Every finding on record at Victoria Gardens of Allen

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety 1 of 1 kitchen. 1. The facility failed to ensure food items were labeled and dated in the walk-in refrigerator.2. The facility failed to ensure expired food items were not in the walk-in refrigerator.3. The Dietary Manager failed to ensure lunch food temperatures were checked on the steam table line. These failures could place residents at risk of food contamination and food-borne illness.Findings included: During an observation on 06/28/26 at 9:12 AM, the following food items were observed in the walk-in refrigerator:Undated and unlabeled hamburger patties in an aluminum container;2 pounds of undated Sliced Smoke Turkey Breast in a resealable food storage bag;3 undated chicken salad sandwiches in resealable food storage bag;2 resealable plastic containers of chicken salad dated 06/14/26;1 resealable plastic container of chili dated 06/20/26;Sliced pickles in resealable food storage bag dated 06/23/26; and1 resealable plastic container with beans dated 06/24/26 During an interview and observation on 06/28/26 at 9:20 AM, the [NAME] stated all dietary staff were responsible for checking the expiration date on food items. The [NAME] stated the date on the bags and containers was the date the food was prepared. The [NAME] stated the food was good for three days and would need to be thrown out. The [NAME] stated she would trash the undated food and the food that was more than three days old. During an interview on 06/28/26 at 11:15 AM, the Dietary Manager stated all kitchen staff were responsible for labeling and dating the items in the refrigerator. The Dietary Manager stated leftovers had to be disposed of by the third day. The Dietary Manager stated expired food should be checked daily. The Dietary Manager stated residents could be at risk of illness from eating out-of-date food. During an observation on 06/28/26 at 11:30 AM, the [NAME] placed the puree meat, puree vegetables and sauce on the steam table with no tops. The [NAME] placed the regular meat (fried chicken breast) and regular vegetables on the steam table with tops at 11:42 AM The Dietary Manager started to plate the residents lunch meal at 12:03 PM, before she checked the temperatures of the food on the steam table. During an interview on 06/28/26 at 1:15 PM, the Dietary Manager stated she checked the temperatures of the food before the [NAME] placed the food on the steam table. The Dietary Manager stated the proper way was to check the temperature on the steam table before service to the residents. The Dietary Manager stated they ran behind and the residents would not be at risk because the temperatures were checked. Record review of facility policy titled, Food Preparation and Handling, revised 06/2019 revealed, e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Record review of the facility's Taking Temperatures policy, revised June 2019, reflected, The facility realizes the critical nature of serving foods at the correct temperatures to ensure the health of its residents. The facility will take and record the temperatures of all foods prior to service. Record review of the Food and Drug Administration Food Code dated 2022 section 3-501.18 reflected: (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it.(2) Is in a container or package that does not bear a date or day.

Based on observation, interview and record review the facility failed to ensure the resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 4 residents (Resident #1 and Resident #2) reviewed for resident rights.The facility failed to ensure staff didn't tell Resident #1 to use her brief to go to the bathroom.This failure could place residents at risk of a decrease in quality of life.Findings include: Record review of Resident #1's face sheet, dated 04/14/26, reflected an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included cerebral infraction-unspecified (type of stroke caused by a blockage of blood flow to the brain), Dementia (is a syndrome characterized by a decline in cognitive function, affecting memory, thinking behavior, and the ability to perform every day activities), depression unspecified (a person exhibits depressive symptoms, but there is not enough information to assigns a more precise diagnosis), lack of coordination (muscle movements become clumsy, unsteady, or imprecise due to disruptions in the brain, nerves, or sensory systems., and urine retention (bladder doesn't empty completely).Record review of Resident #1's discharge MDS, dated [DATE], reflected her BIMS score was 14, which indicated no cognition impairment. Record review of Resident #1's care plan, dated 01/26/26, reflected Resident#1 was totally dependent in toilet use.Record review of Resident #2's face sheet, dated 04/14/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included unspecified Dementia unspecified (is a syndrome characterized by a decline in cognitive function, affecting memory, thinking behavior, and the ability to perform everyday activities), depression Record review of Resident #2's discharge MDS, dated [DATE], reflected his BIMS score was 15, which indicated no cognition impairment. During an observation of video footage at 8:00 AM on 04/14/26, revealed CNA A went into Resident #1 and Resident #2's room, Resident #2 stated she needs to go to the bathroom. CNA A stated I can not take you right now because I can not pick you up Resident #2 stated the lady came in and said she would get assistance. CNA A stated I cannot pick you up by myself, that was the nurse. The nurse cannot do it right now; she has to pass meds. CNA stated you have a diaper, its nothing we can do. If I accidently drop you. [Resident # 1 was heard crying at this point]. CNA stated You got to wait, If you got to go just go, go in your pants and we will clean it up, it take people to help pick you up, we have to be safe; it's nothing I can do right now but see if somebody will come with me.CNA walked out of the room and returned with a meal tray. I got to ask them I am new here today. Resident#1 stated I wet the bed CNA A stated You wet the bed? Resident #1 stated Right now. Resident #2 stated sorry honey.I talked to 2 to 3 people and they said they would come back and they didn't. CNA A stated the other 3 should have done it. Footage showed CNA A walk out of the room, Resident #2 stated I know honey, I'm sorry. Resident #2 was seen walking out of the roomDuring an interview on 04/14/26 at 8:45 AM, CNA F stated nursing staff should try to assist the residents as soon as possible. CNA F stated residents should never be told to have a bowel movement in their brief. CNA F stated the residents are human and deserved to be treated with respect and integrity. During an interview on 04/14/26 at 9:00 AM, CNA D stated it was never ok to tell a resident to have a bowl movement or urinate in their brief. If you need assistance get help from another staff as soon as possible.During an interview on 04/14/26 at 9:05 AM, CNA E stated nursing staff should change the resident as soon as possible. It is their right to be able to go to the bathroom and not in their brief.During an interview on 04/14/26 at 9:15 AM, the DON, ADON B and ADON C viewed the video footage and identified the staff member as CNA A who was from agency. The DON stated staff should never tell a resident to urinate in their brief because that is a dignity concern. The DON stated nursing staff should work together to assist the resident with their needs. Attempted a phone interview with CNA A on 04/14/26 at 9:38 AM, was unsuccessful and left voicemail.During observation and interview on 04/14/26 at 4:00 PM, the Admin, DON and ADON B reviewed video footage again. ADON B and DON stated residents not being changed when asked and told to use it in their brief was a resident rights issue. ADON B stated nursing staff During an interview on 04/16/26 at 8:34 PM, over the phone CNA A stated that was the first time she had worked at the facility with Resident #1 and Resident #2. CNA A stated she did not feel comfortable toileting residents on her own. CNA A stated she did not mind changing the residents. CNA A stated she never told a resident to urinate in their brief. CNA A stated that was not the right thing to do and she did not mind changing the resident. CNA A stated residents wanted to feel as human as possible, and it was a dignity issue not to provide toileting care when asked. Record review of the facility admission agreement, undated reflected. G. Services Provided.Assistance and/or supervision when required with activities of daily living, including but not limited to, toileting, bathing, feeding and ambulation assistance.

Based on observation and interview the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, permitted only authorized personnel to have access to the for 2 (MC#1 and TC#2) of 3 carts on 04/14/26.This failure could place residents at risk of drug diversion. Findings include:During an observation on 04/14/26 at 6:45 AM, it was revealed that the medication cart was left unlocked with the drawer facing outward at the nursing station. Surveyor did not observed staff at the nursing station or within view of Medication Cart#1 and Treatment Cart#2. Surveyor observed that Treatment Cart#2 was unlocked and was adjacent from the nursing station with the drawer's facing outward toward the hallway.During an interview on 04/14/26 at 7:00 AM, LVN G stated he had an emergency and stepped away from the medication cart. LVN G stated the treatment cart stayed unlocked for emergencies. LVN G stated residents with Dementia could take medication from the medication cart and it needed to be locked.During an interview on 04/14/26 at 7:10 AM, RN H stated the medication cart needed to be locked at all times, because residents or visitors could get into the cart and take medications. LVN H stated the nurse who was on the cart that day was responsible for making sure the cart was locked.During an observation on 04/14/26 at 9:40 AM surveyor observed the inside of Treatment Cart#2 which included:4 X Sterile water, USP 500 ML2 X Thera honey Gel, 05 OZ tube1 x Zinc oxide paste - 4 OZ4 x Hydrophilic wound dressing - 71 G3 X Skin Integrity Hydrogel- 4 OZ3 x Hydrogen Peroxide topical solution USP 946 ML During an interview on 04/14/26 at 4:00 PM, the DON stated each nurse was responsible for making sure their medication cart and treatment cart were locked. The DON stated even if the medication cart was at the nursing station the cart should be locked to prevent residents from taking medications from the cart and taking them resulting in a adverse reaction. Surveyor exited without medication/treatment cart secure policy.

Based on interviews and record review the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) level 1 residents with mental illness were provided with a PASRR level 2 evaluation for 1 of 2 residents (Resident #8), reviewed for resident assessment.Resident #8's PASRR level 1 screening form did not reflect mental illness, and the resident did not have a PASRR level II evaluation .This could place residents at risk of not receiving necessary specialized services to meet their individual needs.The findings were:Record review of Resident #8's quarterly MDS assessment, dated 01/15/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's BIMs score was 15 indicating the resident's cognition was intact. Her diagnoses included Bipolar Disorder (mental condition marked by alternating periods of elation and depression), Generalized Anxiety Disorder (disorder characterized by feelings of worry, anxiety, or fear that are enough to interfere with one's daily activities), Post Traumatic Stress Disorder (a mental health condition that's caused by an extremely stressful or terrifying event) and Insomnia (trouble falling and/or staying asleep).Record review of Resident #8's Care Plans reflected:06/17/2025: The resident was receiving Behavioral Health services to assist with her diagnosis of PTSD, Anxiety, and Mood Disorder.06/17/2025: The resident had behaviors such as crying, excessive worry, irritability, and paranoia.Record review of Resident #8's PASRR level 1 screening, dated 09/06/2024 reflected the resident did not have a serious mental illness and serious mental illness was checked as no. An interview on 02/11/2026 at 3:35 PM with MDS Nurse A revealed she did not know why Resident #8 had a negative PASRR level 1 screening. She said the resident's PASRR was completed by the hospital and not checked for accuracy when the resident was admitted . MDS Nurse A stated she was responsible for ensuring that PASRRs were correct. MDS Nurse A stated an inaccurate PASRR could result in the facility not knowing what services the Resident would need to meet her needs. Review of the facility policy, PASRR Rules and Guidelines, dated 01/09/2026, reflected: The intent of this guideline is to identify residents with Mental Illness (MI), Intellectual Disability (ID) or Developmental Disability (DD)/Related Conditions (RC) and to ensure they are properly placed, whether in community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, or ID/DD. The facility Business Development Specialist (BDS) or designee will coordinate with the referring entity to ensure that a PASRR Level 1 (PL1) screening is completed.

Based on observation, record review and interview, the facility failed to ensure that a resident receives treatment and care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (Resident #95) of four residents reviewed for quality of care. The facility failed to ensure RN I completed wound cares to Resident #95 per physician orders. This failure placed residents at risk for the decline in quality of life and the wounds being infected or deteriorating.Review of Resident #95's face sheet dated 02/11/26 revealed he was a [AGE] year-old male, and he was admitted on [DATE]. Admitting diagnoses included, type 2 diabetes, acquired abscess of the left toe, peripheral vascular disease, and chronic osteomyelitis (Reduced blood flow (ischemia) from narrowed arteries limits immune response) left ankle and foot. Review of Resident #95's admission MDS assessment dated [DATE] reflected he had a BIMS score of 15, indicating no cognitive impairment. The resident had orthopedic aftercare following surgical amputation. Review of Resident #95's care plan initiated 02/05/26 reflected, Resident #95 had a partial amputation of left 3rd toe related to diabetes. The goal was for Resident #95's wound to heal and progress without complications. Intervention was to check and document on wound daily for sign and symptoms of infection, drainage, bleeding, any breakdown of skin and impaired circulation (edema (swelling) or pain). Resident #95 had diabetic ulcer of the left plantar foot related to diabetes. The goal was that the resident will have no complications related to ulcer. Intervention was for weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (discharge) and any other notable changes or observations. Review of Resident #95's physician summary dated 02/11/26 reflected an order dated 02/06/26 left 3rd toe: clean with normal saline wound cleanser and paint with betadine (antiseptic used to kill bacteria, fungi, and viruses) and apply adaptic (non-adhering wound dressing) and cover with gauze daily and as needed if soiled or dislodged one time a day for wound care. Left foot plantar: clean with normal saline pat dry, apply collagen powder, cover with foam padding, and wrap with kerlix (gauze bandage rolls) then secure with tape one time a day for wound care. Observation and interview on 02/09/26 at 11:18 AM with Resident #95 reflected the resident was in the wheelchair. The resident was noted with wound dressings to the third left toe. In an interview with Resident #95 he stated his wound care was not completed on the weekend (02/07/26 and 02/08/26). The resident stated wound care had been completed on 02/09/26 in the morning. He stated he was not aware of the state of the wounds. Observation and interview on 02/10/26 at 10:20 AM with Resident #95 during wound care revealed no signs or symptoms of infection to the wounds. The resident denied pain during wound care. In an interview on 02/10/26 at 12:40 PM LVN G revealed she was the treatment nurse, and she completed all wound cares in the facility on Monday through Friday and the charge nurses would complete the wound cares on Saturday and Sunday. LVN G stated that when she was completing wound care to Resident #95, the resident reported his wound care was not completed on the weekend. There were no signs or symptoms of infection to the wounds. LVN G reported to ADON the residents' concerns. In an interview on 02/11/26 at 12:25 PM with LVN H, she revealed she was an ADON. She stated the treatment nurse (LVN G) reported that Resident #95's wound care was not completed over the weekend. LVN H spoke with the resident regarding the concern with the wound care not provided. LVN H stated she tried to talk with the weekend nurse, and she could not get hold of the nurse until today in the morning. LVN H stated the weekend charge nurse reported he had signed he EMAR and when he went to the room the resident was not there, and he did not go back to do the wound care. LVN H stated the weekend charge nurse was expected to complete wound care per the physician orders and failure could cause wound infection or wounds getting worse. In an interview on 02/11/2026 at 2:24 PM RN I revealed he was the weekend charge nurse for Resident #95 on 02/07/26 and 02/08/26. He stated he did not complete the wound care because on Saturday (02/07/26) it skipped his mind and on Sunday (02/08/26) the resident was out on pass, and he saw the resident around dinner time, and he forgot to go back and complete the wound care. RN I stated wound cares were to be completed to prevent the wounds from deteriorating and getting infected. In an interview on 02/11/26 at 3:20 PM with the DON she stated she was not aware that wound care was not completed over the weekend until the ADON reported. The DON stated RN I was expected to complete Resident #95 wound care per the physician orders. The treatment nurse and the ADONs were responsible for making sure the wound cares were completed. Review of the facility policy revised November 2017 and titled Wound Care reflected, . The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.The policy did not have information about providing wound care.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of six residents (Resident #75) observed for infection control. The facility failed to ensure CNA D completed hand hygiene while providing incontinence care to Resident # 75. This failure could place the residents at risk of infection.Record review of Resident #75's face sheet dated 02/11/26 reflected a [AGE] year-old female. She was admitted to the facility 01/14/26. Admitting diagnoses included hypertension, pressure ulcer to the sacrum area (located at the base of the spine) muscle weakness, neuromuscular dysfunction of the bladder (person lacks bladder control)and muscle wasting and atrophy. Review of Resident #75's care plan initiated 01/14/26 reflected Resident #75 had bowel/bladder incontinence related to disease process, impaired mobility and neurogenic disorder (conditions that target how your nervous system). Goal, the resident will remain free from skin breakdown due to incontinence and brief use. Review of Resident #75's admission MDS record dated 01/20/26 reflected that the resident had a Brief Interview of Mental Status score of 14, indicative of no cognitive impairment. Resident #75 required assistance with toileting. In an observation on 02/09/26 at 1:29 PM during incontinent care CNA D provided incontinent care to Resident #75. The resident was soiled with urine and feces, and after CNA D cleaned the resident, she did not complete any form of hand hygiene or change gloves. With the same dirty gloves CNA D applied the clean brief on the resident. In an interview on 02/10/2026 at 1:55 PM with CNA D she stated she was not aware if she was supposed to change gloves and complete hand hygiene after cleaning the resident and she stated she did not have answers to the questions the surveyor was asking her. CNA D stated she did not think she needed to wash hands after changing the resident if she changed gloves. CNA D stated she was supposed to complete hand hygiene and change gloves to prevent transmission of infection. CNA D stated she was in the process of completing the infection training online. In an interview on 02/11/2026 at 11:40 AM LVN E revealed she was the infection preventionist. LVN E stated she had verbally in-serviced all nursing staff including CNA D on infection control. LVN E stated CNA D was expected to maintain infection control while providing incontinent care by completing hand hygiene and changing gloves after cleaning the resident. Hand hygiene was required to prevent transmission of infections. In an interview and record review on 02/11/2026 at 3:57 PM with the DON she stated her expectation was for the staff to maintain infection control while providing care to residents. The DON stated CNA D was to complete hand hygiene and change gloves after cleaning the resident, before applying the clean brief. The DON stated CNA D had been in-serviced on infection control on 02/10/26. The DON provided record of the in-service and it reflected CNA D had been in-serviced. The DON stated the staff was to maintain infection control to prevent the transmission of infections. Review of the facility policy revised December 22, 23 and titled Hand Washing/Hand Hygiene reflected, The facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread on infections to other personnel, residents and visitors. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with hand hygiene is recognized as the best practice for preventing healthcare-associated infection.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 9 rooms (Rooms 104, 105, 108, 209, 212, 306, 307, and 312) of 30 rooms reviewed for accident hazards. The facility failed to ensure the needle sharps containers (which are specialized receptacles designed to safely dispose of sharp medical instruments that can cause injuries or infections) in Rooms 104, 105, 108, 209, 212, 306, 307, and 312 were emptied.This failure could place residents at risk of being injured by a needle, and exposure to bloodborne pathogens. Findings included: Observation on 01/20/26 from 10:00 AM to 11:00 AM revealed all resident rooms have a sharps container mounted inside the resident room by the door. Rooms # 104, 105, 108, 209, 212, 306, 307, and 312, (which were occupied by residents) were noted to have been filled past the Fill line to the point the security flap could not operate. Interview on 01/20/26 at 11:25 AM, LVN A stated the nurses were responsible for replacing sharp containers when they filled to the Fill line on the container. He stated the risk of over filling the container was exposure to bloodborne pathogens from a used needle. Interview on 01/20/26 at 11:55 AM, the ADON stated the nurses were responsible for changing out the sharps containers, but all staff were responsible for monitoring the boxes and alerting the nurse when it needed to be changed. The ADON stated the risk of an over filled container was exposure to used needles which could cause an infection from pathogens on the needle. Interview on 01/20/26 at 2:50 PM, the DON stated she was not aware of the sharps containers being over filled. She stated the nurses and housekeeping both had keys to the boxes and either one could change out a full box. She stated the risk of an over filled container was bloodborne pathogen exposure from a used needle. Record review of the facility's Sharps Disposal, policy, dated January 2012, reflected: .3 c Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container.

Based on interviews and record reviews, the facility failed to ensure resident records were maintained for each resident that were complete; accurately documented, readily accessible; and systematically organized for 1 of 9 residents (Resident #1) reviewed for resident records.LVN B failed to document a telephone order from the physician for Resident #1's cough medicine, guaifenesin.This failure could result in residents not receiving the medication ordered. Findings included:Record review of Resident #1's quarterly MDS, date [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included emphysema, lung cancer, end stage kidney disease requiring dialysis, and diabetes. Record review of Resident #1's care plan, dated [DATE], revealed she had a self-care deficit, had a tumor in her lungs, and went to dialysis every Monday, Wednesday, and Friday. Record review of Resident #1's EHR revealed the resident expired in the evening of [DATE] at the hospital. Record review of Resident #1's progress notes revealed on [DATE] she had a persistent cough. On [DATE], LVN B documented the resident was administered cough syrup for her cough.Record review on [DATE] of Resident #1's physician orders revealed no order for cough syrup. Interview on [DATE] at 2:40 PM, LVN B stated she had contacted Resident #1's nurse practitioner and received a verbal order for guaifenesin 10 ml every 4 hours as needed for cough on [DATE]. LVN B stated she administered the cough syrup immediately because the resident was coughing so severely. She stated she just forgot to enter the verbal order into the physician orders. LVN B stated the risk of not entering the order was the resident not receiving further doses of the medicine when she requested it, or a delay while another nurse called for the order again. Interview on [DATE] at 3:40 PM, the DON stated nurses were allowed to accept a verbal or phone order from the physician or their designee. The process for the nurse was to write the order down and repeat it back to the physician to ensure accuracy of the order. The nurse should ideally enter the order into the EMR and then read it back to the physician, but it was acceptable to enter the order before the end of their shift. The DON stated the risk of not entering the order was the resident not receiving the medication as prescribed and suffering the effects of not taking the medicine, and/or the resident receiving a medication without an order. Record review of the facility's Medication and Treatment Orders policy, dated [DATE], reflected: .2. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record.3. Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis.7. Verbal orders must be recorded immediately in the residents' chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order.

Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #1 and Resident #2) of five residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #1's breathing mask for nebulization was properly stored on 12/07/2024. 2. The facility failed to ensure that Resident #2's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored on 12/07/2024. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Review of Resident #1's Face Sheet, dated 12/07/2024, reflected the resident was an [AGE] year-old female admitted on [DATE]. Resident #1 was diagnosed with chronic respiratory failure (airway to lungs becomes narrow and damaged) with hypoxia (low oxygen level). Review of Resident #1's Comprehensive MDS Assessment, dated 10/15/2024, reflected the resident was cognitively intact with a BIMS score of 15. Resident #1's Comprehensive MDS Assessment listed chronic lung disease as one the of the resident's active diagnosis. Review of Resident #1's Comprehensive Care Plan, dated 10/19/2024, reflected the resident had respiratory failure and one of the interventions was give aerosol (fine spray or mist used to deliver medications) or bronchodilators (medication used to open the airways) as ordered. Review of Resident #1's Physician Order, dated 07/08/2024, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally four times a day for antiasthmatics. Observation and interview on 12/07/2024 at 3:01 PM revealed Resident #1 was in her bed, awake. It was observed that there was a nebulizer machine on top of the resident's right-side table and a breathing mask was connected to the machine. The breathing mask was on top of the machine and was not bagged. The resident said she was on breathing treatment four times a day because of her breathing problem. She said the nurse would put it on and would take it off. She said she do not know where the nurse would put it after he would take it off. She said she was never told to put the breathing mask in a plastic bag and said it was not her responsibility to put it on a bag. She said she do not know when the breathing mask was last changed. 2. Review of Resident #2's Face Sheet, dated 12/07/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #2 was diagnosed with chronic respiratory failure with hypoxia and muscle weakness. Review of Resident #2's Comprehensive MDS Assessment, dated 10/22/2024, reflected the resident was cognitively intact with a BIMS score of 13. Resident #2's Comprehensive MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility. Review of Resident #2's Comprehensive Care Plan, dated 10/27/2024, reflected the resident had respiratory failure with hypoxia and one of the interventions was to give oxygen therapy as ordered by the physician. Review of Resident #2's Physician Order, dated 12/07/2023, reflected O2 @ 2L via NC CONTINUOUS every shift for SOB. Observation on 12/07/2024 at 3:11 PM revealed Resident #2 was in her bed, awake. Resident #2 was wearing the nasal cannula and receiving oxygen. It was also observed that the resident had a wheelchair at bedside with a portable oxygen tank at the back. A nasal cannula was noted connected to the portable oxygen tank and the nasal cannula was hanging on the wheelchair's right wheel. The nasal cannula was not bagged and almost touching the right wheel of the wheelchair. In an interview with CNA B on 12/07/2024 at 3:49 PM, CNA B stated the wheelchair was Resident #2's wheelchair. He said the nasal cannula should not be hanging by the wheel because it would get dirty. He said he would tell the nurse the nasal cannula was hanging by the wheel. Observation and interview with RN A on 12/07/2024 at 3:56 PM, RN A stated the breathing mask and the nasal cannula should be inside a clean bag when not in use to protect them from transfer of germs and probable infection. RN A entered Resident #1's room and saw the resident's breathing mask sitting on top of the nebulizer machine. He disconnected the breathing mask, threw it the trash can and said he would get a new one, and would put the breathing mask inside a bag. He said he administered the resident's breathing treatment around 3 PM and the resident must have removed it when it was done. He said he should have checked if the resident was done, cleaned the breathing mask and put it inside the bag. RN A went out of Resident #1's room. After leaving Resident #1's room, he went inside Resident #2's room, and saw the nasal cannula was hanging at the back at the wheel of the wheelchair. RN A disconnected Resident #2's nasal cannula and threw it in the trash can. He said he would also replace it. He said he did not notice the nasal cannula was hanging and almost touching the wheel of the wheelchair. In an interview with the Administrator on 12/07/2024 at 4:48 PM, the Administrator stated the breathing mask and the nasal cannula should be kept clean to prevent any respiratory infection. He said he would coordinate with the DON regarding the needed in-service about respiratory care. He said the expectation was for the staff to bag the breathing mask and the nasal cannula every time the resident was not using it. In an interview with the DON on 12/07/2024 at 5:17 PM, the DON stated the breathing mask and the nasal cannula should be stored properly when not in use to keep them clean. She said if the breathing mask and the nasal cannula were not bagged, exposed, or touching surfaces that were not clean, there could be cross contamination, respiratory infection, and compromised oxygen administration. She said the expectation was for the staff to be mindful in making sure that the breathing mask and the nasal cannula was properly stored. She said she would make an in-service and re-educate the staff about storing the breathing mask and the nasal cannula properly. Facility's policy for bagging the nasal cannula requested via email to the Administrator on 12/07/2024 at 4:30 PM but was not provided prior to exit.

Based observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of five residents reviewed for Infection Control. The facility failed to ensure that CNA B changed his gloves and performed hand hygiene while providing incontinent care to Resident #2 on 12/07/2024. This failure could place the residents at risk of cross-contamination and development of infections. Findings included: Review of Resident #2's Face Sheet, dated 12/07/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #2 was diagnosed with muscle weakness and muscle atrophy (decrease in size of a body part). Review of Resident #2's Comprehensive MDS Assessment, dated 10/22/2024, reflected the resident was cognitively intact with a BIMS score of 13. Resident #2's Comprehensive MDS Assessment indicated the resident needed maximal assistance for toileting. Review of Resident #2's Comprehensive Care Plan, dated 10/27/2024, reflected the resident had an ADL self-care performance deficit related to weakness and one of the interventions was provide assistance with personal hygiene. Observation and interview with CNA B on 12/07/2024 at 3:49 PM revealed CNA B was about to provide Resident #2's incontinent care. CNA B took with him a box of gloves, wipes, and a brief inside the room and placed them on the resident's overbed table. He did not place any hand sanitizer on the overbed table. He washed his hands and put on a pair of gloves. CNA B raised the bed and lowered the head of the bed. He unfastened the resident's brief, pushed it between the resident's legs, and cleaned the resident's perineal area (area between the thighs) using the front to back technique. After cleaning the perineal area, he took off his gloves, threw them to the trash can, and put on a new pair of gloves. He did not sanitize in between changing of gloves. He assisted the resident to roll towards the wall and started to clean the resident's bottom. After cleaning the resident's bottom, he rolled the soiled brief, pulled it, and threw it in the trash can. He changed his gloves but did not sanitize his hands before putting on a pair of gloves. After changing his gloves, CNA B touched the trash can and tied the plastic bag inside the trash can into a knot. After tying the plastic bag, CNA B took the new brief from the overbed table, put it under the resident, and fixed it. He did not change his gloves after touching the trash can and before touching the new brief. When CNA B was done with incontinent care, he took off his gloves and washed his hands. He stated he did wash his hands before and after incontinent care and he also changed his gloves after cleaning the resident the resident's perineal area and bottom. He said he was supposed to sanitize or wash his hands when he changed his glove to be sure his hands were clean when he put on the new gloves. He said he should have changed his gloves after touching the trash can because the trash can is dirty. He said his action could result to cross contamination and infection. He said he had in-services about hand hygiene and infection control but was not able to apply it. In an interview with the Administrator on 12/07/2024 at 4:48 AM, the Administrator stated staff should wash their hands and change their gloves when needed to prevent transfer of germs and infection. He said the expectation was for the staff to follow the policy and procedures pertaining to infection control and hand hygiene. He said he would coordinate with the DON to do in-services about hand hygiene and infection control. In an interview with the DON on 12/07/2024 at 5:17 PM, the DON stated hand hygiene was the most efficient way to prevent cross contamination and infection. She said staff should do hand hygiene before and after incontinent care and also when gloves were changed. She also the gloves should be changed after touching the soiled brief and after touching the trash to prevent transfer of microorganisms to any clean brief. She said the expectation was for the staff to change their gloves when going from dirty to clean and to do hand hygiene when changing the gloves. She said she would do an in-service for infection control and hand hygiene. She said she would personally monitor them for Review of facility policy, Handwashing/Hand Hygiene 2001 MED-PASS, Inc. revised December 22, 2023 revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub . f. Before donning sterile gloves . h. Before moving from a contaminated body site to a clean body site during resident care . j. After contact with blood or bodily fluids k. After handling used dressings, contaminated equipment, etc.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #81) of eight residents reviewed for ADL care. 1. The facility failed to provide Resident #81 with timely incontinence care on 11/17/24. This failure could place residents at risk for a skin breakdown and infection. Findings included: Record review of Resident #81's annual MDS assessment, dated 08/08/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 15 indicating his cognitive status was intact. His diagnoses included heart failure, cerebral palsy (group of conditions that affect movement and posture), and paraplegia (paralysis that affects the lower part of the body). The resident was dependent on staff for toileting. The resident was always incontinent of bowel and bladder. Record review of Resident #81's care plan reflected: 08/04/24 The resident had an ADL self-care performance deficit related to impaired mobility, weakness, and paraplegia. Facility interventions included resident required 1-2 persons assistance with toilet use. 09/26/24 The resident had bowel/bladder incontinence and was at risk for infection and skin breakdown. Facility interventions included brief use. Staff were to clean the peri-area with each incontinence episode. Review of Resident #81's Task Record, dated 11/17/24, reflected the resident did not have documentation showing that the resident received incontinence care on the 2:00 PM - 10:00 PM shift. An interview on 11/18/24 at 11:20 AM with Resident #81 and his Roommate, Resident #82, revealed he was sitting up in bed. He was awake, alert, and oriented. Resident #81 and his roommate said on 11/17/24 during the 2:00 PM - 10:00 PM Resident #81 had to wait an hour and forty-five minutes to receive incontinence care. Resident #81 said he had to sit in a wet brief the whole time. Resident #81 said he pressed the call light and the nurse, name unknown, told him she did not know where CNA A was. Resident #81 said when CNA A arrived to his room, he told him that he had to take care of all the residents on his other hall before he could get to Resident #81. An interview on 11/19/24 at 1:24 PM with the DON revealed she did not know the true names of the staff who took care of Resident #81 on 11/17/24, but only knew them by their nickname which was not on the employee roster. She said she would find out, but that she had talked to Resident #81 about the issue. The DON said she was going to speak to CNA A and do in-servicing with him about call lights. She said there was not an exact amount of time that a resident should have to wait for incontinence care, but that the care should be provided in a timely manner. She said Resident #81 did not have skin breakdown and there was not a shortage of staff who had worked the shift. The DON said the CNA and nurse were responsible for ensuring residents received timely incontinence care. She said the risk to the resident who did not receive timely incontinence care was risk to the resident's safety. The DON said she was not aware that staff did not document that they provided the resident with incontinence care on the 2:00 PM - 10:00 PM shift for 11/17/24. An interview on 11/19/24 at 1:58 PM with CNA A revealed Resident #81 was on Hall 200 and he was only assigned to Hall 100. He said he had to switch a resident and that was the reason he also had Resident #81. CNA A said he did not know Resident #81 had pressed his call light. CNA A said he started making his rounds at 8:00 PM on Hall 100. He said he did not reach Resident #81's room until around 9:00 PM. He said he did not need anyone's help to do his job and he could switch and do incontinence care for Resident #81 first, but no matter what, someone was going to have to wait for care. CNA A said he did not tell LVN B to help him. He said there was not a staffing issue. He said LVN B did not tell him until after he had finished Hall 100 that Resident #81 had pressed his light. An interview on 11/19/24 at 2:13 PM with LVN B revealed she answered the call light for Resident #81 on the 2:00 PM - 10:00 PM shift on 11/17/24. She said CNA A was busy with another resident at the time she answered the call light. She said she told Resident #81 that CNA A would change him when he finished with the other resident. LVN B said Resident #81 did not tell her how long he had to wait for care. She said it was her responsibility to ensure residents received timely incontinence care. She said she did not go back to Resident #81 to make sure CNA A assisted him. Review of the facility policy, Perineal Care, revised October 2010 reflected: Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . Documentation Care will be reflected in POC PCC .

Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #8) of 3 residents reviewed for pressure ulcers. The facility failed to provide wound care for Resident #8 on 11/16/24 and 11/17/24. This failure could place residents with pressure wounds at risk of the wound worsening, leading to increased pain, infection, delayed healing, serious complications including sepsis, reduced mobility, and a lower quality of life. Findings included: Record Review of Resident #8's Admission Record and MDS assessment revealed a [AGE] year-old male, readmitted to the facility on [DATE] with an original admitted [DATE]. Resident's MDS revealed a BIMS score of 14 indicating he as cognitively intact. Record Review of Resident #8's Diagnosis Report and TAR revealed the following diagnoses: Pressure Ulcer of right buttock, essential (primary) hypertension, Cerebral Infarction, Metabolic Encephalopathy, Frontal Lobe and Executive function deficit following cerebral infarction, sepsis - unspecified organism, cognitive communication deficit, muscle wasting and atrophy, other lack of coordination, muscle weakness (generalized), occlusion and stenosis of unspecified carotid artery, thrombocytosis, infection and inflammatory due to indwelling urethral catheter, myelodysplastic syndrome, osteomyelitis, morbid obesity, type 2 diabetes, generalized anxiety disorder. Record Review of Resident #8's Orders revealed the following medications: -Prostat 30ml for wound 3 times a day -PT, OT, ST to evaluate and treat as indicated -Apply Miconazole powder to scrotal/perinium area after every brief change -Apply Zinc Oxide cream to scrotal/perinium area after every brief change Record Review of Resident #8's Orders revealed the following order: Cleanse wound to right gluteal fold with wound cleanser, pat dry, apply gentamicin, apply Dakin's-soaked gauze, and secure with foam dressing- one time a day for wound care. Record Review of Medication Error Review revealed the error occurred on 11/17/24 between 6 a.m. - 2 p.m. for Resident #8. The date of report was 11/18/24. The report reveals the description of error was noticed TARS not documented on, showing missed treatment orders. The report was signed by DON, ADON, and Nurse #1 on 11/18/2024. Record Review of Resident #8's Progress Notes revealed no progress notes entered for the dates of 11/16/2024 and 11/17/2024. Record Review of Resident #8's Pressure Wound Summary states the wound was evaluated on 11/07/2024. The dimensions of the pressure wound showed the Area as 13.45 cm, Length as 6.12 cm, and Width as 2.65 cm. Record Review of Resident #8's Skin and Wound Evaluation completed on 11/15/2024 revealed pressure wound as type of wound located on Right Ischium, present for 1-2 years. Measurements on the report stated the area as 23.8 cm, width as 7.0 cm, and depth as 3.0 cm. An interview on 11/19/2024 at 9:50 a.m. of Resident #8 revealed resident appeared to be well-groomed, clean hygiene, free from odors, and in clean appropriate clothing. Resident was alert oriented. Resident #8 reported he does not get enough help on the weekends. He stated he has a wound that the dressing needs to be changed every day. He reported his bandage was not changed on Saturday (11/16/24) and Sunday (11/17/24). He said he asked the nurse maybe a dozen times that weekend and kept getting excuses. Resident #8 reported staff told him they are going to change his bandage today. He reported during the week he has the best help; he is not sure why this has to change on the weekend. Resident #8 stated the bed sore came from a previous nursing home. He stated when it developed it progressively got worse. Resident #8 stated he has a wound care guy that comes here on Thursdays once a week to check his wounds and then in between those days the nurses treat his wounds. Resident #8 reported he was not in pain now. He stated he did not believe the wound worsened over the weekend but that the weekday staff would take care of him. On 11/20/2024 an interview with Charge Nurse #1 at 10:44 a.m., Charge Nurse, LVN. Nurse #1 stated she worked at the facility over the weekends only. She stated she is responsible for wound care and had several residents with wound care that she oversaw. Nurse #1 stated she is assigned to Resident #8. Nurse #1 stated she completed wound care on Resident #8 on 11/16/24 and 11/17/24. Nurse #1 stated according to her TAR she did complete the wound care. Nurse #1 stated if a resident does not receive wound care, they could become necrotic, very sick, and septic . Nurse #1 stated she documented the wound care. Observation and Interview of Resident #8 on 11/20/2024 at 10:19 a.m. Surveyor Nurse obtained permission from Resident #8 to observe wound care treatment provided by the ADON/ WCN. Resident #8 stated he did not receive wound care on the weekend (11/16/24-11/17/24). Resident stated he asked more than 4 times for it. Observation of wound care treatment on 11/20/2024. Resident #8 was assisted to reposition onto his left side. Right ischium with large, dark, deep, red, open area with a moderate amount of slough and skin excoriations that is painful to the resident was observed. The nurse took off the dressing and cleaned the wound. The resident stated he wanted medication for pain. The ADON stopped the wound care, and the resident was medicated. ADON was wearing correct personal protection equipment. ADON performed incontinence care to resident. ADON stated the pressure ulcer does not look much different than it did on last Thursday (11/14/24). ADON cleaned the wound, performed hand hygiene, treatment, wet to dry with Dakin's and dressing applied. The ADON was asked why Resident #8 did not receive wound care over the weekend. The ADON/Wound Care Nurse stated that maybe Nurse #1 did not document the treatment on the weekend. The surveyor stated to the ADON that the resident reported not receiving the treatment at all on the weekend. The ADON stated she did not know what happened. Interview with Nurse #2 at 2:15 p.m. on 11/20/2024. Nurse #2 stated she completed wound care for Resident #8 on Friday, November 15, 2024, and Monday, November 18, 2024. Nurse #2 stated during wound care on Monday the 18th, she did not notice worsening condition of the pressure ulcer. Nurse #2 stated the bandage was so saturated that she could not see the date on the bandage . On 11/20/2024 Interview with ADON/Wound Care Nurse. The ADON reported that Nurse #2 completed Resident #8's wound care treatment on Friday 11/15/2024 and Monday, 11/18/2024. The ADON stated she and the physician complete wound care and assessments every Thursday. ADON stated the charge nurse is responsible for ensuring the wound care is done. The ADON stated she completed the follow up to make sure the treatments are done. The ADON stated she was made aware on 11/20/2024 by Resident #8 that he did not receive wound care treatment over the weekend. The ADON stated she was made aware that Nurse #1 did not document the wound care treatment and asked Nurse #1 to come to the facility on [DATE] to complete her documentation but she did not come. The ADON stated she was made aware the documentation was not completed during the morning meeting on Monday, 11/18/2024. An interview on 11/20/2024 with DON. The DON stated she was made aware on Monday this week (11/18/24) that the TAR was not completed by Nurse #1. The DON stated she pulls the TAR report every day. The DON stated once she noticed the TAR was incomplete for Resident #8 for 11/16/2024 and 11/17/2024 she then completed the medication error report. The DON stated she only asked Nurse #1 about the incomplete TAR report. The DON stated Nurse #1 told her that she did complete wound care on Resident #8 on those two days, but she did not click off on the TAR. The DON stated she did not ask Resident #8 if he received wound care on those two days. The DON stated when she reviewed the TAR, it only showed Resident #8 as not receiving wound care over that weekend. The DON stated she asked Nurse #2 what the date on the bandage on Resident #8 stated when she provided wound care on Monday, 11/18/24. The DON stated Nurse #2 told her that the bandage was too saturated she could not see the date. The DON stated she confirmed Resident #8 received wound care by asking Nurse #1 and did not ask Resident #8 if he had received wound care. The DON stated she believes Resident #8 did receive wound care over the weekend. The DON stated from dealings with the resident (Resident #8) and dealing with wound care nurses, and the amount of drainage present, the bandage would not have stayed on if it were not changed. The DON stated she does not have concerns about Resident #8 lying in the past, but Resident #8 has mentioned in the past about not receiving adequate care on the weekends. The DON stated it would have been beneficial to ask Resident #8 if he had received wound care on 11/16/24 and 11/17/24s. The DON reported that lack of wound care could lead to increased risk of infection and deterioration. The DON stated Resident #8 did not receive wound care on 11/6/24 or 11/17/24. Record Review of the facility's Wound Care Policy. The policy states the procedures for appropriate wound care. The policy states that the Purpose of the procedure is to provide guidelines for the care of wounds to promote healing. In preparation, the policy states the following: 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. a. For example, the resident may have PRN orders for pain medication to be administered prior to would care. 3. Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening. Wipe nozzles, foil packets, bottle tops, etc., with alcohol pledget before opening, as necessary. (Note: This may be performed at the treatment cart.) Additionally, the policy states the following regarding documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The name and title of the individual performing the wound care. 4. Any change in the resident's condition. 5. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 6. Any problems or complaints made by the resident related to the procedure. 7. If the resident refused the treatment and the reason(s) why. 8. The signature and title of the person recording the data. 51181

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 (Resident #14, Resident #34, Resident #66, and Resident#69) of 8 residents reviewed for infection control. The facility failed to ensure: 1- RN L disinfected the glucometer in between blood sugar checks for Residents #66 and #69. 2- MA M disinfected the blood pressure cuff in between blood pressure checks for Residents #14 and #34. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: 1- Record review of Resident #66's Quarterly MDS assessment, dated 09/03/23, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses including elevated blood pressure, and type 2 diabetes mellitus. He was unable to complete the interview to determine the BIMS. Record review of Resident #66's physician orders dated 09/28/23 reflected Humalog solution 100 unit/ml, inject as per sliding scale: if 71-130 give o unit, 131-180 give 2 unites, 181-240 give 4 unites. Record review of Resident #69's Quarterly MDS, dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including elevated blood pressure, and diabetes mellitus. She had a BIMS score of 15 indicating she was cognitively intact. Record review of Resident #69's physician orders dated 09/28/23 reflected, inulin lispro solution 100 unit/ml, inject as per sliding scale: if 1-150 give o unit, 151-200 give 3 unites, 201-250 give 6 unites. Observation on 09/26/23 at 11:50 AM revealed RN L performing blood sugar checks, during which time she checked the blood sugar on Resident #66. RN L did not sanitize the glucometer before or after using it on Resident #66. Observation on 09/26/23 at 11:54 AM revealed RN L performing blood sugar checks, during which time she checked the blood sugar on Resident #69. RN L used the same glucometer right after using it on Resident#66. RN L did not sanitize the glucometer before using it on Resident #69. Interview on 09/26/23 at 11:59 AM, RN L stated reusable equipment, like glucometer, should be sanitized with wipes between each resident use (before and after use on each resident) in order to prevent transmitting an infection from one resident to another. She stated she forgot to bring wipes in her medication cart. 2- Record review of Resident #14's Quarterly MDS assessment, dated 09/07/23, reflected she was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses including elevated blood pressure, and type 2 diabetes mellitus. She had a BIMS score of 14 indicating she was cognitively intact. Record review of Resident #14's physician orders dated 09/28/23 reflected, metoprolol tartrate 25 mg tablet, give 1 tablet by mouth two times a day - Special instruction: Hold for systolic blood pressure less than 110, and heart rate less than 60. Record review of Resident #34's Quarterly MDS, dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including elevated blood pressure, and dementia. She had a BIMS score of 15 indicating she was cognitively intact. Record review of Resident #34's physician orders dated 09/28/23 reflected metoprolol tartrate 25 mg tablet, give 1 tablet by mouth two times a day - Special instruction: Hold for systolic blood pressure less than 110, and heart rate less than 60. Observation on 09/27/23 at 7:25 AM revealed MA M performing morning medication pass, during which time she checked the blood pressures on Resident #14. MA M did not sanitize the blood pressure cuff before or after using it on Resident #14. Observation on 09/27/23 at 7:45 AM revealed MA M performing morning medication pass, during which time she checked the blood pressure on Resident #34. MA M used the same blood pressure cuff right after using it on Resident#14. MA M did not sanitize the blood pressure cuff before using it on Resident #34. Interview on 09/27/23 at 7:55 AM, MA M stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use (before and after use on each resident) in order to prevent transmitting an infection from one resident to another. She stated she forgot to wipe the cuff this time. Interview on 09/28/23 at 9:45 AM, the DON stated that her expectation was that staff would sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. She said she was responsible for training staff on infection control. She said that she did routine rounds in the floor to ensure the nurses and med aids were following proper infection control procedures. Record review of facility's policy Cleaning and Disinfection of Resident -Care Items and Equipment, revised October 2018, reflected . d. Reusable items are cleaned and disinfected or sterilized between residents. 3. Durable medical equipment must be cleaned and disinfected before reuse by another resident. 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according . 44600 48235

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #9, Resident 47, and Resident #72) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #9 was shaved and not having facial hair. 2- Resident #47 had her fingernails cleaned and trimmed. 3- Resident #72 had his fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- Review of Resident #9's Quarterly MDS assessment dated [DATE] reflected Resident #9 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included paraplegia (paralysis of the legs and lower body), muscle weakness, lack of coordination, and type 2 diabetes mellitus. Resident #9 had BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #9 required extensive assistance of one-person physical assistance with dressing, and personal hygiene. Review of Resident #9's Comprehensive Care Plan, revised 03/22/23, reflected the following: Focus: Resident at risk for an ADL self-care performance deficit. Goal: will improve current level of function in mobility, transfers, eating, dressing, toilet use, and personal hygiene through the review date. An observation and interview on 09/27/23 at 10:58 AM revealed Resident #9 was sitting in her wheelchair. She had facial hair on her chin. Resident #9 stated she did not like hair on her face, she stated it was embarrassing, and that she would ask one of the nurses to shave it. 2- Review of Resident #47's Quarterly MDS assessment, dated 08/25/2023, reflected Resident #47 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia, muscle weakness, and cognitive communication deficit. Resident #47 had a BIMS score of 7, which indicated her cognition was severely impaired. Resident#47 required extensive assistance of one-person physical assistance with dressing, transfers, and personal hygiene. Review of Resident #47's Comprehensive Care Plan revised 08/14/23, did not address the concern. Observation on 09/27/23 at 9:35 AM revealed Resident #47 was laying in her bed. The nails on both hands were approximately 0.4cm in length extending from the tip of her fingers. The nails were discolored tan, and the underside had dark brown colored residue. Resident #47 was unable to answer questions. 3- Review of Resident #72's Quarterly MDS assessment, dated 08/26/2023, reflected Resident #72 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included muscle weakness, hemiplegia (paralysis of one side of the body) affecting right side, cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). Resident #72 had a BIMS score of 09 which indicated Resident #72's cognition was moderately altered. Resident#72 required extensive assistance of one-person physical assistance with dressing, and personal hygiene. Review of Resident #72's Comprehensive Care Plan revised 09/26/23 reflected the following: Focus: Resident#72 has an ADL self-care performance deficit related to cerebral infarction. Goal: Will maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene through the review date. Observation and interview on 09/27/23 at 9:39 AM revealed Resident #72 was laying in his bed. The nails on both hands were approximately 0.5cm in length extending from the tip of his fingers. Resident #72 stated that he did not like his nails very long, and he stated he did not tell anybody about his nails. Interview on 09/27/23 at 10:20 AM, CNA I stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA I stated she would clean and trim Resident #47 and Resident#72's nails right then. Interview on 09/27/23 at 10:45 AM, RN K stated CNAs were responsible to clean and trim residents' nails as needed. RN K stated only nurses cut residents' nails if they were diabetic. RN K stated no one notified her Resident #47, and Resident #72's nails were long and dirty, and she had not noticed the nails herself. Interview on 09/27/23 at 10:58 AM, CNA J stated CNAs were allowed to shave residents' face. CNA J stated she would shave Resident #9's face to remove the hair from Resident's chin. Interview on 09/28/23 9:46 AM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated residents having long and dirty could be an infection control issue. The DON stated CNAs were responsible to shave residents and remove facial hair for female residents, as needed. The DON stated she was responsible to do routine rounds for monitoring. Record review of the facility's policy titled Fingernails/Toenails, Care of, revised February 2018, reflected Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 1. Nail care includes daily cleaning and regular trimming .

Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for one (Resident #250) of one resident reviewed for respiratory care in that: RN E failed to follow the procedure for tracheostomy care for Resident #250 when he failed to maintain a sterile/clean field for supplies necessary for care and failed to change his gloves and perform hand hygiene during tracheostomy care when going from dirty to clean multiple times. These failures could place residents with tracheostomies at risk for respiratory infections and the risk of lung infections. Findings include: Review of Resident #250's Face Sheet dated 09/27/23 reflected a [AGE] year-old female with an initial admitted [DATE]. Review of Resident #250's comprehensive MDS assessment, dated 09/14/2023, reflected the resident was unable to participate in the interview for cognition. Her active diagnoses included respiratory failure, brain damage, and tracheostomy status. In Section O-Special Treatments, Procedures, and Programs it revealed that she required tracheostomy care (a surgical opening in the neck providing a direct airway through the trachea) and oxygen therapy. Review of Resident #250's Physician orders summary dated 09/27/2023, reflected, .Clean outer trach DRSG QS & PRN .Clean inner cannula QS & PRN . Review of Resident #250's care plan dated 09/06/23, reflected, .resident has a tracheostomy and is at risk for complications .will have no s/sx of infection .ensure trach ties are secure at all times . An observation on 09/26/23 at 03:00 PM revealed RN E entered Resident #250's room to provide tracheostomy care. RN E placed the tracheostomy kit on the resident's bedside table. RN E donned gloves. RN E opened the tracheostomy kit and dumped out all on table except cleaning wand. Cleaning wand was left in tracheostomy kit. RN E poured cleaning liquid into kit where cleaning wand was resting. RN E checked resident oxygen saturation. RN E removed the inner cannula, placed inner cannula in cleaning liquid in tracheostomy kit, and then took cleaning wand and cleaned the inside of the inner cannula. Without removing gloves or performing hand hygiene, RN E put the inner cannula back into place. Without removing gloves or performing hand hygiene, RN E removed the oxygen mask from Resident #250's tracheostomy, removed dirty gauze, replaced with new gauze, and then returned oxygen mask back over tracheostomy site. RN E removed his gloves and washed his hands. In an interview with RN E on 09/26/23 at 3:15 PM, he stated he has been trained one on one regarding tracheostomy care. He stated he was supposed to perform hand hygiene before and after tracheostomy care. He stated he should have removed his gloves and done hand hygiene after cleaning the inner cannula. He stated he knew the procedure was supposed to be an aseptic procedure to reduce the risk of infection. Review of RN E's 1:1 Trach Education reflected he was in serviced at bedside on 09/13/23 by the Respiratory Therapist. In an Interview with the Respiratory Therapist on 09/27/23 at 10:28 AM revealed that the expectation for tracheostomy care was to clean the bedside table with cleaning wipes and let sit for five minutes. Staff were expected to do hand hygiene before starting care, remove gloves and do hand hygiene during care when going from dirty to clean, and to do hand hygiene after completing care. She stated her trainings were 2.5 to 3 hours in length and she did a one-on-one training with RN E. In an interview with the DON on 09/27/23 at 10:10 AM revealed hand hygiene was to be performed anytime a staff member went from a dirty procedure to a clean procedure or change gloves. She stated RN E received one on one bedside training by the Respiratory Therapist. She stated failure for the staff to follow proper procedures could result in infections. Review of the facility's policy, Tracheostomy Care' revised August 2013, reflected, .Aseptic technique must be used .During cleaning or sterilization of reusable tracheostomy tubes .during all dressing changes until the tracheostomy wound has healed .during tracheostomy tube changes whether reusable or disposable .

Based on observation, interview and record review, the facility failed to ensure the resident received services in the facility with reasonable accommodation of resident needs and preferences for 1 (Resident #93) of 7 residents reviewed for call lights. The facility failed to ensure Resident #93's call button was within reach. This failure could place residents at risk for decreased quality of life, self-worth and dignity. Findings included: Review of the quarterly MDS dated [DATE] revealed Resident # 93 was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses for Resident #93 included: epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures, muscle weakness and atrophy (decrease in size and wasting of the muscle tissue; and diabetes. Review of the MDS revealed Resident # 93 required extensive two-person assistance with ADLs. Resident #93 was incontinent of bowel and bladder. The BIMS score for Resident #93 was 15, indicating that he was cognitively intact. Review of Resident # 93 Care Plan dated 07/24/23 revealed resident requires 2 person assist for ADLS. Resident # 93 was incontinent of bowel and bladder. Resident # 93 had a BIMS of 15 indicating he was cognitively intact. Observation and interview on 09/27/2023 at 12:52PM revealed Resident #93 was lying on his bed. Observation revealed the call light was on the floor near the head of the bed on top of the leg of the bedside table. Interview with Resident #93 revealed he could not find his call light. Observation on 09/27/2023 at 12:58 PM revealed LVN F found the Resident #93's call light on the floor. LVN F picked up the special call light ( a flat white pad call light ) ( off the floor and placed it on resident's bed. Interview with LVN F on 09/27/23 at 01:02 PM revealed the call light had to be within the reach of Resident #93 but she found it on the floor. LVN F stated the resident was not able to use the call light device to request assistance since the call light device was on the floor. LVN F stated the call light had to be always within the reach of the resident. LVN F stated staff were responsible for ensuring call lights were within residents' reach. Interview with LVN C on 09/27/2023 at 01:38 PM revealed a call light must be within the reach of the resident all the time. Interview with ADON H on 09/27/2023 at 01:42 PM revealed residents should have their call light device within reach all the time. Interview with the DON on 09/28/2023 at 02:12 PM revealed the call light had to be within the reach of each resident all the time. She stated it was the responsibility of all the staff members to ensure the call light was within the reach of each resident. Review of the facility's policy Answering the call light (Dated March 2021) on 09/28/2023 revealed answering the call light is to ensure timely response to the resident's requests and needs, when the resident is in bed, be sure the call light is within easy reach of the resident.

Based on observations, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 (Residents #47 and #93) of 24 residents reviewed for comprehensive care plans. 1. The facility failed to implement a care plan and implement interventions for Resident #47's ADL deficits of hygiene. 2. The facility failed to implement a care plan for Resident #93's specialized call light device. These failures could place residents at risk of not receiving individualized care and services to meet their needs. Findings included: 1. Review of Resident #47's Quarterly MDS assessment, dated 08/25/2023, reflected Resident #47 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia, muscle weakness, and cognitive communication deficit. Resident #47 had a BIMS score of 7, which indicated her cognition was severely impaired. Resident#47 required extensive assistance of one-person physical assistance with dressing, transfers, and personal hygiene. Review of Resident #47's Comprehensive Care Plan revised 08/14/23, did not have interventions for Resident #47's personal hygiene. Interview on 09/28/23 at 11:53 AM with MDS Coordinator A revealed the intervention for Resident #47's personal hygiene was missing in the care plan. 2. Review of Resident #93's quarterly MDS assessment dated [DATE] revealed Resident # 93 was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses for Resident #93 included: epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures); respiratory failure with hypoxia (a serious condition that makes it difficult to breathe on your own. The lungs cannot get enough oxygen into the blood); muscle weakness and atrophy (decrease in size and wasting of the muscle tissue); and diabetes. Review of the MDS revealed Resident # 93 required extensive two-person assistance with ADLs. Resident #93 was incontinent of bowel and bladder. The BIMS score for Resident #93 was 15, indicating that he was cognitively intact. Review of Resident #93's care plan dated 07/24/23 revealed no documentation that Resident #93 required a special call light. Observation and interview on 09/27/2023 at 12:52PM revealed Resident #93 was lying on his bed. Observation revealed the special call light device (flat not click type) was on the floor near the head of the bed on top of the leg of the bedside table. He stated he could not find his call light. Observation on 09/27/2023 at 12:58 PM revealed the LVN F found resident's call light on the floor. LVN F picked up the special call light device and placed it on resident's bed. Interview with CNA G on 09/28/2023 at 11:30 AM revealed Resident #93 had a special flat call light device. She stated she did not know the reason for Resident #93 to have this special call light device. CNA G stated this special call light device was in resident's room when he got admitted to this room. Interview revealed the previous resident had some issues with his arm in using the regular call light button. Interview with MDS Coordinator A on 09/28/23 at 11:43 AM revealed a special call light must be care planned if the resident was using a special call light device. Observation and interview on 09/28/23 at 11:46 AM revealed the MDS Coordinator reviewing Resident # 93's care plans in the resident medical record on the surveyor's computer. Interview revealed she could not find a care plan reflecting a special call light device for Resident # 93. The MDS Coordinator stated she was primarily responsible to complete the care plan for Resident # 93. The MDS Coordinator stated the interdisciplinary team contributed to care plans. Interview with the DON on 09/28/23 at 2:12 PM revealed the special call light had to be care planned. Interview revealed if Resident #93 had a special call light, then it should be care planed. The DON stated that the MDS Coordinator and Interdisciplinary Team were responsible for developing care plans. Interview revealed the DON was ultimately responsible for care plans. She stated she signed the care plans. Review of the facility's policy Care Plans, Comprehensive Person-Centered revised March 2022 reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident .3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical .well-being. 42971

Based on interview, observation, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Nurses cart hall 400) of 2 carts reviewed for pharmacy services. The facility failed to ensure LVN C and RN K counted controlled drugs every shift change. This failure could result in an inaccurate controlled medication count, and drug diversion. Findings Included: Record review and random count observation of 400 hall nurse's cart with LVN C on 09/26/2023 at 12:28 PM revealed missing signatures for Off duty and On duty for 08/21/2023, 08/31/2023, 09/02/2023, 09/08/2023 of the narcotic count sheet. Interview on 09/26/2023 at 12:38 PM, LVN C stated he should have signed the narcotic sheet before and after counting the narcotics on 08/31/2023, and 09/08/2023. LVN C stated, I counted the narcotics but forgot to sign. LVN C stated this failure could potentially cause a drug diversion. Interview on 09/26/2023 at 12:45 PM, RN K stated she should have signed the narcotic sheet before and after counting the narcotics on 08/21/2023, and 09/02/2023. RN K stated, I counted the narcotics but forgot to sign because sometimes I get busy. RN K stated this failure could potentially cause a drug diversion. Interview on 09/28/23 at 9:45 AM, the DON stated she expected nurses to sign at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse. The DON stated this was monitored monthly by the pharmacy consultant. The DON stated she had never really had a problem so monitoring more often was not required. The DON stated if the staff was not signing the narcotic count sheets, she was unable to prove they were counting. The DON stated it was important to ensure a drug diversion did not occur. Review of the facility's policy Controlled Substances revised April 2019, reflected the following: .8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift 12. At the end of each shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together.

Based on observation, interview, and record review, the facility failed to provide liquids consistent with the residents' needs, for one (Resident #85) of three residents reviewed for liquid inconsistency, in that: Resident #85 was not served nectar thickened coffee during her breakfast meal on 09/28/23. This failure could place residents who have dysphagia at risk for aspiration. Findings included: Review of Resident #85's quarterly MDS, dated [DATE], reflected Resident #85 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of coronary artery disease, diabetes, right-sided hemiplegia (paralysis that affects only one side of your body), aphasia (language disorder that affects a person's ability to communicate) and dysphagia. Resident #85 had a BIMS score of 0 indicating she was severely cognitively impaired. Resident #85 had a feeding tube and a mechanically altered diet which specified a required change in texture of food or liquids. The MDS also reflected Resident #85 was extensive assistance with eating with one-person physical assistance. Review of Resident #85's order summary report dated 09/28/23 reflected a diet order, dated 07/20/23, of regular diet mechanical soft texture, nectar consistency for diet. Review of Resident #85's comprehensive care plan dated initiated on 04/03/23 and revised on 05/11/23 reflected, the resident had altered nutritional status due to dysphagia and moderate protein calorie malnutrition. Resident #85 had diet order of nectar thickened liquids. Interventions included to offer diet per orders. Review of Resident #85's Modified Barium Swallowing Study dated 07/18/23 reflected Resident #85 had diagnosis of dysphagia and diet recommendations for Resident #85 were mechanical soft and nectar thick liquids. Observation on 09/28/23 at 9:05 AM revealed Resident #85's meal ticket for breakfast had diet order for mechanical soft and nectar diet. Interview on 09/28/23 at 9:18 AM with CNA D revealed Resident #85 liked to have coffee each morning with her breakfast and she gave her coffee this morning when she brought her tray into resident's room for breakfast. Interview on 09/28/23 at 9:25 AM with the Dietary Manager revealed Resident #85 was on nectar thickened liquids and it was on her meal ticket. She stated Resident #85 got thickened juice on her tray but was not aware of Resident #85 drinking coffee in the morning with her breakfast tray. She stated the coffee pitcher she provided to the hall tray was not thickened. The Dietary Manager stated the kitchen did not provide nectar thickened liquid coffee for Resident #85. She stated coffee was available with the hall trays for dietary staff to give to residents not on thickened liquids. She stated Resident #85 having nectar thickened liquids would need to come from the kitchen on her tray. She stated she would follow-up with Resident #85 to ensure nectar thickened liquids including coffee were provided to her. Interview on 09/28/23 at 11:15 AM with the Speech Therapist revealed Resident #85 had a recent swallow study. She stated Resident #85 was on nectar thickened liquids and at risk for silent aspirations. She stated Resident #85 not getting nectar thickened liquids would place her at risk for aspirations and choking risk for resident. She was not aware of Resident #85 getting coffee that was not nectar thickened liquid. Follow-up interview on 09/28/23 at 11:20 AM with CNA D revealed Resident #85 had her thickened juice on the breakfast tray this morning from the kitchen. She stated she poured Resident #85 coffee this morning from the warm pitcher provided for the hall trays. Interview on 09/28/23 at 11:23 PM with LVN F revealed Resident #85 should only get nectar thickened liquids and was at risk for aspirations and choking if resident not provided thickened liquids. Interview on 09/28/23 at 12:09 PM with the DON revealed Resident #85 should have nectar thickened liquids diet as ordered and would place resident at risk for aspirations and choking. Review of facility's policy Dysphagia - Clinical Protocol revised September 2017 reflected The staff and physician will identify individuals with a history of swallowing difficulties or related diagnoses such as dysphagia, as well as individuals who currently have difficulty chewing or swallowing food .If a modified consistency or other restrictions are indicated .nursing will obtain an order for such restrictions from Physician. The policy did not reflect about following the physician order for nectar thickened liquids diet.

Based on interview and record review, the facility failed to obtain from hospice the most recent hospice plan of care specific to each patient, hospice election form, the physician certification and recertification of the terminal illness specific to each patient and hospice medication information specific to each patient for one (Residents #24) of two residents reviewed for hospice. The facility failed to obtain the required hospice documentation for Resident #24 including hospice election form, the physician recertification of terminal illness, updated hospice plan of care and updated medication list from Hospice O. This failure could result in services and treatments not being coordinated. Findings included: Review of Resident #24's face sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cerebral infraction (stroke), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), epilepsy (seizure disorder), dementia and heart failure. Review of Resident #24's quarterly MDS assessment dated [DATE] reflected she required extensive assistance with ADLs and indicated she was on hospice services. Review of Resident #24's Physician Order Summary Report reflected a physician order dated 12/02/22 which indicated Resident #24 was admitted to Hospice O for diagnosis of chronic obstructive pulmonary disease. Review of Resident #24's Hospice O book reflected the last Comprehensive Assessment and Plan of Care was dated 02/28/23 which included medication list. Her Hospice O book did not have a hospice election of benefits or physician re-certification/certification of terminal illness. Interview on 09/28/23 at 11:36 AM with LVN C revealed Resident #24 received Hospice O services and Resident #24's hospice documentation was in her hospice O book. Interview on 09/28/23 at 11:55 AM with ADON P revealed she had only been the ADON for about three weeks at the facility. She stated she could not find any other hospice book for Resident # 24. ADON P stated the nurses were responsible for communicating with hospice and if they needed any help, they could reach out to her. Interview on 09/28/23 at 12:05 PM with LVN Treatment Nurse revealed she was the previous ADON. She stated she did not know who the facility's liaison for hospice was. She stated she was not aware of what required hospice documentation the facility needed for residents on hospice services. Interview on 09/28/23 at 12:11 PM with the DON revealed Resident #24' hospice book was missing hospice election of benefits, physician recertification not signed for Resident #24, a current hospice care plan and did not have a current medication profile list. She stated it was important for the facility to have the required hospice documentation for communication and continuity of care for residents on hospice. She stated social worker was responsible for communicating with hospice and ensuring hospice provided required documentation. Interview on 09/28/23 at 12:37 PM with the Social Worker revealed she contacted hospice company when resident was being admitted to hospice services. She stated she also contacted resident's hospice company to invite to facility's care plan conferences when resident was on hospice services. She was unaware of the required hospice documentation the facility needed for residents on hospice services. She stated she was not aware of until today she was responsible for ensuring residents on hospice services provided the facility with the required hospice documentation on each resident. Review of facility's policy Hospice Program revised July 2017 reflected the Social Worker was designated to coordinate care provided to the resident by out facility staff and the hospice staff .He or she is responsible for the following: .d. Obtaining the following from information from the hospice: (1) the most recent hospice plan of care specific to each resident; (2) hospice election form; (3) physician certification and recertification of the terminal illness specific to each resident .(7) Hospice physician and attending physician (if any) orders specific to each resident .

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents and hazards for 1 of 2 resident reviewed (Resident #1) in that: The facility failed to ensure Resident #1 received the proper staff supervision during transport from [CONDITION(S)] treatment. Resident #1 was left in the facility van alone without ventilation from windows, no air conditioning, strapped in her wheelchair with seatbelt over her chest for approximately 20-30 minutes in 98 degrees outside weather. She stated she had been yelling and screaming, then beating on the window to get someone's attentions. (Resident #1 started crying at this time in the interview.) She stated she thought she was going to die in a van because it was hot. She stated she checked the temperature on her phone, and it was 98 degrees outside. This failure could place residents requiring supervision and transportation by the providers at risk for heat related sickness, excessive heat exposure, emotional distress up to and including death. The Noncompliance was identified as past noncompliance. The IJ began on 06/23/22 and removed on 06/24/22. The facility had corrected the noncompliance before the survey began. Findings included: Review of Resident #1's undated Face Sheet on 07/18/22 revealed she was a[AGE] year-old female with an admissions date of 01/29/2022 and discharged on [DATE] home to family. Resident #1's diagnoses included: [CONDITION(S)] irregular heartbeat, Hypertension (high blood pressure), [CONDITION(S)] in [CONDITION(S)] (gradual loss of kidney functions, [CONDITION(S)] (high cholesterol, Unspecified Lack of Coordination, Abnormal Posture, Dehydration (06/23/22), Type 2 diabetes (blood sugar impairment), anxiety disorder and Major Depressive Disorder. Review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS of 13 with moderate impairment, and coded for [CONDITION(S)]. She functioned with a 2-person transfer support. Record Review of Resident #1's Care Plan dated 05/30/22 revealed that she has an ADL Self-Care Performance deficit and requires assistance with hygiene (bathing/showering), choices, supervision, cueing, encouragement, physical assistance to dressing, and transferring. Record Review of DON's progress notes dated Resident #1 on 06/23/22 revealed the following Chief Complaint I was left in the hot van Subject: Received a call from the nurse that the patient was left inside the van with the van off. The patient was alert and tearful. Vital signs are stable, and no distress noted. Stat CMP and CPK ordered. Visited the patient and seen her lying in the bed comfortably. She just finished eating her dinner. The patient was alert and oriented.She states that I was left in the hot van. She follows verbal commands, able to move all extremities without difficulty, and PEARRL-(pupils equal round and reactive to light). Patient denies pain, headache, dizziness, shortness of breath, chest pain, or palpitation. She voices that she feels tired due to post [CONDITION(S)]. No acute distress noted. VITALS: BLOOD PRESSURE: 118/72; PULSE: 77; TEMP: 97.6; RESPIRATION RATE: 20; OXYGEN SATURATION: 97% on RA; WEIGHT: 185.6 Ibs. MEDICATIONS: - All medications have been reviewed and updated. PAST MEDICAL HISTORY: - Type 2 DM; HTN; HLD; CHF; BLE [CONDITION(S)], [CONDITION(S)] (Hemodialysis on a Tuesday, Thursday, Saturday); [CONDITION(S)] Ayr; History of falls; [CONDITION(S)]; UTI; Depression; Anxiety disorder. PAST SURGICAL HISTORY: Right ankle ORIF. Interview on 07/17/22 at 11:30 AM, FM-N Family revealed on 06/23/22 she received a text message from Resident #1 requesting she call the facility to come and get her out of the van, because she was hot. She stated Resident #1 had been in the van approximately 15 minutes. She stated she did not ask details from Resident #1 at that time. FM-N stated she called the receptionist and spoke with CNA-B to tell them Resident #1 was left in the van outside with doors locked. FM-N stated this was approximately 11:30 am. FM-N stated CNA-B hung up the phone, to go out to the van. FM-N stated she called back as she wanted to remain on the phone to assure Resident #1 was rescued. FM-N stated she should have called 911. FM-N stated CNA-B could not get in the van due to it being locked. CNA-B went back in the facility to locate CNA-A the driver of the van. FM-N stated the van door was unlocked, and Resident #1 was crying as she was very afraid. Interview on 07/18/22 at 9:44 a.m., Resident #1 revealed on 06/23/22 CNA-A dropped off Resident #3 and picked her up from [CONDITION(S)] as usual. She stated it was 11:50 a.m. when they returned to the facility from [CONDITION(S)]. Resident #1 stated CNA-A parked the van, cut it off, and locked the doors. Resident #1 stated she was waiting for him to come around to the other side to get her. Resident #1 stated he went in the building. Resident # 1 stated she believed he was in facility for approximately 30 minutes. Resident #1 stated after 20 minutes she texted FM-N asking her to contact the receptionist to come get her out the van because she was hot. She stated she had been yelling and screaming, then beating on the window to get someone's attentions. (Resident #1 started crying at this time in the interview.) She stated she thought she was going to die in a van because it was hot. She stated she checked the temperature on her phone, and it was 98 degrees outside i. She stated she does not know what the temperature was inside, the van, but it was very hot, and however she could not breathe. CNA-B came out to the van and then ran back inside for help. CNA-A was located, and he unlocked the door. Resident #1 stated she instantly started yelling at him where did you go? why did you leave me in the van? CNA-A and CNA-B along with the ADON helped Resident #1 out of the van in her wheelchair and took her to her room. Resident #1 stated she does not know if an assessment was completed, she just wanted to get to her room and rest. Resident #1 stated while in the van driving back to the facility, CNA-A was talking on his cell phone, with one hand on the steering wheel and the other holding the phone to his ear. She stated the conversation was personal not business. Resident #1 stated this (being locked in the van) has not happened before. Resident #1 stated the windows were up, no air conditioner on, van off, and she was strapped down at the at the wheels of her chair and a seatbelt across her chest to secure her during travel. She could not unlatch the seatbelt nor reach the latch on the wheel. Interview with CNA-B on 7/18/22 at 1:04 p.m. revealed that she was the new transportation technician and CNA staffing coordinator for the facility. CNA-B stated she's responsible for staff scheduling for all CNA's and transporting residents to the [CONDITION(S)]. CNA-B stated currently there was only one resident being transported to [CONDITION(S)], Resident #3 room 503A. CNA-B was trained for transportation by HR and marketing staff. Training included facility procedures regarding van inspections before you leave and upon returning to the facility to transport residents, van logs, checking out patients from the nursing station. CNA-B stated during transport she communicates with the residents to assure that they were well and not in distress. She stated she does not talk on her cell phone while driving, however she does use it for navigations. She denies any reports of CNA-A talking on his phone while transporting residents. CNA-B stated she was not aware of any previous incidents of resident being left on the van. She stated on 06/23/22 at approximately 11:30 AM, while working at the receptionist desk, she received a call from the FM-N stating Resident #1 was left on the van and needed her to go and get her off the van. CNA-B stated she looked out the blind from the lobby window to see if she could see someone in the van. She saw movement and proceeded to seek help from the DON. CNA-B stated she recalled CNA-A parking the van and entering the facility seeking the gas card to put fuel in the van. CNA-A did not mention that a resident was in the van. CNA-B stated approximately 8 minutes before the call from FM-N, she observed CNA-A parking the van and entering the facility, which usually indicated that no passengers were on the van. CNA-B waived down the DON to tell her someone was left on the van. The DON went to the van, and it was locked. CNA-A was located and asked if he left someone on the van, and his response was Oh No. At that time, CNA-A ran to the van with the keys and unlocked the door. CNA-B stated Resident #1 started crying out loud stating that she was afraid. CNA-B stated Resident #1 was unbuckled from seatbelt, wheelchair belts unlocked, and assisted Resident # 1 and took her to room. CNA-B does not know if Resident #1 was assessed by nursing staff. CNA-B stated that she was not asked to write a statement based on her information regarding the incident. CNA-B stated that once the DON was involved, she returned to her work task. CNA-B stated that when she is absent, contractor transportation was provided for [CONDITION(S)] residents. CNA-B stated that the procedure for transporting included the following (see record review below for a complete review of this form): 1. Transporter get the keys to the van 2. Van log the walk around inspection. 3. Drive the van to the front door of facility under the awning. 4. Let the gate down for resident with wheelchair access. 5. Check inside of the van. 6. Enter the facility to get the resident from the nursing station 7. Make sure you have the correct resident 8. Make sure you get the right [CONDITION(S)] Paperwork for the right patient. 9. Assist resident in van and secure the wheelchair with hooks on wheelchair tires and place the seatbelt over the resident and make sure it was secure. 10. Close all doors and lock. Interview with Resident #3 on 07/19/22 at 2:00 PM revealed that he attended [CONDITION(S)] three times a week Tuesday, Thursday's, and Saturdays. Resident # 3 was transported to the van by facility staff. Resident # 3 denied knowledge of any resident's being left on the van unsupervised. Resident # 3 stated that he had never been left alone at the van by staff since being admitted at the facility. Resident # 3 stated that CNA-A and CNA-B both communicate with him while transporting and never talk on their cell phones. Interview with Social Worker (SW) on 07/19/22 at 2:00 PM revealed she interviewed Resident #1the the following day in room on 06/24/22 at approximately 12:30 PM. Resident #1 reported to her that CNA-A picked her up from [CONDITION(S)] and brought her back to facility and parked in the handicap space. Then, he got out of the van. Resident #1 stated she thought that CNA-A was coming around to let her out, of van, but he was nowhere around. The Social worker said she asked the resident if the driver said anything during the drive to the facility, or after he parked the van. The resident stated he didn't say anything to me ever. He didn't even open a window. Social worker asked how the resident was found, she stated she texted FM-N who then called the facility. The resident texted her FM-N at 11:35 AM, FM-N called the facility at 11:37 AM. Record Review of CNA-A's written statement on 06/23/22 revealed Can Report About Leaving Resident Inside the Van. At about 11:15a, on Thursday morning, I went to pick up the resident in question at the [CONDITION(S)] enter we arrived at 11:32 a.m. at the facility. She stated that she hurried and dashed out of the van to the office of the boss to collect the gas card, when I was asked by an employee to help transfer a resident with the Hoyer Lift. During that process I was called about the resident in the van I believe it took about 15 to get back to the patients. In this regard, I conclude to the best of my knowledge that the above-mentioned information is about what transpired in tat whole exercise. Interview with the ADM on 07/19/2022 at 2:15 PM revealed the ADM learned of the incident on 06/23/22 from the DON who was no longer at the facility. The ADM stated she instructed the DON to assess the resident, contact the MD, contact the family, and get statement from CNA-A. ADM stated once CNA-A statement was completed suspend him pending investigation. ADM stated CNA-A reported he was hurrying trying to get the gas card to fill up the van, and when he entered the building, another aide requested assistance with another Resident. FM-N called the facility and notified staff that the resident was on the van. Approximately 10-15 minutes later CNA-A, was located and by DON to come to the van. CNA-A walked out to the van, unlocked, and assisted the resident out of the van along with the DON. Resident was assessment revealed no distress or adverse injury. Resident was given water and assessed further for hydration. ADM stated the protocol for returning residents and transferring, were to pull into the front door under the awning in front of the receptionist and unload the residents, then park. ADM stated Resident #1's assessment revealed no adverse injury or emotional distress from the incident. Resident was given water and placed on monitoring to further assess for hydration. ADM stated CNA-A has never admitted to her that he knew the patient was in the van. It was her belief that when he parked, according to procedure the van was empty and forgot to get the resident off the van. ADM stated they had trained staff to complete a log before leaving and upon return, checking the van before and concluding a walk through the van and around the van upon returning to the facility. ADM stated staff were allowed to use their cell phone for driving directions. ADM stated she did not know CNA-A was talking on the phone while driving the resident back to the facility, and this was the first that this has been mentioned. ADM contacted the CNA registry today to report CNA-A. ADM stated CNA-A was suspended pending the findings of the investigation for leaving Resident #1 on the facility van on 06/23/22. ADM stated upon concluding the investigation, CNA-A was terminated. She stated the resident was assessed and the MD, family, and administrator were all contacted. She stated that resident did not sustain any injuries. ADM implemented new log with instructions of conducting inspections before and after transporting a resident. (See detailed list in record review). Record Review of facility provider investigation report summary dated 06/23/22 completed by the Administrator r with reference to Resident #1, revealed that Completed investigation. Investigation revealed that the CNA driver arrived at the facility at 11:15 am, he pulled into a parking spot and got out and went into the facility to get the purchase card (P-Card) to get gas for the facility van. While in the building another CNA asked him to assist her with getting a resident up with the Hoyer Lift. The resident text her family member at 11:35 am that she was left in the van, at 11:37 am the family member called the facility and informed the nurse that Resident #1 was left in the van. The nurse immediately went outside to the van, resident was alert and tearful, and was given a cold water bottle and was assisted to her room. The resident said that she was scared during the time that she was left in the van and didn't know why he didn't get her out when he arrived at the facility. The temperature was 93 degrees at the time of the incident. The nurse assessed the resident no distress noted. The Physician was notified and order Stat labs, confirmation # 662. The Nurse Practitioner assessed the resident, noted that the resident was alert and oriented with no distress noted. Lab results was fine, no new orders. A review of facility training dated 6/24/22, revealed that CNA-B was in-serviced and trained on Loading and unloading a resident in a wheelchair on a transport van, securing resident's wheelchair properly, Safe Transport and precautions , proper use of lift gates and parking once returning. A review of facility in-service dated 6/24/22 regarding the transportation policy and procedures that was reviewed with the facility only transportation staff (CNA-B) revealed training that included newly implemented logs with step by step instructions including, van assessment and observation checks prior to entering the vehicle to pick up the resident. Other tasks include the date, room # of resident, time leaving and returning to the facility and return the resident to her room. Final step included parking and locking the van upon completing a walkthrough of the vehicle. A review of the facility Transportation log dated 7/14/22 revealed that the log was being utilized and documented correctly for the Transport of Resident #3. Interview with DON was not conducted as she was no longer at the facility as of 07/19/22. Interviews attempted by telephone with CNA-A on 07/18/22 at 3:00 PM and 07/19/22 at 3:29 PM. CNA-A did not return call. Interview attempted with the ADON, who was out on quarantine 07/18/22 3:05 PM; 07/19/22 at 4:23 PM; 7/20/22 at 9:45 AM; 2:41 PM; and 6:05 PM and left a detailed message for a return call. Review of CNA-A's personnel file revealed that he was hired on 05/17/22 with the job title of Driver/CNA. CNA-A signed a document dated 05/17/22 , titled ATTACHMENT 1 ACKNOWLEDGEMENT, acknowledging that he received and read the Senior Care Centers, LLC Fleet Safety Policy and viewed the Sure-LOK Wheelchair Restraints by Schetky NW Bus Sales www.youtube.com/watch?v=uyCMMzKpnXw&app=desktop. Record Review of the facility's undated policy, Travel Log Documentation , revealed the following task were to be completed before leaving the facility and upon returning. Date, Resident Room, Time Left Facility, Time Returned to Facility, Resident returned to room Van Parked and Locked. Review of Closed National Weather Service (NWS) heat warning system revealed in [NAME], TX [NAME]] on 06/23/22 at approximately 11:30 AM temperatures were 98 degrees. The information below provides guidance to escalating temperatures for humans being left inside of a closed car with windows and air conditioning off: 10 mins (air 105.8 - 114.8°F) - vehicle interior heat advisory 20 mins (air over 114.8°F) - excessive vehicle interior heat warning