care information. She said as far as she knew, the facility nursing staff did not have access to the information on those devices. She said the information the facility had was in individual notebooks at the nurses' station. During an interview with the DON and ADON on 12/23/2023 at 09:50 AM, the DON said hospice staff had not been told Resident #1 required specific devices for drinking coffee because a Hot Liquid Assessment completed on 11/19/2023 indicated Resident #1 could manage hot liquids without any assistive devices. The DON said there were no residents who used lids on their cups. During an interview with the DM on 12/23/2023 at 10:00 AM, she said she was responsible for ensuring meal tickets included information specific to each resident including any assistive devices to be used. She said she was not aware that Resident #1 required any assistive devices. The DM said the facility did not have any lids for the coffee cups. She said the facility had sippy cups for residents who are at risk for spilling hot liquids. During an interview with ADM on 12/23/2023 at 11:00 AM, she said the facility does not use lids for their coffee cups. During a phone interview with Hospice Chaplain D on 12/23/2023 at 11:11 AM, she said that on 12/12/2023, she wheeled Resident #1 to a table in the dining room and gave her a half cup of coffee because she knew the resident's hands shook some. She said she went to visit another resident in the dining room and after about 10 minutes, she looked over at Resident #1 and saw her push herself away from the table, pick her coffee cup up from her lap and throw it to the floor. She said she went to Resident #1, saw that she had spilled her coffee, lifted the pant leg away from the thigh, and held it while she called for help. She said the pants did not feel hot and the resident denied any pain. She said she was not aware Resident #1 was to have a lid on her coffee cup. During a phone interview on 12/23/2023 at 11:28 AM with LVN E, she said the Medication Aide made her aware that Resident #1 had spilled her coffee onto her leg. She said she and the medication aide took Resident #1 to her room, removed her pants, and saw a pink, non-blistering line down her left lateral thigh. She said she applied a cold compress to the area and notified the nurse practioner, Hospice Nurse on call, and the family. During an interview with DON on 12/23/2023 at 1:44 PM, he said hospice staff are invited to the care plan meetings but do not always come. He said the 11/19/2023 Hot Liquid Assessment that indicated Resident #1 was capable of handling hot liquids in a cup was correct. He said the 11/29/2023 Hot Liquid Assessment that indicated Resident #1 was to have a cup with a lid and supervision when drinking hot liquids was incorrect.

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to the keys for 1 of 2 rooms (medication room and DON office) used for storage of medications and other biological chemicals. The facility failed to ensure the DON's office located on Hall D was secured and unable to be accessed by unauthorized personnel. This failure could place residents at risk for medication misuse, medication diversion, and injury related to ingestion or use of biological chemicals. Findings included: During an observation on 09/12/2023 at 12:05 PM, the following items were noted on open shelves on a wall in the DON's office: 16 bottles (100 tablets each) of Vitamin D3 25 mcg, 1 bottle (100 tablets) [NAME] 500mg Extra Strength Aspirin, 1 unopened box containing 300 cough suppressant lozenges, 1 bottle (16 oz) Dakins Solution (wound cleaner containing sodium hydrochloride), 1 bottle (12oz) Hydrogen Peroxide, 16 bottles (32oz size) hand sanitizer refill solution, 1 partially used plastic container of Drug Disposal (for disposing of drugs), and 10 tubes A&D ointment, and 1 bottle (24 oz) Acaricid (surface disinfectant cleaner). The door to the DON's office was open and nobody was in the office. During an observation on 09/13/2023 at 09:40 AM, the door to the DON's office was noted open and nobody was in the office. The same items were noted on the open shelves. There were 2 residents in wheelchairs on the hall. During an interview with the DON at 1:40 PM on 09/13/2023, the DON said the items on the shelves had probably been there since he came in March, 2023. He said he had planned to take the shelves down. The DON stated these items were accessible to residents and should be in a secure location and not available to unauthorized persons. Record review of the facility's undated policy titled Storage of Medications indicated the facility's purpose was to ensure that medications are stored in a safe, secure, and orderly manner. 6. Compartments containing medications are locked when not in use.

Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 2 residents reviewed for respiratory care. (Residents #6 and 15). The facility failed to change the oxygen humidifier bottle and water for Resident #6 and Resident #15. These failures could place residents who required respiratory care at risk for respiratory infections. Findings included: 1. Record review of the face sheet dated 08/10/22 indicated Resident #6 was an [AGE] years old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #6 usually made herself understood and others. Resident #6 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated she had moderately impaired cognition. The MDS indicated Resident #6 required extensive assist with bed mobility, dressing, toileting, personal hygiene, and bathing. The MDS indicated that Resident #6 had [CONDITION(S)] (a condition involving [MEDICATION(S)] of the airways and difficulty or discomfort in breathing) and required oxygen. Record review of the care plan dated 07/19/22 for Resident #6 indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 08/08/22 at 11:09 a.m., Resident #6 was in in bed wearing a nasal cannula. The nasal cannula was attached to a humidified water bottle filled with water connected to an oxygen concentrator. The oxygen concentrator was on and running at 2 liters of oxygen. The humidified water bottle was dated 07/25/22 and the label indicated for single use only. During an observation on 08/09/22 at 3:50 p.m., Resident #6 was in bed wearing a nasal cannula connected to an oxygen concentrator with humidified water. The oxygen concentrator was on and running at 2 liters of oxygen. The humidified water bottle was dated 07/25/22 and the label indicated for single use only. During an observation on 08/10/22 at 9:10 a.m., Resident #6 was in bed wearing a nasal cannula connected to an oxygen concentrator with humidified water. The oxygen concentrator was on and running at 2 liters of oxygen. The humidified water bottle was dated 07/25/22 and the label indicated for single use only. During an interview on 08/10/22 at 01:10 p.m., LVN A said night shift nurses were supposed to change oxygen tubing and humidified water every Sunday night and dated. LVN A said Resident #6 and Resident #15 used oxygen and humidified water. LVN A said Resident #6 and Resident #15's humidified water bottle was dated 07/25/22. LVN A said she worked the night shift on 07/25/22 and she was the last one to change Resident #6 and Resident #15's humidified bottles because the dates on the bottles were written by her. LVN A said they had no clean humidified water bottles at the facility because they changed supply companies a couple weeks ago and they have not been delivered yet. LVN A said they are refilling Resident #6 and Resident #15's humidified water bottles until they get some. LVN A said she did not realize Resident #6 and Resident #15's humidified water bottles said, for single use only and should not be refilled. LVN A said if oxygen tubing and humidified water are not changed weekly bacteria could grow and place a resident at risk for a respiratory infection. LVN A said Resident #6 and Resident #15's oxygen tubing and humidified water bottle had not been changed and they were at risk for a respiratory infection. During an observation on 08/10/22 at 01:59 p.m., there were no prefilled or disposable humidified water bottles in the supply room. During an interview on 08/10/22 at 02:09 p.m., the administrator said the DON was responsible for ordering supplies but was on vacation, so she was responsible until her return. The administrator said they changed supply companies about a week and a half ago and she had ordered humidified water bottles sometime last week. The administrator said she was not aware of any supplies on back order and the humidified water bottles should have been delivered but did not know for sure. The administrator said she expected the night shift nurses to change and date the oxygen tubing and humidified water every Sunday night. The administrator said she was not aware the oxygen tubing for Resident #6 and Resident #15 was not dated and their humidified water was dated 07/25/22. The administrator said if oxygen tubing and humidified water are not changed weekly bacteria growth can occur and place a resident at risk for a respiratory infection. The administrator said Resident #6 and Resident #15 were at risk for a respiratory infection and their oxygen tubing and humidified water should be changed and dated to prevent infection. Record review of the facility Oxygen Administration policy undated indicated, .1. Check physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Prefilled, sealed, disposable humidifiers may be changed per facility procedure .g. Label humidifier with date and time opened. Change humidifier and tubing per facility procedure . 2. Record review of consolidated physicians' orders dated 8/10/2022, indicated Resident #15 was [AGE] years old, admitted on [DATE] and had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated Resident #15's oxygen humidifier should be changed every week on Sundays. Record review of the most recent comprehensive MDS dated [DATE], indicated Resident #15 usually made herself understood and usually understood others. The MDS indicated Resident #15 had a BIMS (brief interview for mental status) score of 12. The MDS indicated Resident #15 required extensive assistance with bed mobility, transfers, dressing and personal hygiene. The MDS indicated Resident #15 was dependent with toileting and locomotion on and off the unit. Record review of the care plan dated 6/16/2022 did not address Resident #15's oxygen concentrator or humidifier. During an observation on 8/9/2022 at 1:40 p.m., Resident #15 was in bed wearing her oxygen canula with the oxygen concentrator on. Resident #15's oxygen humidification bottle was dated 7/25/2022. During an observation and interview on 8/9/2022 at 2:55 p.m., Resident #15 said the staff assisted her with her oxygen and nebulizer equipment care. Resident #15's oxygen humidification bottle was dated 7/25/2022. During an observation on 8/10/2022 at 9:05 a.m., Resident #15 was resting in her bed with her oxygen canula on and the humidification bottle on the concentrator was dated 7/25/2022. The oxygen concentrator was turned on.

Based on observation and interview the facility failed to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 12 residents reviewed for medication storage (Resident #15). The facility did not ensure Resident # 15's medications were kept in a secured location. Resident #15 had 2 bottles of the over-the-counter medication Bio-Freeze at her bedside. This failure could place residents at risk for overuse and adverse effects of medication and harm. Findings included: Record review of consolidated physicians' orders dated 8/10/2022, indicated Resident #15 was [AGE] years old, admitted on [DATE] and had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no order for Bio-Freeze (used to treat minor aches and pains of the muscles and joints) and no orders for self-administration of medications. Record review of the most recent comprehensive MDS dated [DATE], indicated Resident #15 usually made herself understood and usually understood others. The MDS indicated Resident #15 had a BIMS (brief interview for mental status) score of 12. The MDS indicated Resident #15 required extensive assistance with bed mobility, transfers, dressing and personal hygiene. The MDS indicated Resident #15 was dependent with toileting and locomotion on and off the unit. Record review of the care plan dated 6/16/2022, indicated Resident #15 was at risk for pain and had interventions including non-pharmacological pain relief measures, encourage resident to verbalize pain at onset, observe for non-verbal signs of pain and provide as needed medications as indicated. The care plan indicated Resident #15 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 8/9/2022 at 1:40 p.m. a bottle of Bio-Freeze was observed on Resident #15's bedside table. During an observation and interview on 8/9/2022 at 2:55 p.m., a bottle of Bio-Freeze was observed inside the open top drawer of the bedside table next to Resident #15's bed within her reach and one on top of the overbed table within her reach. Resident #15 said she used the Bio-Freeze when she could get someone to put it on her. She said she used it for the pain in her shoulders and sometimes needed help to reach the right spot. Resident #15 said staff had assisted her to put this on a few minutes ago but could not recall who the staff was. During an observation on 8/10/2022 at 9:05 a.m., Resident #15 had two bottles of Bio-Freeze within her reach. One bottle on the over bed table and one bottle inside the open top drawer of her bedside table. Resident #15 said she had her family purchase and bring the Bio-Freeze to help with her arthritis pain. During an interview on 8/10/2022 at 10:45 a.m., LVN A said any prescriptions or over the counter medications had to have an order from the physician to be kept at the bedside. LVN A said medications kept at the bedside without an order could lead to overuse or misuse of the medication. LVN A said she had not been made aware of the Bio-Freeze at Resident #15s bedside and she did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/10/2022 at 10:45 a.m., MA B said medications could not be left at the residents' bedside without an order. MA B said this could lead to overuse of the medication by the resident. MA B said she was not aware of any Bio-Freeze in the residents' room and wound notify the charge nurse immediately. During an interview on 8/10/2022 at 11:30 a.m., the administrator said medications could not be left at the bedside without an order to do so. The administrator said the facility had other residents who wander and could come in and find the medication and could put in their mouth. The administrator said she expected staff to look for these types of items in the room daily during their rounds and remove any medications without an order to be in the room. Record review of an undated policy titled Medication Self-Administration indicated residents are not permitted to administer or retain any medications in his or her room unless their attending physician writes an order for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview and record review, the facility failed to ensure an infection prevention and control program designed to help prevent the development and transmission of communicable diseases was established and maintained for infection control related to COVID-19 (a virus that is spread from person to person causing mild to severe respiratory symptoms) for 7 of 7 residents (Resident #'s 1,2,3,4,5,6,7) reviewed for infection control. The facility did not screen residents that tested negative for COVID-19 daily for fever, chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting, diarrhea, or contact in the last 14 days with someone diagnosed or under investigation for COVID-19. This failure could place residents at risk by exposing them to communicable diseases and infections. Findings included: 1.Record review of Resident #1's face sheet indicated he was [AGE] years old and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's clinical record from 10/01/21 to 10/02/21 indicated there was no COVID-19 screening. Record review of a nursing note for Resident #1 dated 10/03/21 at 2:04 p.m. indicated he tested positive for COVID-19. Record review of Resident #1's Minimum Data Set (MDS) dated [DATE] indicated the resident did not speak, did not make his needs known, and rarely understood others. He was dependent on staff for most ADLs. 2.Record review of Resident #2's face sheet indicated he was [AGE] years old and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact, made his needs known, and understood others. He required extensive assistance with ADLs. Record review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's clinical record from 10/01/21 to 10/02/21 indicated there was no COVID-19 screening. Record review of a nursing note for Resident #2 dated 10/03/21 at 2:04 p.m. indicated he tested positive for COVID-19. 3.Record review of Resident #3's face sheet indicated he was [AGE] years old and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's MDS dated [DATE] indicated he had intact cognition, made his needs known, and understood others. He required limited assistance with most ADLs. Record review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's clinical record from 10/01/21 to 10/02/21 indicated there was no COVID-19 screening. Record review of a nursing note for Resident #3 dated 10/03/21 at 1:58 p.m. indicated he tested positive for COVID-19. 4.Record review of Resident #4's face sheet indicated she was [AGE] years old and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's MDS dated [DATE] indicated she had intact cognition, made her needs known, and understood others. She required supervision assistance with ADLs. Record review of Resident #4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's clinical record from 10/01/21 to 10/02/21 indicated there was no COVID-19 screening. Record review of a nursing note for Resident #4 dated 10/03/21 at 2:04 p.m. indicated she tested positive for COVID-19. 5.Record review of Resident #5's face sheet indicated she was [AGE] years old and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #5's MDS dated [DATE] indicated she had impaired cognition, made her needs known, and understood others. She required extensive assistance with ADLs. Record review of Resident #5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's clinical record from 10/01/21 to 10/06/21 indicated there was no COVID-19 screening. 6.Record review of Resident #6's face sheet indicated she was [AGE] years old and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's MDS dated [DATE] indicated she had severely impaired cognition, sometimes made her needs known, and understood others. She required extensive assistance with ADLs. Record review of Resident #6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's clinical record from 10/01/21 to 10/06/21 indicated there was no COVID-19 screening. 7.Record review of Resident #7's face sheet indicated he was [AGE] years old and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #7's MDS dated [DATE] indicated he had impaired cognition, usually made his needs known, and usually understood others. He required extensive assistance with most ADLs. Record review of Resident #7's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #7's clinical record from 10/01/21 to 10/06/21 indicated there was no COVID-19 screening. During an interview on 10/06/21 at 11:59 a.m., LVN A said nurses did not complete COVID-19 screenings on negative residents. She said they only completed daily COVID-19 skilled nursing notes on COVID-19 positive residents that included vital signs. During an interview on 10/06/21 at 12:30 p.m., LVN B said nurses were not screening all residents for COVID-19 symptoms. She said they completed COVID-19 skilled nursing notes for residents that were positive. During an interview on 10/06/21 at 2:35 p.m., LVN C said nurses were assessing symptoms for residents that were positive for COVID-19 and it was documented in the COVID-19 skilled notes. He said he only screened COVID-19 negative residents if there was an order and it popped up on the resident's MAR. During an interview on 10/06/21 at 3:40 p.m., the administrator said all residents should have a daily COVID-19 screening. She said she thought the screening was scheduled daily on the resident's MAR. During an interview on 10/06/21 at 3:44 p.m., the DON said all residents should be screened daily for COVID-19 symptoms. She said the nurses were responsible for screening the residents. She said the facility assessed COVID-19 positive residents using the skilled COVID-19 assessment tool in the computer. She said all residents had orders for daily COVID-19 screenings, but they were not entered correctly and were not showing up on residents' MARs. Record review of the facility's undated COVID-19 policy indicated .we will monitor residents upon admission, readmission, and daily for signs of fever and/or respiratory symptoms at least once per shift .

Based on observation and interview the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 OTC stock storage area (DON's office) and 1 of 1 nurse cart. The facility failed to remove expired medications from the stock of over the counter medications storage available for resident use. The facility failed to have an opened date on Resident #9's [MEDICATION(S)] and failed to remove Resident 30's [MEDICATION(S)] after 28 days of being opened. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications. 1.During an observation on 06/23/21 at 3:05 PM the over the counter stock,(OTC) was stored in the DON's office, contained one (1) bottle of [MEDICATION(S)] 5 mg ([MEDICATION(S)]) expired 3/21. This medication was sitting on the shelves with the other OTCs available for administration. During an interview on 06/23/21 at 3:09 PM the DON said my medication aide was responsible for going over these medications. She said I'll have to talk to her. 2. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . the orders indicated on 05/20/2021 [MEDICATION(S)] sliding scale (insulin administered according to what the blood sugar number is) was ordered four times a day. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 06/23/21 at 3:13 PM Resident #30's [MEDICATION(S)] had an opened date of 5/22/21 and was available for administration. 3. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/26/19 [MEDICATION(S)], 60 units, two times a day was ordered by the physician. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 06/23/21 at 3:14 PM Resident #9's [MEDICATION(S)] had no open date for when it was opened and it was available for administration. During an interview on 06/23/21 at 3:15 PM LVN A said she did not know who checked the carts for expired medication. She said [MEDICATION(S)] was good to use, after opened date, for 30 days. An undated insulin expiration policy indicated: it is the policy of the facility to appropriately store, use and dispose of insulin. Procedures: .2. All insulin once opened or removed from the refrigerator must be DATED. 3. All insulin, once opened or removed from the refrigerator expires in 28 days and must be taken out of use and be replaced (per facility protocol for discontinued/expired medication) An undated medication labeling policy indicated: .3. Labels for individual drug containers must include: .h. expiration date .6. Labels for OTC drugs must contain: .b. Expiration date .

Based on interview and record review, the facility failed to conduct COVID-19 testing of all staff based on the positivity rate of COVID-19 in the county. The facility did not provide testing of staff for COVID-19 (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older) during September 2020 and October 2020 as required based on their county's positivity rate. This failure could place staff and residents at risk for illness and death. Findings included: A record review of CMS publication, QSO 20-38-NH, states, Routine testing should be based on the extent of [MEDICAL CONDITION] in the community, therefore facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency. Reports of COVID-19 county-level positivity rates will be available on the following website by a A record review on August 28, 2020 (see section titled, COVID-19 Testing): https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg. It indicated if the county positivity rate in the past week was greater than 10%, minimum testing frequency is twice a week. A record review of an undated policy titled COVID-19 Testing Policy indicated: *The facility will utilize their county's COVID positivity rate in the prior week as the trigger for staff testing frequency. *The facility will test staff per the routine testing intervals as follows: *If the community COVID-19 activity is low and the county positivity rate in the past week is <5%, the minimum testing frequency of staff will be once a month. *If the community COVID-19 activity is medium and the county positivity rate in the past week is 5%-10%, the minimum testing frequency of staff will be once a week* *If the community COVID-19 activity is high and the county positivity rate in the past week is >10%, the minimum testing frequency of staff will be twice a week. * (*This testing frequency presumes availability of Point of Care testing on-site at the nursing home or where off-site testing turnaround is <48 hours.) *Should the 48-hour turn-around time not be met due to community testing supply shortage, limited access or inability of laboratories to process test within 48 hours, the facility will document its efforts to obtain quick turn-around test results with the identified laboratory or laboratories and its contact with the local and state health departments. *The facility will monitor their county's positivity rate every other week (e.g. first and third Monday of every month) and adjust the frequency of performing staff testing according to the testing intervals as outlined above. *If the county positivity rate increases to a higher level of activity, the facility will begin testing staff at the frequency of the testing intervals as outlined above, as soon as the criteria for the higher activity are met. *If the county positivity rate decreases to a lower level of activity, the facility will continue testing staff at the higher activity level until the county positivity rate has remained at the lower activity level for at least two weeks before reducing the testing frequency. A record review of CMS archived data for COVID-19 Test Positivity rates per county accessed on 12/01/20 at https://data.cms.gov/stories/s/q5r5-gjyu indicated Van Zandt County had the following positivity rates: * Week Ending 11/18/20 25.5% * Week Ending 11/11/20 20.4% * Week Ending 11/04/20 16.7% * Week Ending 10/28/20 15.5% * Week Ending 10/21/20 14.4% * Week Ending 10/14/20 10.4% * Week Ending 10/07/20 5.9% * Week Ending 9/30/20 5.5% * Week Ending 9/23/20 4.7% * Week Ending 9/16/20 6.6% * Week Ending 9/09/20 9.6% * Week Ending 9/02/20 12.3% During an interview on 11/30/20 at 9:28 a.m., the DON/IP said the facility started testing staff on 11/17/20. The DON/IP said there was no routine testing of staff prior to 11/17/20. During an interview on 11/30/20 at 2:00 p.m., the DON/IP said during the month of September the County Positivity Rate was low, less than 5%. The DON/IP said during the month of October the facility was trying to work with a lab to do routine testing of staff, but the lab could not return the results to the facility within 48 hours. The DON/IP said she had spoken to the lab to try and work through the issues, but there was no documentation of the conversation. The DON/IP said she had received two point of care testing systems, but could not recall when they were received. The DON/IP said corporate representatives had directed the facility not to use the point of care testing systems. The DON/IP said she was not aware of CMS Memorandum 20-38-NH regarding routine testing of staff, nor had she notified local or state public health officials that the facility was unable to perform the required testing. During an interview on 11/30/20 at 3:12 p.m., the administrator confirmed that there was no routine testing of staff during the months of September and October 2020, because the facility had difficulty finding a lab to meet the testing requirements. The administrator said the corporate representative had directed the facility not to use the point of care testing systems the facility had received. The administrator said she was not aware of CMS Memorandum 20-38-NH regarding routine testing of staff. During an interview on 11/30/20 at 3:53 p.m., the DON/IP said there was no one at the facility responsible for checking the county positivity rate for COVID-19. The DON/IP said she checked it for her own knowledge, but had not checked it this month. The DON/IP accessed a website at www.covidactnow.org which indicated the county positivity rate for Van Zandt county was 25.5%. The DON/IP said she did not know how often staff testing should occur based on the County Positivity Rate of 25.5%. A record review of an email from the Director of Operations to the DON titled [MEDICATION NAME] Testing Devices, dated 8/25/20, indicated in part .you may not begin using the devices until I have given the all clear. A record review of an email from the Director of Operations to the DON titled Large Shipment, dated 10/8/20, indicated the facility was to receive ANOTHER testing process from CMS. The email indicated in part .let me know once your shipment arrives but DO NOT USE unless you've heard from me that we've been approved for use.

Based on interview and record review, the facility failed to ensure an effective infection control program to help prevent the development and transmission of communicable diseases and infections were maintained related to COVID-19 (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older) for 2 of 19 staff reviewed for infection control. CNA B and CNA C were allowed to work even though they did not complete pre-duty screening for symptoms consistent with COVID-19 before beginning their shift on 11/27/20. COVID-19 test results received 11/28/20 indicated CNA B and CNA C were positive for COVID-19. The facility screening process did not include all required elements. This failure could place residents and staff at risk for contracting COVID-19. Findings included: A record review of TITLE40 SOCIAL SERVICES AND ASSISTANCE PART 1 DEPARTMENT OF AGING AND DISABILITY SERVICES CHAPTER 19 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION SUBCHAPTER CC COVID-19 EMERGENCY RULE indicated a nursing facility must screen all residents, staff, and people who come to the facility for the following criteria: *signs or symptoms of COVID-19, including chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting or diarrhea. 1. During an interview on 11/30/20 at 9:28 a.m., the DON/IP said CNA B and CNA C were tested for COVID-19 on 11/25/20 as a part of routine testing done by the facility. The DON/IP said the facility received the results on 11/28/20 which indicated CNA B and CNA C were positive for COVID-19. The DON/IP said CNA B and CNA C had last worked on 11/27/20. The DON/IP said the facility screening process consists of 2 documents which are required. First, a screening log which includes the following fields to be completed: *time *name *reason for screen *CMS questions answered *temp reading *phone number The second document titled Screening Checklist which had the following fields to be completed: *wash hands or use alcohol-based hand rub *indicate presence of fever, sore throat, cough, or new shortness of breath (if yes to any do not enter the building *indicate whether the individual has travelled internationally or domestically within the last 14 days to locations where COVID-19 cases have been confirmed, or worked in another health care setting that has confirmed COVID-19 cases (if yes to any do not enter the building) *purpose of visit/entry (employee, service provider, visitor) *remind individual to wash hands or use hand sanitizer throughout their time in the building *do not shake hands with, touch, or hug individuals, and limit distance to 6 feet between yourself and resident Review of screening documents for 11/27/20 indicated: CNA B had completed the Screening Checklist, but it was undated. There was no corresponding entry on the Screening Log to indicate he completed pre-duty screening before entering the building. CNA C had an entry on the Screening Log, but had no Screening Checklist to indicate she had completed pre-duty screening before entering the building on 11/27/20. During a telephone interview on 11/30/20 at 1:06 p.m., CNA C said she worked 10p-6a shift on 11/27/20. CNA C said she had completed the Screening Log and the Screening Checklist before entering the building, and did not know why there was not a record of the Screening Checklist. She said she did not have any symptoms on 11/27/20. She said there was not always someone at the screening location actively screening staff. During a telephone interview on 11/30/20 at 1:25 p.m., CNA B said he worked 2p-10p on 11/27/20. CNA B said there was always someone at the door to take temperature and complete the Screening Log. CNA B did not know why there was not an entry on the screening log to indicate he had been screened before entering the building on 11/27/20. He said he did not have any symptoms on 11/27/20. Record review of an undated policy titled COVID-19 Prevention and Control indicated all healthcare workers will be screened prior to or at entry to the facility, to include chills, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea. The policy did not specify pre-duty screening should include cough or shortness of breath. The Screening Checklist revised 6/18/20 did not include screening for chills, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, or diarrhea. During an interview on 11/30/20 at DON, IP at 12:02 p.m., the DON/IP said she was not aware that pre-duty screening required all symptoms associated with COVID-19 had to be included on the Screening Checklist.

Based on interview and record review, the facility failed to ensure employees received instruction on dementia as part of their orientation for 2 of 2 newly hired staff reviewed for in-service education. (DON and LVN B) The facility did not ensure the DON and LVN B completed the required dementia training as part of their orientation. This failure could affect residents with dementia at risk of a poor quality of care by staff with inadequate training when caring for dementia residents. Findings included: The personal file for the DON indicated she did not receive dementia management training as a part of her orientation. The DON hire date was 6/24/19. The personal file for LVN B indicated she did not receive dementia management training as a part of her orientation. LVN B hire date was 8/6/19. During an interview on 10/23/19 at 2:05 p.m., the ADON and DON said they were not aware dementia management was required orientation training. The ADON said the human resource clerk covers: pre-employment forms, welcome, employment forms, key facility policies, benefits, compliance program and resident's rights; the administrator covers: abuse and neglect; maintenance covers: fire prevention, life safety, disaster preparedness, accident prevention and safety awareness and right to know -hazardous material; the ADON covers: falls and restraints, prevention and control of infection, confidentiality and HIV/AIDS/HBV/TB. The ADON said she did not specifically cover dementia management but covered how to handle a resident in general. The DON said she did dementia trainings throughout the year. During an interview on 10/23/19 at 2:08 p.m., the administrator said she thought dementia was an annual requirement she was not aware dementia management was a required orientation training also. She said during the new hire orientation she was responsible for the abuse and neglect information, but she did not cover dementia. An undated prevention and reporting of suspected resident abuse and neglect policy page #22 of 49 in the new hire packet indicated in the training section A - Training will be provided to new employees through orientation and ongoing training programs. Training will be included, but not limited to: . dementia management and resident abuse prevention. B - Document training of staff; maintain with the facility's educational records. During an interview on 10/23/19 at 3:20 p.m., the facility was asked for additional information at exit, no additional information was provided.

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate receiving of all drugs and biologicals. The facility did not have a system of records of receipt of drugs in sufficient detail to enable an accurate reconciliation when receiving the medications from the delivery driver. The facility did not have a system of records of receipt of all controlled drugs in sufficient detail to enable an accurate reconciliation when receiving the medications from the delivery driver. This failure could place the facility at risk for drug diversion. Findings included: An untitled sheet/log in the medication book dated 10/15/19 indicated medications were filled on 10/15/19. There was no signature or delivery date and time as to the medications being received. An untitled computer-generated form/log indicated medications ordered on [DATE]. The medications had individual check in boxes and medications were not checked in. An untitled sheet/log in the medication book dated 10/18/19 indicated medications were filled on 10/18/19. There was no signature, delivery date or time as to when the medications were received. The sheets/logs included controlled drugs An untitled computer-generated form/log indicated medications ordered on [DATE]. The medications had individual check in boxes and medications were not checked in. During an interview on 10/21/19 at 12:40 p.m., MA [NAME] said staff checking in medications were to fill out all the information on the sheets and keep a copy. She said they were also to check the medications in on the computer-generated form. She said it was not always done. During an interview on 10/21/19 at 01:25 p.m., the DON and ADON said staff should be checking off medications on the sheet when they check them in, she said if they do not get to check them in on the computer system there is documentation of the medications received. They both said the original sheet went back to the pharmacy with the driver. During an interview and record review on 10/21/19 at 3:45 p.m. an untitled fax dated 10/18/19 from the pharmacy was provided. The fax indicated a staff signature showing the medications were received, but there was no indication of delivery date and time. There was also no indication if all the medications on the lists were received. The DON said all the information was not filled out on the form. She said she was able to account for all the medications received after going through the medication room and carts. She said the procedure they were using could result in a drug diversion. An undated Receiving Medication from the Pharmacy policy indicated when the medications were verified the shipping manifest was to be signed indicating medications were delivered and a copy of the shipping manifest was to be made and placed in the Orders Received book at the nurse station. There was no information about checking the medications in on the computer manifest. During an interview on 10/23/19 at 3:20 p.m., the facility was asked for additional information at exit, no additional information was provided.

Based on interview and record review the facility failed to ensure Pre-Admission Screening and Resident Review (PASSR) level 1 was completed accurately for 2 of 7 residents reviewed for PASRR. (Resident #s 9 and 27) The facility did not accurately complete PASSR Level 1 screenings for Resident #s 9 and 27. This failure could place residents with mental illnesses at risk for diminished quality of life and not receiving care and services in accordance with individually assessed needs. Findings included: 1.) Physician orders [REDACTED].#9 was a [AGE] year-old female readmitted on [DATE] with [DIAGNOSES REDACTED]. An order dated 11/27/17 indicated Resident #9 received [MEDICATION NAME] (antipsychotic) twice daily for [MEDICAL CONDITION] disorder. An order dated 05/25/17 indicated Resident #9 received [MEDICATION NAME] (antimanic) twice daily for [MEDICAL CONDITION] disorder and [MEDICATION NAME] (antipsychotic) twice daily for [MEDICAL CONDITION] disorder. An annual MDS dated [DATE] for Resident #9 indicated in section A1500: PASRR section was marked no for serious mental illness. The MDS indicated the resident had [DIAGNOSES REDACTED]. A revised care plan dated 07/30/19 indicated Resident #9 had behavior problems related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interventions: anticipate and meet the resident's needs and assist the resident to develop more appropriate methods of coping and interacting. A PASRR Level 1 Screening (PL1) dated 01/01/17 indicated Resident #9 was negative for mental illness. The electronic chart or hard chart from 1/2017 through 10/23/19 had no indication a PASSR Level 2 Evaluation (PL2) had been done for Resident #9. During an interview on 10/23/19 at 10:30 a.m., the MDS nurse said Resident #9 should have been positive for mental illness on the PL1 Screening with the [DIAGNOSES REDACTED]. 2.) A Physician order [REDACTED].# 27 was a [AGE] year old male who originally admitted on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Order also included: [MEDICATION NAME] 2mg tablet one per day effective 12/29/18 for [MEDICAL CONDITION] with delusions, [MEDICATION NAME] capsule delayed release particles 60mg effective 6/2/17 in the morning for depression related to major [MEDICAL CONDITION], and [MEDICATION NAME] tablet 50mg one per day effective 5/17/19 due to [MEDICAL CONDITION]. A revised care plan dated 9/16/19 indicated Resident #27 had behavior problems related to [MEDICAL CONDITION] and [MEDICAL CONDITION] with delusions. Interventions: anticipate and meet the resident's needs and assist the resident to develop more appropriate methods of coping and interacting. A significant change MDS dated [DATE] for Resident # 27 indicated in section A1500: PASRR section was marked no for serious mental illness. The MDS indicated the resident had [DIAGNOSES REDACTED]. The PASRR Level 1 screening dated 01/01/2017 completed by the facility for a change of ownership indicated Resident # 27 had no evidence or an indicator of a mental illness in section C0100. The electronic chart or hard chart from 8/2017 through 10/23/19 had no indication of a PASSR Level 2 Evaluation had been done for Resident #27. During an interview on 10/23/19 at 9:51 a.m., the MDS nurse said she was responsible for doing the PASSRs. She said Resident #27 should have had a positive PASRR Level 1 Screening and a PASSR Evaluation completed. The MDS nurse said the qualifying [DIAGNOSES REDACTED]. She said she started as the MDS nurse in (MONTH) (YEAR) and the previous MDS nurse had completed Resident #27's PASSR 1. During an interview on 10/23/19 at 1:0 7 p.m., the MDS nurse said Resident #27 did not have a [DIAGNOSES REDACTED]. An undated PASRR policy indicated It is the policy of this facility to ensure the all residents are screen and appropriately addressed via the PASRR process as outlines by regulations. The results of this process will be used to develop, review and revise the residents care plan. During an interview on 10/23/19 at 3:20 p.m., the facility was asked for additional information at exit, no additional information was provided.