Every finding on record at Vista Ridge Senior Care

Based on observation, interview, and record review, the facility failed to implement its policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for CR 8 (CR #1, CR #2, CR #3, CR #4, CR #5, CR #6, CR #7, CR #8) of 8 CR reviewed for food and nutrition services. 1. The facility failed to have a system in place for reheating resident food items brought in from outside sources to ensure safe food handling and were not allowing residents to bring in food from outside sources.2. The facility failed to accurately document temperature recordings of nourishment station refrigerators. These failures could place residents at risk for foodborne illnesses.Findings included: Observation on 8/19/25 at 11:30 AM of 2nd floor nourishment station revealed no refrigerator present at station. Observation on 8/19/25 at 12:30 PM of 1st floor nourishment station on hall 3 revealed no refrigerator present at station. Observation on 8/19/25 at 1:00 PM of 1st floor nourishment station on hall 2 revealed no refrigerator present at station. Observation on 8/19/25 at 3:30 PM of 1st floor nourishment station on hall 1 revealed no refrigerator present at station. During a confidential Resident council meeting on 8/20/25 at 10:15 am, a concern regarding resident's right to bring in outside food to store and heat was voiced. Residents stated they no longer have access to the breakroom, fridge, or microwave. On 8/20/25 at 10:15 am A resident in the confidential interview stated about 3 weeks ago they went out to a local restaurant and returned with some leftover pizza. Resident stated she asked a CNA to warm up their pizza and the CNA told her she was not able to warm the pizza for her. Resident stated the CNA told her that residents were no longer able to use the microwave or refrigerator. Resident stated she asked to speak to the ADMIN. Resident stated the ADMIN told Resident that residents could not use the microwave because it could overheat and cause burns. Resident stated she told ADMIN she had been using a microwave for 20-25 years and never had a burn or other incident. Resident asked for a skills test to prove she could use the microwave. Resident stated she asked ADMIN what she was supposed to do with her pizza, she stated he responded, Eat cold pizza. Resident stated they took their privilege away to have food from the outside brought in and they can't have personal refrigerators anymore. It was stated the breakroom was taken away from the residents and given to the staff, a coded lock was added to the door. They advised surveyor it's the room across from the living room. Resident stated they were unsure as to why the changes were implemented. Four of the residents stated they would like to have access to the room for their food they bring in or someone bring them. Observation and interview on 8/20/25 at 11:45 AM, revealed ADMIN provided the facility policy for outside food. The ADMIN stated there has been a mistake and the facility would get refrigerators for the nourishment stations today. ADMIN stated he was mistaken about the facility not providing refrigerators for the residents to put their personal food from outside in. ADMIN stated he had been misled by another staff member about the facility policy regarding outside food and reheating food. ADMIN stated currently the facility was using the staff breakroom refrigerator to label and date resident's food and the staff food. Observation on 8/20/25 at 11:49 AM of 1st floor staff breakroom refrigerator revealed the breakroom refrigerator was observed to contain food and drink items labeled with residents' names and room numbers mixed in with other food and drink items that were unlabeled and undated, making it difficult to distinguish if items belonged to staff or residents. There were 5 cartons of vanilla liquid nutrition formula with expiration dates of October 25, 2024, and some snack cheese snack bars with expired dates of June 29, 2025. There were some Shakes indicating for people on dialysis, no names, labels or dates, Med Pass 2.0 nutritional shakes, no label indicating name or date. Also observed box of fast food with no names or date, several plastic bags with food items, no names, no dates. Observation of nourishment station refrigerator on 08/21/25 at 9:26 AM on 1st floor hall 2 revealed refrigerator had 12 half egg salad sandwiches dated 8/20/25 with a discard date of 8/23/25 and 1 pudding cup dated 8/20/25. Temperature log reflected temperature of 36 Fahrenheit recorded at 9:00 AM on day 2 no actual date recorded. Observation of nourishment station refrigerator on 08/21/25 9:30 AM on 1st floor hall 3 revealed refrigerator had 11 half egg salad sandwiches dated 8/20/25 with a discard date of 8/23/25 and 1 bottle of sparkling water black raspberry flavored undated and unlabeled. Temperature log reflected temperature of 12 Fahrenheit recorded at 5:50 PM on day 1 no actual date recorded. Observation of nourishment station refrigerator on 08/21/25 9:41 AM on 1st floor hall1 revealed refrigerator had 11 half egg salad sandwiches dated 8/20/25 with a discard date of 8/23/25. Temperature log reflected temperature of 38 Fahrenheit recorded at 9:00 AM on day 2 no actual date recorded. Observation of refrigerator on 08/21/25 10:41 AM on 1st floor dining room revealed refrigerator had 14 pudding cups, 13 gelatin cups, and 24 prune juice cups. Several individual boxes of various cereals on shelf next to refrigerator. Temperature log reflected last temperature recorded of 35 Fahrenheit dated 8/20/25. No temperature recorded for 8/21/25 at this time. Observation of refrigerator on 08/21/25 10:50 AM on 2nd floor dining room revealed refrigerator to be empty and no temperature log on clipboard. Observation of nourishment station refrigerator on 08/21/25 10:53 AM on 2nd floor revealed refrigerator had 3 half egg salad sandwiches dated 8/20/25 with a discard date of 8/23/25, 7 cans of soda pop, and 2 cartons on ensure supplement beverage. Temperature log reflected temperature of 42 Fahrenheit dated 8/21/25 10:40 AM. Interview on 8/20/25 at 4:49 PM, LVN stated she had worked at the facility previously for 2 months as PRN status and now this was her 3rd day on the floor working. LVN was asked do residents store their food brought in from outside. LVN stated no residents on the 2nd floor bring food in. LVN stated if family brings food it was eaten at that time and then discarded. LVN stated if a resident or family was to bring in food, she will ask the nurse manager on what to do in that situation. When asked about the facility training on outside food policy, LVN stated she has not been trained. Interview on 8/20/25 at 5:19 PM, revealed CNA F stated she had worked for the facility for 8 years, at this location and the sister facility location. She was asked where the outside food was stored when brought in. CNA F stated she has not had that situation occur at this facility. She stated the only food she has seen brought was when a resident has a birthday party, and it was eaten then, and nothing kept. CNA F stated at the sister facility location, there was a refrigerator to store the foods, and they label and date with the resident's names. Interview on 8/20/25 at 5: 35 PM, revealed CNA E stated she has worked for this facility for 8 years. CNA E was asked did she know of the facilities outside food policy. CNA E stated, before today, the facility didn't allow outside food, but today they changed the rule and added refrigerators. CNA E stated they removed the policy 2-3 months ago and brought it back today. CNA E stated they were unsure why the changes had been made. CNA E stated they used the microwave in the kitchen to heat the food. Interview on 8/20/25 at 5:55 PM, the DON was asked about outside food policy, she stated if family brought in food, they the family must label with room number and date it. The DON stated she would print out policy and give it to the family if they have a question on discarding of the foods. The DON was asked where the outside food was stored, she stated usually stored downstairs in the nutrition room but now in the employee breakroom (for a month or so). DON stated it was made an employee breakroom, but residents used to have access to this room. The DON was asked how the resident's food was warmed up. DON stated, the facility struggles with that part (a lot of times facility does not allow reheating of food in the microwave by staff for the residents) she stated it was not easy to do temperature checks. She stated if it was soup then that was easy to do a temp check but anything solid, they do not allow it to be brought in. DON was asked did she feel this violated the residents' right to have outside food brought in. The DON stated, this environment can't do it safely, safety was our priority, and we (the facility) can't safely heat, and check temperatures DON stated they had a resident to complain her pizza needed warming up. DON was asked how the residents obtain their foods from the employee breakroom; she responded residents ask the staff for it. DON was asked has she read the Outside Food Policy, she stated she has looked at policy, but things were unclear. DON stated she had been trained by corporate. DON stated ADMIN was responsible for policy compliance. Interview on 8/21/25 at 10:30 AM, CNA B stated he has been a CNA at this facility for 12 years. CNA B was asked about the facilities outside food policy. He stated the food will have to be date, labeled with name and time. CNA B stated residents have a 24-48-hour window to consume the items. CNA B was asked where these items are stored, he stated they have new refrigerators that came yesterday for the residents. He stated prior they put the items in the employee breakroom refrigerator for about a year. CNA B stated the 10/6 shift checks the dates on the food and discard after the proper time. In an interview on 08/21/2025 at 6:18 PM with CNA A, she stated the following: residents are allowed to bring in food from outside. Families can bring in food that meet the resident's diet. Facility staff are supposed store the food by dating the food, write the residents name, residents room number, and after 3 days, the food product would be thrown out. The CNAs and Nurses oversee monitoring the food that was stored for the residents. The resident food from outside source was stored in the refrigerator that was in the staff break room, it was the staff and residents' food that were stored together previously. The staff's food was marked with their name to differentiate from resident's food. The resident's food from outside source in terms of reheating has been an issue since the microwaves for the residents were removed approximately 8 months ago and all the facility staff was told not to reheat the resident's food by the Dietary Manager. Prior to the microwaves being removed, all facility staff reheated the resident's food. It effects the resident's quality of life as it interferes with the resident's homelike environment and if the residents need something to be reheated, the residents should be able to. It deprives the residents from their rights if food was brought in from family and the residents can't reheat it. She's been trained to properly store and reheat resident's food. The facility staff underwent in-services yesterday, 08/20/2025, and now facility staff can reheat the resident's food in the kitchen although she thinks it's a cross-contamination issue since the resident's food was coming from outside. Residents can get assistance from facility staff to reheat food in the kitchen microwave, but not the microwave in the staff break room. There was now as of today, 08/21/2025, refrigerators for the residents to store food. The Administrator and Director of Nursing were responsible for ensuring residents had somewhere to store or reheat outside food. In an interview on 08/21/2025 at 6:43 PM with ADON, she stated the following: I have been trained on abuse and neglect. The training for abuse and neglect went over suspecting abuse and neglect to report it, investigate it, keep the residents safe from an unsafe situation, and the types of abuse and neglect. The abuse and neglect coordinator are the Administrator. I have received training on resident rights. Resident rights training went over the right to refuse care, and the right to be involved in their care treatment. Residents are allowed to have food from outside sources. The facility staff just got residents new refrigerators during survey and previously prior to the survey, resident's food was stored in the staff break room refrigerator in which the resident's food was dated and labeled their name. The resident's food was thrown out by the third day. Resident food brought from outside source can be reheated as of now, previously facility staff couldn't reheat due to not being able to properly check the food temperatures for safety. Moving forward, the facility staff are now going to have food reheat stations along with new refrigerator and educate facility staff on how to properly check food temperatures. The facility started to do in-services for reheating residents' food and will have ongoing trainings moving forward. Dietary will oversee conducting the trainings for reheating and storing the resident's food. It was making a negative impact on the residents due to the residents being disappointed on not being able to reheat and store their food. Residents were able to reheat and store their food prior until it was taken away from the residents approximately 4 months ago per her knowledge. ADON stated she was unsure of why the changes were made. Residents not being able to reheat and store their food goes against resident rights due to residents aren't given a choice to reheat food they bring from outside. The nursing staff was responsible for ensuring residents have somewhere to store or reheat outside food. In an interview on 08/21/2025 at 7:24 PM with ADMIN, he stated the following: I have received training on abuse and neglect. The training for abuse and neglect went over mental abuse, physical abuse, isolation, misappropriation, and to whom to report the suspected abuse or neglect. The ADMIN stated the abuse and neglect coordinator was the Administrator, and Corporate. ADMIN stated he had received training on resident rights. Resident rights training went over everything that the residents have rights for such as, activities, right to mail, right to phone calls, and right to privacy. Expectations was for all residents to follow these protocols. Resident's quality of life can be affected if these protocols are not followed such as, lead to depression, start acting out, shutting down, and get angry. The residents are allowed to bring in outside food of choice, and he was misled about it because he was advised by a staff member that they could not reheat food. It has now been changed that they will be reheating food for residents moving forward and educate all staff to be able to appropriately temperature check the food, this goes for all staff as well as they have started to in-service staff and will in-service everyone moving forward. A staff member lied to him about the reheating process for residents and he takes accountability about that since he did not further investigate the matter. The Dietary Manager will oversee reheating food for the residents. The microwave that residents can use will be in the kitchen area moving forward. The refrigerator was not for staff to put food in combined with residents' food, moving forward there will be mini refrigerators for the residents to store their food separately. It was a negative outcome for the residents since they could not reheat the food of choice. It goes against resident's rights and was not a policy that was followed, it was meant to protect the residents for safety but goes against the policy for residents. The Administrator and or the Dietary Manager was responsible for ensuring residents have somewhere to store or reheat outside food. Record review of Storage of Resident Food Brought by Families or Others policy, dated 12/2016 and revised on 07/2017, reflected under heading Policy overview: Taking into consideration resident's personal and cultural food preferences, any food that was brought into the community for resident consumption by families or other individuals would be stored and handled per facility safe food handling standards. Under heading Policy detail:1. Each community will designate a unit refrigerator for the storage of perishable foods unless the resident has his/her own refrigerator in their room.2. The unit refrigerator temperature for food storage shall be recorded daily (32-40F).3. All perishable foods must be stored in re-sealable containers with tight fitting lids in the designated refrigerator. Containers will be labeled with the resident's name, the item, the preparation date, and discard date which was 72 hours or less if required by state and local health code. Intact fresh fruit may be stored uncovered at room temperature. 4. The nursing associate and/or designee will be responsible for discarding perishable foods on or before the discard date.5. Dining services will provide educational materials on safe food handling procedures (such as hot holding or transporting foods containing perishable ingredients at room temperatures above 40 degrees F) to residents and /or visitors bringing food from outside sources.6. Facility associates involved in food storage, handling, or service will follow facility safe food handling standards. Record review of In-service reflected In-service provided to staff on 8/20/25 at 7:00 PM and 8/21/25 at 8:45 AM titled Storage of Resident Food Brought by Families or Others with 25 staff signatures. Attached to in-service sign in logs was the Storage of Resident Food Brought by Families or Others policy. Further review of in-service revealed internal temperature of 165F required for reheating of resident foods.

Based on observations, record review and interviews, the facility failed to prepare food by methods that conserve nutritive value and flavor for 4 pureed diets of 1 of 1 kitchen reviewed for food and nutrition services.The facility failed to ensure [NAME] G refrained from adding an unmeasured amount of liquid to southwestern style chicken pureed during meal service on August 20, 2025.This failure could place all 4 residents who received a pureed diet at risk for diminished or altered nutritional status and potential weight loss.Findings included: Observation on August 20, 2025, at 4:27 PM, revealed [NAME] G took an unmeasured amount of liquid from a pitcher and added to the southwestern style chicken in the food processor and blended.Interview conducted with [NAME] G on August 20, 2025, at 4:31 PM, revealed she used broth to puree the southwestern style chicken. [NAME] G was asked how many servings of chicken she prepared. She stated four. When asked what amount of bread she used, she replied she was not sure, but stated she used enough so the product would stand on its own like mashed potatoes. [NAME] G stated this was how she had been told to prepare it by a previous supervisor who no longer worked at the facility. When asked if she used the recipe book for pureed and other modified diet textures, she stated she had never been shown how to use the recipe book. [NAME] G was then escorted to the recipe book by surveyor. The DSD intervened and stated they use the recipe cards hanging on the wall. The DSD stated to [NAME] G, we looked at it earlier, remember. [NAME] G reviewed the recipe card which called for 2 ounces of poultry gravy or other gravy mix per 1 serving of chicken. [NAME] G was asked what the potential harm could be if recipes were not followed for specific diets. She stated she did not know. [NAME] G then stated she would begin using the recipes moving forward, stating she had never been shown the recipes for the 4 pureed foods and had been trained by a previous manager who was no longer employed at facility.During an interview on August 20, 2025, 4:48 PM, the pureed food policy was requested from the DSD.Interview with DON on August 20, 2025, at 5:55 PM, the DON was asked if she could explain the facility puree process for the residents ordered pureed diets. The DON stated she does not prepare the food herself. She explained she expected the dietary staff to ensure consistency in the puree foods, and that her understanding was the puree meals should be the same as the regular diet served on the plate. She reported that she had never seen the recipes and relied on what the kitchen staff communicated to her. She stated that the pureed meals appear similar on the trays served as a regular diet. When asked if she knew what should be used to puree food, she stated she was unsure. When asked what could happen if the puree diet recipe was is not followed, she stated that residents could potentially lose calories if too much broth was used. She added that if water was used, the taste and nutritional value of the food may be affected. The DON was asked do dietary staff puree with water, she stated she didn't know. Interview conducted on August 21, 2025, at 10:15AM, [NAME] H stated she was trained on all diet textures. [NAME] H stated they received the recipe cards weekly. She stated she followed the specifications on the recipe card for pureed and other diet textures. [NAME] H stated she mostly used milk for pureed diets.Interview conducted with DSD on August 21, 2025, at 3:25PM. DSD stated she has been working at the facility since July 18, 2025. DSD stated she believed the previous Dietary Service Director trained dietary staff previously on preparing diet textures. DSD stated moving forward it will be her providing the in-services. DSD stated each daily menu has a corresponding recipe with the diet modifications. DSD stated it is the standard to cross train the dietary staff across the nursing facility and the assisted living facility. DSD stated all the dietary staff are trained on both kitchen procedures. DSD stated her expectations is for all dietary staff to follow the recipes. DSD stated if they do not follow the recipe they are not in compliance, and each component is important in following the standard. DSD stated the potential risk of harm from not following the recipe could lead to quality being lost and nutrition can be compromised. Interview conducted with CDM on August 21, 2025, at 4:27PM. CDM stated she has worked at the facility for 3 1/2 years. CDM stated the Dietary Director is responsible for training all dietary staff on the different diet textures. When ask the potential risk of harm for not following the recipe, CDM did not provide an answer. Record Review of facility diet order conducted on August 20, 2025, revealed there were 4 residents on pureed diets.The policy /protocol for pureeing food was not provided at the time of exit.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to label and date all food items located in the walk-in refrigerator, freezer and in the dry food pantry area on 8/19/2025, 8/20/2025, and 8/21/2025. 2. The facility failed to discard expired food items located in the walk-in refrigerator and in the dry food pantry area.3. The facility failed to ensure that dietary staff [NAME] G on 8/20/2025 at 3;35 PM, practiced appropriate hand hygiene and glove use when necessary, during food preparation activities, such as between handling raw fish and other foods, to prevent cross-contamination.These failures could place all residents who received meals from the kitchen at risk of foodborne illnesses. The findings included: Observation during the initial tour of the kitchen on 8/19/2025 beginning at 9:30 AM, the following was observed:Walk-in refrigerator:3 Packages of hamburger buns, not labeled or dated.20 1-pound blocks of Margarine, not labeled or dated. 3 -32 oz containers of yogurt, not labeled or dated. 1 can of energy drink (not labeled or dated, assumed to be a staff drink, which was in refrigerator)2 large packages of hot dog buns, (not labeled correctly, only had 8/14, not sure if that is discard date or date placed in refrigerator.Bag of past discard date of Sun-Dried tomatoes (prepared date-7/17/25, use by 8/17/25) 1 -5lb package of thawed Ground Beef past discard date (prepared date-8/14, use by 8/16)4 Cartons pasteurized liquid whole eggs- not labeled or dated. 1 large bag looking resembling chicken breast, not labeled or dated. Freezer:1box of 4 chicken tender fritters, not labeled or dated.2 pizza crust dated 5/10 with expiration date of 8/06/2025. Dry Food Pantry area:1 open bag of powdered sugar with expiration date of 8/16 on package. (CDM took out and said she is discarding the package)3 containers of beef base paste, not labeled or dated.4 bags of green lentils not labeled or dated.3 bags of refried pinto beans, not labeled or dated.1 opened bag of elbow macaroni, not labeled or dated.1 large bin of opened cornmeal with prepared date of 6/16, no year or discard date. Observation of second floor kitchen/dining area on 8/20/2025 beginning at 9:33 AM, revealed in self service area 10 individual packages of toasted oat cereal, five packages were expired dated (2- expired on April 17, 2025, and 3 expired on July 16, 2025). Observation 8/20/2025 at 11:28 AM, observed DSD to be removing the tray of cereal and drinks from the 2nd floor dining self-service section. DSD stated she was rotating out the choices. Observation during follow up tour of kitchen on 8/20/2025 beginning at 3:30PM, the following was observed: A clear plastic 32-ounce container contained fish with water running over it. The container was incorrectly labeled item-cheese, prepared date-8/11/25 and use by date of 8/18/25.Observation on 8/20/2025 at 3:35 PM, [NAME] G, did not use proper hand hygiene while handling raw fish. After removing her gloves, she failed to wash her hands and then proceeded to season the fish.Observation on 8/20/2025 at 3:40 PM, of walk-in refrigerator, freezer and in the dry food pantry area:1 -5lb package of thawed Ground Beef past discard date (prep date-8/14, use by 8/16) remained13-1-pound blocks of Margarine, not labeled or dated3 Tubes of thawing meat that resembled pork loin, labeled incorrectly (item: thawing, prep date: uncooked, discard date: meats)1 large loaf of bread with expiration date of 7/11/2025 from food manufacturer, a written date of 8/18, no year, no indication if it's the received date or discard date)1 large bin of opened cornmeal with prep date of 6/16, no year or discard date.1 7ounce opened container labeled seeds tunnel, (prep date:6/24/25, use date:7//24/25)Observation on 8/20/2025 at 4:05 PM of self-service area revealed the expired cheerios from upstairs self-service area was placed in this area. The previously noted 5 packages expired (2-expired April 17, 2025, 3 expired on July 16, 2025.Observation noted on final visit to kitchen on 8/21/2025 beginning at 10:15 AM, revealed of walk-in refrigerator, freezer and in the dry food pantry area:1 large bin of opened cornmeal with prep date of 6/16, no year or discard date1 -5lb package of thawed Ground Beef past discard date (prep date-8/14, use by 8/16) remained10-1-pound blocks of Margarine, not labeled or dated3 Tubes of thawing meat that resembled pork loin, not labeled or dated. labeled from previous day removed.1 large pan of thawing sliced carrots, with only a prep date of 8/21/25 An interview conducted on 8/20/2025 with DSS at 9:33 AM, revealed the second-floor dining hall was not used. She stated it is only used to deliver trays and the nurses and CNAs would get the food items out of the self-service area for alternative choices.An interview on 8/20/2025 at 11:58 AM, revealed the DSD had been in the position for 3 weeks at the facility. The DSD was asked about the labeling policy of the snack food in adjacent rooms in the dining areas. The DSD stated those areas were considered self-service and the policy was to label with date received, put label on tray when received, and the date it expired. DSD stated the snack items were kept in self-service upstairs and some kept in self-service downstairs. DSD stated she is restocking the tray for the area upstairs since the kitchen is not being used upstairs. DSD was asked what is the potential harm that could occur to the residents if they were to eat the expired foods. DSD stated the food is not expired and that it has a best by date, she stated the two are not the same. DSD stated for dry goods it may not be up to standards regarding taste and quality. She stated cold items are more of a health hazard and they can cause some issues. An interview and observation were conducted with [NAME] G on August 20, 2025, at 3:35 PM. [NAME] G was asked, what was in the container, she stated it was fish thawing. [NAME] G stated she just grabbed a clean container and put the fish in it to thaw. She stated sometimes the labels getting missed during cleaning, it just depends on who is cleaning. [NAME] G then took the container of fish and walked it over to a prep area. She was observed to wash her hands and put on gloves and then she removed the fish from the container and placed on a flat baking sheet. She was observed to remove the gloves and then went back to the fish and started seasoning the fish without washing her hands after removing the gloves. [NAME] G stated she has been trained on proper handwashing and food safety protocols. [NAME] G was asked the correct procedure when using gloves in the kitchen, she responded she is supposed to use the two-finger method to remove the gloves and then wash your hands. [NAME] G was asked why she did not wash her hands after removing the gloves and proceeding to handle the raw fish, she stated she just forgot. [NAME] G was asked the potential harm. that could result from not using proper hand hygiene, she stated it can cause transmission of viruses and diseases. An interview was conducted with DON on 8/20/2025 at 5:55PM. DON was asked if she was familiar with the labeling, dating, and discarding of food policy in the kitchen. She stated that she has not reviewed the policy. DON was asked her expectation of the dietary staff when labeling, dating, and discarding of expired. She stated, I would imagine they will follow up on whatever the policy says. DON was asked the potential risk to residence if the labeling, dating, and discarding of the food products are not followed the DON stated she has an opinion regarding expiration dates. She stated what she thinks and believe is different. She stated items like rice does not really expire and beans last a long time. She stated with meat, milk and cheese products, a person could become sick. She stated, anything else, nothing really happens. DON was asked was she okay with outdated products being served, she stated she expects the dietary staff to discard of outdated products. August 20, 2025, 5:53 PM, kitchen food labeling policies were requested from ADMIN.An interview was conducted with [NAME] G on August 21, 2025, at 10:15 AM. [NAME] G stated she has been working at the facility since June 6, 2025. She stated she was trained on labeling, dating and discarding food policy. She stated all dietary staff are to label all items with received date, open date and discard date. [NAME] G stated the potential harm that could happen to a resident if given outdated food products could lead to illnesses like salmonella, she stated a resident can become hospitalized and sometimes a fatality could happen.Additional Interview conducted with DSD on August 21, 2025, at 3:25PM. DSD stated she has been working at the facility since July 18, 2025, as the Director of Dining Services. DSD stated the standard policy for labeling and dating food products is to label with date received, date opened and dated to be used by. Surveyor showed DSM pictures of the past due ground meat that was observed 3 days in the refrigerator. DSM stated her expectations is for dietary staff to throw out expired meats. DSM was asked the potential harm to residents if consumed. DSD stated expired meat, and dairy products are dangerous, and it would be terrible if residents consumed the expired product. Interview conducted with CDM on August 21, 2025, at 4:27PM. CDM stated she has worked at the facility for 3 1/2 years. CDM was asked the policy and protocol on labeling food products in the kitchen. CDM stated all food products are to be labeled and dated with date received, date opened, and date to discard if opened. DSM stated every single dietary person is trained on labeling of all items. CDM stated meat is to be discarded 3 days after being pulled from the freezer. CDM was asked the potential harm that could happen to residents if the policy is not followed in discarding items timely, CDM stated, I decline to answer that question, clearly we are going to discard. CDM was asked about the hand hygiene protocol in the kitchen when handling meat. CDM stated gloves are to be used when handling the raw meat. CDM stated hands should be washed before putting on gloves and immediately after removing gloves. CDM was asked the potential harm of not following proper handwashing, she stated, clearly cross contamination. Record review of facility policy named Labeling -DS-04.028, effective date of 2005 revealed:Policy Overview-All food items must be labeled and dated before storing.Policy Detail:1. Upon receipt from vendors, all non-perishable food items must be labeled with the receive date (month and year) before putting in dry storage. This should be done, even if the food item has a used by or sell by date marked by the manufacturer.2. All prepared items must have a label with the name of item date, and time prepared, by whom, and discard /used by date. Discard/ used by dates should be no more than 3 days for leftover hazardous foods and 7 days for all other prepared food.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Resident #42, Resident #20, and Resident #57) reviewed for infection control. 1. The facility failed to ensure CNA A was following prescribed Enhanced Barrier Precautions by not putting on a gown before providing peri-care to Resident #42. 2. The facility failed to ensure CNA B was cleansing male residents properly and conducting hand hygiene and glove change during peri-care for Resident #20. 3. The facility failed to ensure CNA D was conducting proper Foley catheter care for Resident #57. These failures could place the residents at risk of transmission of disease and infection.Findings included: Resident #42 Observation on 08/19/25 at 1:49 PM revealed Resident #42 had Enhanced Barrier Precaution signage on the outside of her door with PPE (gloves, gowns, and masks) available in plastic drawers outside of the room. Observation further revealed Resident #42 had a peg tube. Observation on 08/20/25 at 9:44 AM of CNA A going into Resident # 42's room with a package of briefs to change resident. Further observation revealed Resident # 42 had sign on door for EBP with PPE cart outside of resident room. Observation of CNA A not donning PPE (putting on a gown) before entering Resident # 42's room to perform peri-care (when a resident has soiled their brief and their private area needs to be cleaned). Observation on 08/20/25 at 9:50 AM of CNA A exiting Resident # 42's room with bag containing soiled brief and going into soiled utility room to dispose. Interview on 08/20/25 at 10:30 AM, CNA A stated she had worked at the facility for 9 years. CNA A stated that Resident # 42 was on EBP for her Peg tube. CNA A stated she is aware she messed up earlier this morning when she went in to Resident # 42's room to provide peri-care since she did not put on her PPE. CNA A stated she could not give a reason as to why she did not don her PPE besides she just got in a hurry and forgot. CNA A stated if PPE is not worn it could negatively affect the resident by a contaminant getting into the resident's Peg tube which could lead to an infection. CNA A stated she has been trained on Abuse, Neglect, Resident Rights, and EBP. CNA A stated the facility uses CBT and in person trainings. Review of the Enhanced Barrier Precautions Resident List, dated 08/19/25, reflected Resident #42 was on the list due to having a peg tube. Record review of Resident #42's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke), hemiplegia and hemiparesis (weakness and paralysis on affected side due to a stroke), gastrostomy status, dysphagia (difficulty swallowing), neuromuscular dysfunction of bladder (nerves in the bladder no longer communicate with the brain), cognitive communication deficit, atrial fibrillation (irregular heart rate), and presence of cardiac pacemaker (implanted inside chest wall to assist a regular heart rate). Record review of Resident #42's Quarterly MDS assessment dated [DATE] reflected a BIMS Score of 05, which reflected a severe cognitive impairment. The MDS reflected Resident #42 was incontinent of bowel and bladder and needed substantial/maximal assistance with the help of two or more people for all her activities of daily living, including eating, drinking, hygiene, positioning, and toileting. Record review of Resident #42's Care Plan, last revised on 06/18/25, reflected she required use of Enhanced Barrier Precautions related to feeding tube/peg tube. The goal was for Resident #42 to not have adverse psychosocial outcome due to Enhanced Barrier Precautions use during care. The interventions reflected staff were to use PPE (hand hygiene, gloves and gown) when providing high contact care activities, providing direct care, and management of tube feedings. Resident #20Observation on 08/20/25 at 1:15 PM of peri-care for Resident #20 revealed CNA B and CNA D turned her to the left side, brief removed and placed in the trash. CNA B conducted handwashing, and clean gloves were put on. CNA B placed a clean under pad, and Resident #20's bottom was cleansed with wipes. CNA B then touched the clean brief that was on the bedside table with soiled gloves. CNA B conducted hand hygiene and changed his gloves. CNA B then placed the contaminated brief to Resident #20, on top of the clean under pad. He then conducted hand hygiene and put on clean gloves and cleansed the peri-area with wipes. CNA D then verbally prompted CNA B to replace the brief on Resident #20. Interview on 08/20/25 at 1:26 PM with CNA B who stated he knew he had touched the clean brief with contaminated gloves, and he knew he was not supposed to do peri-care that way. CNA B stated he had received training on infection control protocols, hand hygiene, and peri-care. Record review of Resident #20's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included syncope and collapse, hypotension, intracerebral hemorrhage resulting in hemiplegia and hemiparesis, dysphagia, chronic obstructive pulmonary disease, hypertension, low back pain, Alzheimer's disease, and cognitive communication deficit. Record review of Resident #20's Quarterly MDS assessment dated [DATE] reflected a BIMS Score of 03, which reflected a severe cognitive impairment. The MDS reflected Resident #20 had diagnoses of Alzheimer's disease, dementia (memory loss and brain degeneration), and hemiplegia and hemiparesis (weakness and paralysis). Resident #20 was dependent on 2 or more helpers for all her activities of daily living, including eating, drinking, hygiene, positioning, and toileting. Resident #20 was always incontinent of bowel and bladder. Record review of Resident #20's Care Plan, last revised on 08/18/25/25, reflected the potential for impairment to skin integrity. Resident #20 would be free from skin breakdown through review date. Interventions included keeping her skin clean and dry, assist with turning and reposition as needed, reduce friction and shearing with use of lift/transfer sheets, and evaluate skin condition on a daily and weekly basis. The interventions also reflected to assist Resident #20 with activities of daily living and mobility as needed. Resident #57 Observation on 08/20/25 at 1:35 PM of peri-care and urinary catheter care for Resident #57 revealed CNA D cleansed the catheter tubing from the urethra/meatus (opening in body where urine comes out) and out around approximately 3-4 inches with only one wipe. CNA D also did not cleanse Resident #57's peri-area. Interview on 08/20/25 at 2:07 PM with CNA D who stated he knew he was supposed to cleanse the tubing with three wipes, and stated the brief was not wet so she did not need peri-care at that time. CNA B stated he had received training on infection control protocols, hand hygiene, and peri-care. Record review of Resident #57's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included multiple sclerosis (a disease that causes breakdown of the protective covering of nerves, which can cause numbness, weakness, trouble walking, vision changes, and other symptoms), neuromuscular dysfunction of bladder (when communication between the brain and the nerves in the spinal cord that control bladder and bowel function become interrupted), intestinal obstruction, presence of prosthetic heart valve (heart valve replacement), difficulty in walking, hypertension, and atrial fibrillation (irregular heart rate). Record review of Resident #57's Comprehensive MDS assessment dated [DATE] reflected she had a BIMS Score of 15, which reflected no cognitive impairment. The MDS reflected Resident #57 had an indwelling catheter and was occasionally incontinent of bladder. The MDS further reflected diagnoses of multiple sclerosis, urinary tract infection, and presence of prosthetic heart valve. Record review of Resident #57's Care Plan, dated 08/08/25, reflected she had a urinary catheter related to a neurogenic bladder (when an injury or disease interrupts the electrical signals between your nervous system and bladder function). The goal reflected Resident #57 would show no signs and symptoms of urinary infection through the review date and relevant intervention(s) included catheter care per policy. Interview on 08/21/25 at 06:16 PM, CNA A stated she had worked at the facility for 9 years. She stated it was important for staff to perform hand hygiene between residents, so staff members do not transmit any germs from one person to another. CNA A stated if staff members do not follow good hand washing/hand hygiene and infection control protocols, an infection could be passed from one person to another. CNA A stated when providing catheter care to residents, the catheter tubing should be cleansed with 3 wipes from the meatus (urinary opening) and out. CNA A further stated she had been in-serviced on infection control protocols, including handwashing/hand hygiene, enhanced barrier precautions, and catheter care. She stated the prevention of infections included frequent hand washing and hand hygiene, glove changed when going from dirty to clean/front to back, and wear gown and gloves for enhanced barrier precautions. Interview on 08/20/25 at 4:30 PM, the DON stated she had been in the current role for about 4 months. She stated she was hired to be the ADON, had become the interim DON, and now full time DON. The DON revealed she heard about CNA B touching the brief with soiled gloves. The DON stated she would be doing further in-servicing with CNA B on infection control and conducting peri-care. The DON stated CNA B had been a CNA for several years in the facility and performed other duties such as showers, feeding, and transfers. The DON stated overall it was her responsibility for ensuring staff were following infection control measures when providing direct care for the residents. She further stated the ADON was the Infection Preventionist, and the ADON kept up the list of residents who were on Enhanced Barrier Precautions, signage and PPE carts outside of the resident rooms, along with catheters and PICC lines. The DON stated she and the ADON double checked and verified residents with catheters, PICC lines, gastrostomy tubes, etc. The DON stated both she and the ADON monitor how staff were doing with handwashing/hand hygiene, and infection control by conducting spot checks during the workday. The DON further stated she and the ADON would then talk with the staff about their observations and what could be done more efficiently. She further stated the ADON had been doing competencies with staff. The DON stated she was not sure of the policy, but in nursing school they were taught to cleanse the catheter tubing at least three times, and from the meatus and out. She stated when a resident was on EBP her expectation was all staff providing direct care to the resident put on gloves and a gown. The DON stated staff had completed check offs and competencies on infection control, catheter care, and Enhanced Barrier Precautions. She stated the potential negative outcome for residents was they could become sick from cross contamination. Interview on 08/21/25 at 06:45 PM, the ADON/IP stated she had been employed at the facility for 14 years. She stated infection control was a team effort, and the DON and herself were responsible for ensuring staff were doing hand hygiene/following infection control measures when providing care for the residents. She stated she worked in the facility for 40 or more hours per week, and more than 20 hours were spent on Infection Control. The ADON/IP stated she conducted in-services on Infection Control topics with staff, along with other clinical supervisors and the DON. Topics of in-servicing included handwashing/hand hygiene, conducting peri-care, catheter care, and Enhanced Barrier Precautions. The ADON/IP stated she observed and monitored how staff were conducting hand hygiene and following infection control measures by watching staff during their daily routine by showing up in the resident rooms during care, assisted with resident care, and by observing staff members' habits. The ADON/IP stated policy on catheter care included cleansing the tubing with three wipes. During Enhanced Barrier Precautions, staff should put on a gown when administering peg tube feedings or medications, changing residents' clothing, check and change and peri-care, emptying catheter bags and providing catheter bags, and any time it was possible to have contact with the residents' body and body fluids. During peri-care, hand hygiene and glove change should be done when going from dirty to clean, and from front to back. The ADON/IP stated a potential negative outcome for the residents would be the spread of infection to the residents. Interview on 08/21/25 at 07:24 PM with the ADMIN, who stated he had been here for 3 years. The ADMIN stated everyone was responsible for following Infection Control protocols in the community. He further stated the Infection Preventionist was responsible for education, along with the DON. The ADMIN stated everyone was responsible for spot checking while staff were providing resident care, using the restroom, and going from one room to another. He stated the DON, the IP, and himself made resident rounds, monitor, and track and trend any abnormal happenings, antibiotic stewardship, and this was all a part of our Quality Assurance. The ADMIN stated when staff were not conducting handwashing and following Infection Control measure, a potential negative outcome for the residents would be the potential to spread infection from resident to resident. Policies: Review of the facility's Policy and Procedure on Enhanced Barrier Precautions, dated 09/2022, reflected:Policy Overview: Enhanced barrier precautions (EBPs) should be utilized to reduce transmission of multi-drug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities.Policy Detail:1. Enhanced barrier precautions (EBPs) should be used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms to residents.2. EBP are used in conjunction with standard precautions and expand the use of PPE (personal protection equipment) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to associate hands and clothing.3. The infection control recommendations for EBP will be determined on the point of care task or activity. Use hand hygiene, gown, and gloves (high-contact activity) when providing care under clothes or dressings, providing bundled AM or PM care including oral care, dressing, bathing, grooming, doing dressing changes, and providing peri-care.4. EBPs are indicated with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.9. Signs are posted on the door or wall outside the resident room indicating EBP precautions and PPE are required. Review of the facility's Policy and Procedure on Handwashing/Hand Hygiene, dated 01/2021, reflected:Policy Overview: This community considers hand hygiene the primary means to prevent the spread of infections.Policy Detail: C. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based had rub, etc.) shall be readily accessible and convenient for associates use to encourage compliance with hand hygiene policies.G. CDC recommends using Alcohol Based Hand Sanitizer with 60-95% alcohol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water during routine resident care.8. Before moving from a contaminated body site to a clean body site during resident care.9. After contact with a resident's intact skin.10. After contact with blood or bodily fluids. The facility did not provide a policy on providing indwelling catheter care.

Based on observations and interviews, the facility failed to post, in a form and manner available for all residents and resident representatives, the required contact information for the public and the entire facility including telephone number of the Long-Term Care Ombudsman program for the facility's postings for 1 of 1 facility reviewed for resident rights. The facility did not have the Ombudsman Program sign posted with contact information. This failure could affect resident representatives and place residents at risk of not having access to a written description of their rights, advocacy groups, and a decreased quality of life by not having access to Ombudsman information for resources.Findings included: Observation on 08/20/2025 at 9:12 AM, revealed the Ombudsman posted notice located on the second floor on the wall by the facility entry way of the double doors of the foyer. The posting was posted on the right side of the wall as you exit the building, and facing in front of you to the left as an individual would be entering the double door building. Residents would have to go to the second floor, in and out of the facility entry way of the double doors of the foyer in order to have access to the Ombudsman posted information. In a Confidential Resident Council meeting on 08/20/2025 at 10:15 AM, residents stated they did not know where the Ombudsman's contact information was posted. Residents stated they did not know how to contact the Ombudsman. Residents stated Ombudsman was not present at any Resident Council meeting. Residents reported they do not know the name of the Ombudsman assigned to this facility. Residents stated they had not been told how to contact the Ombudsman. Several Residents stated if information was posted, such as the Ombudsman's information, it is not at their eye level. Residents stated the facility post information at the staff's eye level. Residents stated they do not see things where the facility staff posts them due to the majority of the residents were in wheelchairs. Residents stated they would appreciate if the facility would post things where it is assessable to their eye level. Observation on 08/20/2025 at 11:08 AM, revealed during a walkthrough of the facility, on the first floor, there was no visible posting information for how to contact the Ombudsman on second floor hallways. There was Ombudsman posted information in a glass shadow box near the elevator on the first floor. The posted Ombudsman information was in small lettering out of view for individuals in wheelchairs to read. There were water hydration stations under the glass shadow box that obstructed and prevented individuals from getting closer to read postings. Observation on 08/20/2025 at 11:14 AM, revealed during a walkthrough of the facility, on the second floor, there was no visible accessible information on how to contact the Ombudsman. There was a procedure posting notice located by the nursing station with the Ombudsman's phone number was about 6 and a half feet from the floor in small print, not visible or accessible for residents in wheelchairs or with vision deficits. In an interview on 08/20/2025 at 5:55 PM, the ADMIN stated there was not a facility policy on posted Ombudsman information. In an interview on 08/21/2025 at 12:34 PM, the REM stated she had not provided the residents information on the Ombudsman, nor had she invited the Ombudsman to a Resident Council meeting. She stated that she had started employment at the facility as of July 2025. She stated to not know who the Ombudsman is and does not know where the posted Ombudsman information is located. In an interview on 08/21/2025 at 12:45 PM, the RED stated the following she had never invited the Ombudsman to a Resident Council meeting, but she had spoken to residents about the Ombudsman, mainly when they have a lot of questions. She said she would print the Ombudsman information and provide it to the residents. She stated she did not know the name of the local Ombudsman. She stated she thought the glass shadow box on the first floor near the elevator was accessible to all residents with the Ombudsman information in it. She stated it's the facility management staff responsibility to post Ombudsman information. Observation on 08/21/2025 at 12:54 PM, the RED revealed Ombudsman posted information by the elevator located in a glass shadow box of the first floor approximately five and a half feet high in small lettering print and not easily accessible to individuals in wheelchairs or with vision deficits. In an interview on 08/21/2025 at 12:56 PM, the RED stated the Ombudsman posted information was not accessible to individuals. She stated she would work on getting bigger signs and placed lower in areas to accommodate residents right to accessibility of Ombudsman information. In an interview on 08/21/2025 at 6:18 PM, CNA A stated she thought the Ombudsman posting information should be in the break room or nursing station. CNA A said had not seen it for sure, but it could be provided should the residents ask the facility staff for it by asking her supervisor or another staff member. She is not sure if residents have access to Ombudsman posted information without having to ask facility staff and believes the Ombudsman leaves the residents business cards if the Ombudsman visits, but she is not sure. She can't say that the residents don't have the information for the Ombudsman, and she isn't sure if it would negatively affect the residents. She states it goes against resident rights if they did not have access to the Ombudsman information. The Administrator is responsible for making sure residents have access to the Ombudsman information. In an interview on 08/21/2025 at 6:43 PM, the ADON stated the Ombudsman posting was near the elevator on each floor, and residents pass by it. She said her opinion, the Ombudsman posting was not accessible to residents in a wheelchair. She would have to ask her supervisor if the Ombudsman posted information was anywhere else in the facility. The ADON said she felt the facility needed a bigger print of the Ombudsman information because it was too small for residents to see. She thought the Ombudsman posted information is on both floors near the elevator but is not sure. She stated residents could be negatively affect if they do not have access to this information including individuals in wheelchairs. It can negatively impact residents and residents should have access to it, but residents can ask staff where it's at. She is not sure if all staff in the facility knows where the Ombudsman posted information is located. Ombudsmen offer additional information or resources, and it's part of the staff's duty to be able to offer Ombudsman information to residents. She is not aware of any additional Ombudsman posting in the glass case near the elevator besides a printout from what she has seen. This goes against resident rights if the residents do not have access to Ombudsman information. Residents have the right to have access to the Ombudsman posted information regardless being in a wheelchair or not. The Administrator is responsible for the Ombudsman posted information to be accessible to all residents in the facility. In an interview on 08/21/2025 at 7:24 PM, the ADMIN stated the Ombudsman posted information is near the elevator downstairs in a glass case and is also located at the entrance of the front door that residents can go to. The residents had access to Ombudsman posted information in his opinion. He honestly can't tell if it is at someone's eye level. He can't tell if it is at resident's eye level based on height and it might be difficult for a resident if in a wheelchair to be able to see the posted Ombudsman information. In terms of it negatively affecting the residents, he states residents have access to the Ombudsman information and it is posted where residents can see it. Staff tell residents where it is and residents are informed of their rights. Administrator oversees making sure the Ombudsman information is posted for the residents with easy accessibility. He doesn't know who the Ombudsman was for the facility.

Based on observations, interviews, and record review. The facility failed to ensure results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to survey were readily available to examine for 1 of 1 facility. The required documents were not posted in a location readily accessible and visible to all residents, their legal representatives, or family members. This failure could place all residents of the facility at risk of limited' rights to access information regarding the facility's compliance with state and federal requirements.Findings included: An observation conducted on August 19, 2025, at 4:02 PM, revealed the facility's survey results book was found in the entry foyer on the second floor. The survey book was noted in an acrylic wall book holder with no signage reflecting where the survey book was located. A brief look at the survey book revealed the last survey results were a complaint investigation dated September 2024 and full book results for years 2024 and 2023.An observation conducted on August 20, 2025, at 9:12 AM, revealed the facility's survey results book remained in the entry foyer on the second floor. There was no sign posted stating the location of the survey results. There were no 2025 survey investigations from, January 15, 2025, February 5, 2025, March 3, 2025, March 17th, 2025, April 7, 2025, May 20, 2025, and June 18, 2025posted in the survey binder. An observation conducted on August 21, 2025, at 10:54 AM and again at 3:56 PM, revealed the facility's survey results book remained in the entry foyer on the second floor, still no sign posted stating the location of the survey results. The book did not include any 2025 complaint surveys. During a confidential group interview conducted on undisclosed date and time, five confidential residents stated they had not known where or how to access the survey results in the facility. They had not understood or been aware the survey book existed or that they were able to review the results. Residents also stated when things were posted it is not at their eye level. They stated they do not see things above because most of them were in wheelchairs. Residents stated they would appreciate if the facility would post things where it was visually accessible. Record Review conducted completed August 20, 2025, at 5:05 PM, revealed the facility completed survey investigations on January 15, 2025, February 5, 2025, March 3, 2025, March 17th, 2025, April 7, 2025, May 20, 2025, and June 18, 2025.August 20, 2025, 5:53 PM, state survey book policy was requested via email from the ADMIN.August 21, 2025, 8:25 AM, during interview, the ADMIN stated there was no facility policy for the survey book.Interview conducted August 21, 2025, 6:19 PM, CNA A stated she had worked at the facility for 9 years. CNA A was asked did she know the location of the facility survey results binder, she responded at the nurse's station. She stated the residents do not have access to the survey book. CNA A was asked did she know what was included in the survey book, she responded she did not know what was inside the survey book. CNA A was asked do she know what the survey book was, she stated, no. CNA A stated she do not recall being trained on the survey book. CNA A stated the ADMIN was probably responsible for the survey book binder.Interview conducted on August 21, 2025, at 6:19 PM, the ADON stated she had worked at the facility for 14 years. The ADON stated the facility survey book was located between the double doors at the front of the facility entrance. The ADON was asked do she know what is required to be in the survey binder, she stated is not sure what is supposed to be in the survey book. The ADON was asked did she think the survey book was readily accessible to residents, family members and legal representatives, she stated, It is right there when you walk in, between the double doors, I think on top of a table, they can just open it up. The ADON stated she would go to the ADMIN if there was a question on the survey book. The ADON was asked whose responsibility is it to notify the residents of the whereabouts of the survey book, she stated, it was all the facility staff's responsibility to inform the residents. The ADON was asked do she think the survey book is accessible for all the residents on the first floor, she stated yes, they can take the elevator up and go to the book. The ADON stated the door is always open leading into the double door area, the one leading outside lock at certain times. The ADON stated residents have a right to know the results of the surveys.Interview conducted on August 21, 2025, at 7:30 PM, the ADMIN was asked the location of the facility survey results binder. ADMIN stated when you walk into the vestibule (small entrance area), it's to the left in a cubby hole. The ADMIN stated a sign is there. The ADMIN was asked the location of the sign as one was not observed the last 3 days. The ADMIN stated he just put one up, he stated it's not the prettiest sign but one is there. ADMIN stated it was the administrator's responsibility to maintain and update the survey book. ADMIN stated the survey book should include the past 3 annual surveys and any off-cycle deficiencies. The ADMIN was informed that the 2025 survey investigations were not maintained in the facility's survey binder as required. The ADMIN stated that 2 weeks ago the 2025 survey investigations were present in the book. The ADMIN left to retrieve the survey binder, returned, and stated to the surveyor, you are correct, they are missing. The ADMIN stated he felt the survey book was accessible to residents and all visitors. He further stated there was a sign at the desk indicating that the survey results were available. When the surveyor asked where at the desk the sign was located, the ADMIN responded that he believed it was there. No sign was observed, and the ADMIN did not show surveyor the sign. ADMIN was asked how not the results having readily available could have affected the residents; the ADMIN stated residents have the right to know the results. The ADMIN stated he told family members on tours how to review facility results. The ADMIN stated the survey book was readily accessible to everyone. When asked if he believed it was accessible for all residents on the first floor, he responded, yes.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment and maintain a temperature range of 71' to 81' Fahrenheit for 38 (room numbers 2, 6, 8, 9, 11, 14, 16, 17, 23, 25, 28, 31, 32, 33, 46, 48, 49, 50, 51, 55, 64, 65, 66, 68, 72, 73, 74, 75, 78, 81, 84, 86, 87, 91, 94, 96, 97, 98) of 58 rooms on the 1st and 2nd floor reviewed for temperature of the environment, in that: The facility failed to ensure resident rooms had working heaters, working thermostats, and residents were warm. The facility failed to screen residents for signs and symptoms of hypothermia. For an unknown period of time: Rooms 2, 6, 8, 11, 14, 16, 17, 23, 25, 28, 32, 33, 46, 48, 49, 50, 51, 64, 65, 66, 72, 73, 74, 75, 78, 81, 87, 97, 98 occupied with residents did not have working heaters. room [ROOM NUMBER] occupied with a resident did not have a working thermostats. Rooms 2, 8, 9, 16, 23, 25, 31, 32, 49, 51, 55, 68, 74, 75, 84, 86, 87, 91, 94, 96, 97, 98 had observed temperatures of less than 71 degrees Fahrenheit. room [ROOM NUMBER] displayed the lowest temperature of 57.7 degrees Fahrenheit. An Immediate Jeopardy (IJ) was identified on 01/11/25 at 5:00 PM. The IJ template was provided to the facility on [DATE] at 5:00 PM. While the IJ was removed on 01/14/25 at 4:32 PM, the facility remained out of compliance at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of shivering, confusion, slurred speech, numbness, and hypothermia (occurs when your body temperature drops below 95 F (35 C). Findings included: Review of Resident #1's (room [ROOM NUMBER]) face sheet dated 01/13/25 reflected an [AGE] year-old male who was originally admitted to the facility on ,d+[DATE], readmitted on [DATE], and on 08/05/24 with diagnoses that included chronic kidney disease stage 3, dependence on renal dialysis (a procedure that removes waste and excess fluid from the blood when the kidneys are no longer functioning properly), and chronic respiratory failure. Review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of 14, which indicated intact cognition, mobility device of wheelchair, and active diagnosis of medically complex conditions including respiratory failure. Review of Resident #1's order dated 08/06/24 revealed renal dialysis, 5 days a week. Interview on 01/10/25 with Resident #1 at 8:10 pm reflected he had been very cold for several days in his room, but he can't remember when. He stated, it was like a refrigerator, it actually felt like a refrigerator. When asked if he told anyone he was cold he said, hell yes, he told everyone. He told the CNAs, the nurses (he could not recall staff names) and the staff all commented on how cold it was in his room. Review of Resident #2's (room [ROOM NUMBER]) face sheet dated 01/13/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia (a medical condition where the lungs are not effectively exchanging oxygen from the air into the bloodstream), pulmonary fibrosis (a lung disease that causes scarring, making it difficult to breathe), and dependence on supplemental oxygen. Review of Resident #2's MDS dated [DATE] reflected a BIMS score of 15, which indicated intact cognition, mobility devices of walker and wheelchair, active diagnosis of debility (physical weakness, especially as a result of illness), cardiorespiratory conditions, including respiratory failure. Interview on 01/10/25 with Resident #2 at 7:28 pm reflected he was very cold when the cold front came through for about 2 or 3 days and complained numerous times. He said he, felt like he was camping out in the mountains and could not stay warm, and his nose felt cold. He said he complained numerous times and they kept saying they were going to fix it. He said he did not want to get up and go to the bathroom it was so cold. He said they did not offer to move him to another room and every one knew it was cold but did not provide the name of people he discussed the cold with. Review of Resident #3's (room [ROOM NUMBER] ) face sheet dated 01/13/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure and dependence on renal dialysis (a procedure that removes waste and excess fluid from the blood when the kidneys are no longer functioning properly). Review of Resident #3's MDS dated [DATE] reflected a BIMS score of 11, which indicated moderate cognitive impairment, active diagnosis of medically complex condition and respiratory failure. Review of Resident #3's order dated 12/22/24 revealed renal dialysis. Interview on 01/10/25 with Resident #3 at 8:17 pm reflected he had no heat at all the night he was admitted into the facility and he froze. He said he complained about it, and he heard a lot of people complained about it because they were cold at night. Resident #3 said he knew Resident #1 complained about the cold. Review of Resident #4's (room [ROOM NUMBER]) face sheet dated 01/13/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included cutaneous abscess of buttock (a pus-filled pocket that develops under the skin on the buttocks) and personal history of other diseases of respiratory system. Review of Resident #4's MDS dated [DATE] reflected no diagnosis or assessment information. A review of Resident #4's MDS section 3 dated 01/14/25 reflected a BIMS score of 12, which indicated moderate cognitive impairment. An observation on 01/10/25 of Resident #4's room at 10:32 pm revealed it was very cold in his room and the thermostat had a reading of 57.5 degrees Fahrenheit. He was wearing a jacket over his pajamas and socks beneath a blanket. Interview on 01/10/25 with Resident #4 at 10:32 pm revealed, I am cold. Review of Resident #5's (room [ROOM NUMBER]) face sheet dated 01/13/25 reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, stage 5, cognitive communication deficit, and end stage renal dialysis (a procedure that removes waste and excess fluid from the blood when the kidneys are no longer functioning properly). Review of Resident #5's MDS dated [DATE] reflected a BIMS score of 15, which indicated intact cognition, mobility device of wheelchair, active diagnosis of medically complex conditions. Review of Resident #5's order dated 10/01/24 revealed renal dialysis 5 days a week. Interview on 01/10/25 with Resident #5 at 9:09 pm reflected she had been freezing cold all day and she wore gloves and a coat all day. Resident #5 said a family member came to visit and it was so cold in her room, her family member left the coat and gloves she was wearing for her to wear. She said everyone who entered her room, including staff (she could not recall their names) remarked on how cold it was. Review of weather underground url: https://www.wunderground.com reflected the following temperatures in Fahrenheit: Sunday January 5, 2025 high of 75, low of 36 Monday January 6, 2025 high of 46, low of 29 Tuesday January 7, 2025 high of 48, low of 26 Wednesday January 8, 2025 high of 41 low of 35 Thursday January 9, 2025 high of 41, low of 36 Friday January 10, 2025 high of 44, low of 35 According to the National Institute on Aging, indoor temperatures as low as 60 to 65 degrees Fahrenheit can lead to hypothermia in older adults. Observations of thermostats and resident room temperatures (in Fahrenheit) 01/10/25 revealed: room [ROOM NUMBER] 10:16 pm - thermostat completely black, unable to read room [ROOM NUMBER] 10:17 pm - 66 degrees room [ROOM NUMBER] 10:19 pm - 65 degrees room [ROOM NUMBER] 10:21 pm - 65 degrees room [ROOM NUMBER] 10:23 pm - 66.5 degrees room [ROOM NUMBER] 10:24 pm - 68.5 degrees room [ROOM NUMBER] 10:25 pm - 67 degrees room [ROOM NUMBER] 10:27 pm 69 degrees room [ROOM NUMBER] 10:29 pm 65 degrees room [ROOM NUMBER] 10:31 pm 69 degrees room [ROOM NUMBER] 10:32 pm 57.7 degrees room [ROOM NUMBER] 10:34 pm 67.5 degrees room [ROOM NUMBER] 10:35 pm 70 degrees room [ROOM NUMBER] 10:39 68.5 degrees room [ROOM NUMBER] 10:40 pm 68 degrees room [ROOM NUMBER] 10:41 pm 69.5 degrees room [ROOM NUMBER] 10:43 pm 68 degrees room [ROOM NUMBER] 10:43 pm thermostat completely black, unable to read room [ROOM NUMBER] 10:45 pm 70.5 degrees room [ROOM NUMBER] 10:48 pm 69 degrees room [ROOM NUMBER] 10:51 pm 66 degrees room [ROOM NUMBER] 10:52 pm 70 degrees room [ROOM NUMBER] 10:54 pm 68 degrees Observations on 01/10/25 7:06 pm until 01/11/25 12:05 am of no direct care staff or administrative staff observed offering hot beverages, additional sweaters, or blankets to the residents. Review of facility TELS - reflected: work order number 12023 room [ROOM NUMBER] this room is very cold family is in the room and are very upset that it is so cold open date 12/3/24 11:57 am closed dated 12/3/24 3:43 pm work order number 11978 the room temp is cold room [ROOM NUMBER] open dated 11/21/24 8:29 am closed dated 11/22/24 11:09 am work order number 12019 the resident said the room is [to] cold room [ROOM NUMBER] open date 12/03/24 9:10 am closed dated 12/07/24 am work order 12035 this room is cold room [ROOM NUMBER] dated 12/06/24 1:30 pm closed 12/06/24 12:00 pm work order 12037 this room is cold room [ROOM NUMBER] dated 12/6/24 1:31 pm closed 12/6/24 4:13 pm work order 12039 this room is cold room [ROOM NUMBER] dated 12/06/24 4:14 pm closed 12/06/24 4:14 pm work order 12040 this room is cold room [ROOM NUMBER] dated 12/06/24 1:34 pm closed 12/06/24 4:14 pm work order 12041 this room is cold room [ROOM NUMBER] dated 12/06/24 1:34 pm closed 12/06/24 4:15 pm work order 12083 rooms in SNF are too cold main building SNF 2nd floor, dated 12/06/24 1:34 pm closed 12/21/24 11:53 pm closed 12/26/24 12:18 pm work order 11927 . the A/C heater are not working room [ROOM NUMBER] dated 11/07/24 10:49 am closed 11/08/24 10:31 am work order 12092 . it is cold in this room check A/C window unit, make sure it is sealed room [ROOM NUMBER], dated 12/26/24 1:18 pm closed 12/31/24 11:51 am work order 12096 check the room temp in this room room [ROOM NUMBER], dated 12/26/24 1:18 pm closed 12/31/24 11:51 am work order 11926 the a/c heater is not working in this room, room [ROOM NUMBER], dated 11/07/24 10:49 am closed 11/08/24 10:31 am work order 11979 check the heater in this room room [ROOM NUMBER], dated 11/21/24 10:33 am closed 11/23/24 8:35 am work order 11983 the temp is cold in this room room [ROOM NUMBER], dated 11/21/24 1:16 pm closed 11/22/24 12:11 pm work order 11986 the heater in this room is not working room [ROOM NUMBER] dated 11/22/24 10:36 am closed 11/22/24 12:13 pm work order 12044 this room is cold room [ROOM NUMBER] dated 12/09/24 9:06 am closed 12/16/24 3:02 pm Review of facility maintenance policy checklist revealed steps need to be taken during the winter months to minimize disaster related preparation checklist. It should be used in conjunction with this document prior to all extreme cold/inclement weather events to ensure we are prepared in each department for every event and signed by the MD and Administrator on 11/14/24. Checklist document reflected, Resident and vacant rooms should keep their apartment heat sources set to minimum of 75 degrees during freezing weather in case of power outage checked as complete. Review of in-service dated 01/07/25 given by the DCS topic cold/inclement weather at 3:30 pm reflected extreme heat and cold measures policy was discussed including monitoring temperatures every 2 hours, if there are areas that fall below 68 degrees Fahrenheit, residents must be moved to common areas that meet the proper temperature , all staff should be familiar with the symptoms of cold related illnesses and the initial treatments that should be initiated and, if the minimum temperature is not maintained, the emergency evacuation plan must be activated. The direct care staff was not included in this in-service. Signatures on the in-service reflected only the following administrative staff members attended: The Administrator The manager for clinical services, LVN The Director of Admissions The Social Services Assistant The Assistant Director of Clinical Services The Director, Human Resources Interview on 01/13/25 with the MD at 3:43 pm revealed the facility had a what to do during cold weather policy and a checklist to follow to implement during cold weather. He revealed he felt there was some miscommunication between residents and staff about room temperatures and Resident #4's room should never have been 57.5 degrees. Interview on 01/13/25 with LVN A at 7:08 pm revealed she had worked at the facility for about [AGE] years and the heating system had not worked for the last couple of years and the facility had been putting a bandage on the problem. Interview on 01/10/25 with CNA A at 9:15 pm revealed that the heaters are not working in every room, and she knew for sure that the heaters were not working in rooms [ROOM NUMBERS] and there were residents in the rooms. She said she was concerned about the residents because the heaters were not working, and she was concerned residents were cold. Interview on 01/10/25 with LVN C at 12:16 am revealed, when asked the signs and symptoms of hypothermia LVN C listed: Cold skin Slower breathing Blue/pale skin Shivering Any signs of distress Interview on 01/10/25 with CNA D at 12:12 am revealed, when asked the signs and symptoms of hypothermia CNA D listed: Shivering Change in mental status Blue lips/fingers/cloudy skin Hyperventilating Interview on 01/10/25 with CNA E at 12:14 am revealed, when asked the signs and symptoms of hypothermia CNA E listed: Shaking Feverish Interview on 01/10/25 with CNA F at 12:15 am revealed, when asked the signs and symptoms of hypothermia CNA F did not know the signs and symptoms of hypothermia. Interview on 01/14/25 with the dialysis nurse at 3:30 pm he revealed that residents have complained to him that it had been cold and he had put three separate work orders for the receptionist and spoken to the nurses. He said Resident #1's room was, like a meat locker. He said dialysis residents are frailer because of the dialysis treatment and that it is important to keep them warm. Interview on 01/13/25 with a family member of Resident #5 at 12:23 pm stated she visited Resident #5 on 12/31/24. She revealed it was freezing cold when in Resident #5's room. She said the staff said they were having trouble with the heat in some of the rooms. She said she stayed about 4 hours and was told by facility staff that they were working on getting the heater fixed. She left her coat and gloves with Resident #5 to wear because it was so cold. She said that everyone who entered Resident #5's room on 01/31/24 commented that the room was cold. She said she assumed that the heater was going to be fixed because she was told that the heater would be fixed. Resident record reviews of progress notes for Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 of reflect no monitoring of room temperatures and no monitoring for sign/symptoms of hypothermia were being conducted. Review of email dated 01/13/25 from facility heater repair provider at 3:13 pm reflected the findings on each resident room HVAC unit as of 1/12/25: The Following 43 rooms have bad compressors and control boards and are not operational, due to the age and overall condition of the units compressor replacement is not recommended. 4, 5, 6, 7, 16, 18, 23, 24, 25, 26, 27, 28, 29, 33, 36, Dialysis, Conference Room, 39, 40, 41, 43, 45, 46, 49, 50, 51, 54, 56, 58, 64, 66, 67, 72, 73, 75, 78, 80, 81, 83, 87, 88, 90, 95 The Following 5 units have active refrigerant leaks, the units were charged up but due to the size of the system the added freon is only a temporary fix and heating/cooling is temporary 8, 10, 11, 22, 32 The following 2 units have bad Blower motors and will need further diagnostics once repaired 14, 44 The following 6 units have bad reversing valves and will need further diagnostics, Due to the age and condition of the unit I do not recommend making this repair 17, 48, 65, 74, 94, 98 The following 2 units only have a bad thermostat 13, 82 The Following unit has a cracked loop and will need to be replaced 97 Review of facilty resident list report dated 01/13/25 revealed that the following rooms were occupied with residents: 1, 2, 3, 6, 8, 9, 11, 14, 15, 16, 17, 19, 21, 23, 25, 28, 30, 31, 32, 33, 34, 46, 48, 49, 50, 51, 53, 55, 57, 59, 60, 61, 62, 63, 64, 65, 66, 68, 69, 71, 72, 73, 74, 75, 77, 78, 80, 81, 82, 84, 86, 87, 89, 91, 94, 96, 97, 98. A review of the facilty resident list report dated 01/13/25 and the email dated 01/13/25 from facility heater repair provider reflected that room numbers 2, 6, 8, 11, 14, 16, 17, 23, 25, 28, 32, 33, 46, 48, 49, 50, 51, 64, 65, 66, 72, 73, 74, 75, 78, 81, 87, 97, 98 occupied with residents, did not have working heaters. Interview on 01/13/25 with the facility employed contract HVAC technician at 3:30 pm revealed on 01/08/25 he knew that there was no heat in rooms [ROOM NUMBERS] and there were residents in the rooms. He said the residents said they were cold but did not add additional comments. He said he had been employed as a HVAC technician for [AGE] years and was deeply concerned about it getting colder and the residents not being warm. He said the problem was the heat exchanger because it had been dirty for such a long time it caused permanent damage to the HVAC in all the resident rooms. He said the best the facility could do was to offer vented heating/cooling units for all the resident rooms. He said he brought the problem with the heating/cooling to the attention of the facility about a year ago and they were dealing with the consequences of them not being proactive. Interview on 01/10/25 with the Administrator at 9:56 pm revealed that if residents were cold, they were offered a change of room, but that residents could make their own choices, and had the option to decline, and did decline room changes when offered. The administrator revealed staff did not explain the room change would not be permanent and residents could return to their room when the heating could be adjusted in their regular rooms. Interview on 01/14/25 with the Administrator at 2:24 pm revealed if residents were too cold the largest issue would be hypothermia, which would lead to an emergency visit to the hospital and residents could die if the hypothermia was extreme. When asked why staff did not follow through with making sure the actions in the in-service dated 01/07/25 were taken by his staff, he said he did not know and said the whole situation had brought a concern to the facility. Review of facility House Temperature & Extreme Heat and Cold policy last revised 05/2022 reflected Policy overview - A comfortable community temperature is maintained for the residents per state or Federal regulations. A safe and comfortable indoor temperature range is generally defined for the older adults as 71-81 degrees or per state regulation. Follow the [facility] Emergency Plan and begin resident monitoring for possible adverse effects from extreme cold or heat. Policy Detail - Temperature Falls outside the safe comfortable range. The executive director/designee should notify the district director of operations and regional maintenance technician when the community indoor temperature falls outside the safe and comfortable range. A nurse should evaluate resident symptoms of physical distress related to extreme temperatures outside the safe and comfortable range as soon as possible and notify the physician/healthcare provider of findings. Evacuation is an emergency and determining an alternate healthcare setting. In the instance of temperatures that could adversely affect a residents' health and safety, the community should follow the emergency plan and determine an alternate and temporary healthcare setting. Notify appropriate parties. A nurse should evaluate resident symptoms of physical distress related to extreme temperatures outside the safe and comfortable range as soon as possible and notify the physician/ health care provider of findings. Follow the emergency plan for preparing, managing, and potentially evacuating from the community. Resident monitoring: the health and Wellness director, director of clinical services /designee/charge nurse is responsible for the monitoring of resident health conditions during times of community emergencies and/ or during indoor temperatures outside of the safe and comfortable ranges. Monitoring should include - observing residents every one to two hours for signs and symptoms of heat or cold related conditions as indicated in the extreme heat and cold measures document. Reporting adverse effects to the executive director and the health and Wellness director, director of clinical services. Providing warming or cooling measures, as indicated in the extreme heat and cold measures document. Check resident temperatures every one- two hours is indicated for clinical judgment. Notifying the physicians/health care provider and family/responsible party of resident condition changes in agency per state regulation (conditions that pose a threat). The ADM and CSD were notified on 01/11/25 at 5:00 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 01/13/25 at 2:00 PM: Facility Policy Dated 10/2015 Quality of Life - Home Like Environment. The community associates and management shall maximize, to the extent possible, the characteristics of the community that reflect a personalized, home like setting. These characteristics include: comfortable temperatures Facility policy dated 1/2018 temporary excessive cold measures: monitor indoor temperatures every one to two hours initiate resident checks every one to two hours to offer hot beverages/ fluids and evaluate for and assess signs and symptoms of hypothermia encourage residents to dress in layers and use blankets for warmth check all doors and windows for drafts. Eliminate drafts when possible by drawing a curtain/shades on days when the temperatures are below freezing. Encourage residents to sit away from window slash drafts. Encourage residents to wear appropriate winter clothing while indoors and to dress in layers with appropriate outerwear when leaving the building. Residents should also wear a hat or ear covering or gloves when going outdoors. Encourage residents not to partake in outdoor activities for extended period of time. Extreme or Extended Periods of Cold Monitor indoor temperatures at least hourly until the heating system has been repaired. Notify the district director of operations, regional maintenance technician, and district director of clinical services/ regional director of clinical operations. Communicate indoor temperatures with district or divisional leadership for possible evacuation. If there are areas that fall below 68 F, residents must be moved to common areas that meet the proper temperature. The area must be of sufficient size to safely accommodate the residents. Check residence temperatures every hour, offering hot beverages, evaluate for signs of hypothermia. All staff should be familiar with the symptoms of cold related illness and at the initial treatments that should be initiated. If the minimum temperature is not maintained, the emergency evacuation plan must be activated. Cold related illness What to look for - Hypothermia Shivering Confusion Memory loss Drowsiness Exhaustion Slurred speech Slow, irregular pulse Numbness Decreased level of consciousness Plan of Removal Immediate Threat On 1/11/2025 an abbreviated survey was initiated at the facility. On 1/11/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Threat states as follows: F 584 Safe, clean, comfortable, home-like environment: The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Action: On 1/11/25, resident #1 was interviewed by Social Service Coordinator about the comfort of her room temperatures. This was documented on an interview sheet . On 1/11/25, the Maintenance Technician installed a portable [vented] heater in resident's # 1 room. On 1/11/25, a licensed nurse completed vital signs and evaluated resident # 1 for symptoms of hypothermia and documented in the electronic medical record. No symptoms noted . On 1/11/25, resident #2 was interviewed by Social Service Coordinator about the comfort of his room temperatures. This was documented on an interview sheet. On 1/11/25, the Maintenance Technician installed a portable [vented] heater in resident's # 2 room. On 1/11/25, a licensed nurse completed vital signs and evaluated resident # 2 for symptoms of hypothermia and documented in the electronic medical record. No symptoms noted. On 1/11 -1/12/25 a licensed nurse completed a vital sign temperature and evaluated all current residents for symptoms of hypothermia and documented in the electronic medical record. No symptoms noted. On 1/11/25, the community received nineteen (19) portable [vented] heaters to install for residents that had concerns with room temperatures and/ or to be installed in rooms in which the thermostat was not functioning. On 1/11/25, a licensed nurse reviewed the 24-hour Summary Report from the electronic medical record from 1/3/25- 1/11/25 to determine if there was symptoms of hypothermia documented. No documentation was identified for symptoms of hypothermia. On 1/11/25, Social Services Coordinator completed 46 out of 58 resident interviews about the comfort of their room temperatures. Residents identified to have a grievance were provided with portable [vented] heaters, room change options, and/ or extra blankets. The resident interviews were documented on an interview sheet. On 1/11/25, the Maintenance Technician audited every resident room to determine if the thermostat was functioning. Thirteen (13) rooms were determined to have thermostats that were not functioning correctly. The rooms identified were 58, 66, 72, 74, 75, 78, 81, 97, 8, 4, 7, 28, and 69 . The Maintenance Technician installed portable [vented]heaters with the temperature display in the occupied resident rooms. Unoccupied rooms identified will not be used until a portable [vented] heater with a temperature display is installed or the room thermostat is replaced. On 1/11/25, the Regional Maintenance Technician ordered fifteen (15) additional portable [vented] heaters that display the room temperature. On 1/12/25, Social Services Director reviewed the Grievance Log for 12/15/24 to 1/11/25 to identify any grievances related to room temperatures. Starting on 1/11/25, Clinical, Maintenance, and/ or designee are auditing room temperatures of resident rooms every two (2) hours for the next five (5) days. If no occupied rooms are temping below 68 degrees the room temperature audits will continue three (3) times a day for two (2) weeks, daily for four (4) weeks, and daily for five (5) weeks. If the outside weather is at or projected to be below 40 degrees a baseline room temperature of each resident room will be obtained. If any occupied resident room temperature is below 68 degrees the House Temperature and Extreme Heat and Cold Policy will be followed. This audit includes documenting the room thermostat temperature, obtaining a room temperature with an infrared thermometer, and if applicable the portable [vented] heater room temperature. This audit is documented on an audit sheet . Based on the most recent audit results on 1/12/25 there are two unoccupied rooms (rooms [ROOM NUMBERS]) below 68 degrees. These rooms will remain unoccupied until repairs are completed and room temperatures are above 68 degrees. The Administrator and/ or designee will audit the room temperature log daily for five (5) days, three (3) times a day 1 or two (2) weeks, daily for four (4) weeks, and daily for five (5) weeks to validate compliance. On 1/11- 1/12/25, the Maintenance Technician and/ or designee will re-train designated associate (s) who are auditing room temperatures, on how to operate the infrared thermometer and that the designated associate needs to notify the licensed nurse immediately if the room temperature is below 68 degrees. If the resident room temperature is between 68 and 71 degrees an interview will be conducted by a licensed nurse or designee with the resident and/ or representative to determine if this is their desired room temperature. If the resident and/ or representative respond no; offer a room change, extra blanket, move to the common area, or warm beverage until heater can be evaluated by Maintenance. This retraining shall occur prior to the associate conducting a room temperature audit. The associates not available on 1/11- 1/12/25 will receive the re-training prior to being assigned to audit room temperatures. This training will be documented on an in-service sheet and a teach back will be used to verify knowledge of content. On 1/11- 1/12/25, the Director of Clinical Services (DCS) and/ or designee re-educated licensed nurses and certified nursing assistance on the Homelike Environment Policy, emergency evacuation and transfer agreement process, and House Temperature and Extreme Heat and Cold Policy including symptoms of hypothermia, notification to Healthcare Provider and resident representative if the resident is having symptoms of hypothermia, the measures to take if an occupied resident's room temperature is below 68 degrees, and notification to the Administrator and/ or designee if low room temperature can't be resolved. The associates not available on 1/11- 1/12/25 will receive be re-educated prior to working their next scheduled shift. This training will be documented on an in-service sheet and a teach back will be used to verify knowledge of content. Starting on 1/11/25, if a resident's room temperature is below 68 degrees the following items will be initiated until the resident is located to another room with a room temperature above 68 degrees, appropriate repairs are completed to the resident's room heater, and/ or a portable [vented] heater is installed in that resident's room. A licensed nurse or certified nursing assistant will obtain the residents temperature every hour, and a licensed nurse will evaluate the resident every hour for symptoms of hypothermia and document this in the medical record . If symptoms of hypothermia are identified this change of condition will be documented in the medical record, and the Healthcare Provider and Resident Representative will be notified. If the room temperature is not corrected the Administrator or designee will be notified to provide further direction related to initiating an emergency transfer plan to another location. Starting on 1/12/25 and ongoing, new admissions rooms will be checked by Maintenance and/ or designee to validate that the heater and thermostat are working and that the room temperature is in the correct range. If a repair needs to be made this will be documented on a work order. Work orders will be entered into the electronic system by the Administrator, Maintenance associates, or concierges. Paperwork orders will be available at each nurse's station and concierge's desk. For oversight by the Administrato

Based on interviews and record reviews, the facility failed to develop a comprehensive care plan within seven days after completion of the comprehensive assessment and no more than 21 days after admission for two (Resident #1 and #2) of five residents reviewed for care plans. The facility failed to ensure Resident #1's and #2's comprehensive care plans were completed within seven days after completion of their comprehensive assessments. This deficient practice could place residents at risk of not receiving assistance with activities of daily living and sustaining a serious injury, impairment or death. Findings included: Resident #1 Review of Resident #1's face sheet, dated 10/07/24, reflected he was a [AGE] year-old male who was initially admitted to the facility on [DATE], readmitted on [DATE], and his own RP. Review of Resident #1's medical diagnoses, dated 10/07/24, reflected he had unspecified angina pectoris (A type of chest pain caused by reduced blood flow to the heart), unspecified hyperlipidemia (A condition in which there are high levels of fat particles (lipids) in the blood), pressure ulcer of right heel that was unstageable and sacral region that was stage three, and anemia in chronic kidney disease (a common condition that occurs when the kidneys can't produce enough erythropoietin, a hormone that signals the bone marrow to make red blood cells). Review of Resident #1's comprehensive MDS assessment, dated 09/07/24, reflected he had a BIMS score of 15, which indicated he was cognitively intact. Review of Resident #1's care plan log, dated 10/07/24, reflected he had a comprehensive care plan started on 09/28/24. There was no completion date. Review of Resident #1's care plan review, started on 09/28/24, reflected nursing, resident programs, and social services departments have not reviewed and completed their review sections of Resident #1's comprehensive care plan. Resident #2 Review of Resident #2's face sheet, dated 10/07/24, reflected she was a [AGE] year-old female who was initially admitted to the facility on [DATE], readmitted on [DATE], and her own RP. Review of Resident #2's medical diagnoses, dated 10/07/24, reflected she had acute posthemorrhagic anemia (a condition that develops when you lose a large amount of blood quickly), postprocedural hemorrhage of a genitourinary system organ or structure following a genitourinary system procedure (bleeding that occurs after a medical procedure performed on any part of the urinary or reproductive system), hydronephrosis with renal and ureteral calculous obstruction (a condition where one or both kidneys swell due to a blockage in the urinary tract), other abnormalities of gait and mobility, neoplasm of unspecified behavior of bladder (abnormal growth of tissue in the bladder), and an unspecified chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breathe by restricting airflow to the lungs). Review of Resident #2's comprehensive MDS assessment, dated 09/21/24, reflected she had a BIMS score of 8, which indicated she had moderate cognitive impairment. Resident #2 was dependent on staff for toileting and showering, partial-moderate assistance with oral hygiene, and supervision/touching assistance with eating. Review of Resident #2's care plan log, dated 10/07/24, reflected she had a comprehensive care plan started on 09/24/24. There was no completion date. Review of Resident #2's care plan review, started on 09/24/24, reflected dietary, dietary leadership, and resident programs departments have not reviewed and completed their review sections of Resident #2's comprehensive care plan. During an interview on 10/07/24 at 11:25 a.m., LVN A stated nurses participated in residents' care plan process. LVN A stated the MDS Coordinator was responsible for overseeing residents' care plan process. LVN A stated if residents did not have a comprehensive care plan, then staff would not know how to care for the residents. During an interview on 10/07/24 at 11:37 a.m., the Clinical Records Supervisor stated the facility had an offsite MDS Coordinator who was responsible for working on residents' comprehensive care plans. During an interview on 10/07/24 at 11:40 a.m., the DON stated the MDS Coordinator worked remotely on residents' comprehensive care plans. An attempt to contact the MDS Coordinator was made on 10/07/24 at 11:46 a.m. A voicemail and call back number was left. The MDS Coordinator did not return the call before exit conference. During an interview on 10/07/24 at 11:51 a.m., the DON stated she needed to ask her staff when residents' comprehensive care plans were to be completed. During an interview on 10/07/24 at 12:11 p.m., the DON stated residents' comprehensive care plans were to be completed within 14 days of a residents' admission to the facility. During an interview on 10/07/24 at 12:19 p.m., the DON stated she reviewed the facility's comprehensive care plan policy and found that residents' comprehensive care plans were to be completed within 7 days of the completion of residents' comprehensive MDS assessments. Review of the facility's comprehensive care plans policy, effective 11/2017, reflected: 8. The resident's comprehensive care plan will be developed within seven (7) days of the completion of the resident's comprehensive MDS assessment in accordance with the CMS RAI completion guidelines.

Based on observations, interviews, and record review, the facility failed to implement their written policies and procedures to report, prohibit, and prevent abuse for one (Resident #1) of five residents reviewed for developing and implementing abuse and neglect policies, in that: The facility failed to implement abuse policies and procedures when they failed to protect Resident #1 from being abused by his SO/AP. The facility failed to report and investigate all suspected abuse and/or aggressive behaviors when staff reported observing SO/AP slap, hit, punch, grab, kick, yell, and shake Resident #1 and reported suspicious bruises, skin tears, and a burn on Resident #1's body and abdomen. By failing to implement these policies, the facility failed to identify and assess all possible incidents of abuse and investigate and report all allegations of abuse within timeframes required by federal requirements. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/30/2024 at 1:30 PM. While the IJ was removed on 09/01/2024 at 01:41 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of undetected abuse, trauma, and/or decline in feelings of safety and well-being or psychosocial harm. Findings included: Record review of Resident #1's face sheet dated 08/10/2024, reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Glioblastoma (brain cancer), cerebral edema (swelling of the brain), muscle wasting and atrophy, seizures, hypertension (high blood pressure), and cognitive communication deficit (difficulty with speech). Resident #1 had also been diagnosed with difficulty swallowing and was a high risk for aspiration. Record review of Resident #1's MDS assessment, dated 05/21/2024, reflected a BIMS score of 12, which indicated moderate cognitive impairment. Resident was at risk of developing pressure ulcers but had no current pressure ulcers or injuries. Resident had skin tears, pressure reducing device for chair and bed. Negative for any behaviors. Resident was dependent for self-care and required maximal assistance to move from sitting to lying flat on bed. Record review of Resident #1's initial care plan initiated on 05/15/2024 revealed no behavioral problems. Resident required assistance with ADLs due to weakness, brain cancer, cognitive deficit, and history of seizures. Resident required two -person assistance for transfer. Resident had difficulty swallowing and had a puree/thin liquid diet with 1:1 assistance for eating, monitor meal intake with each meal, and monitor weights as ordered. SO/AP was non-compliant with texture modified diet order and ordered excessive quantities of food for the resident. Resident had impairment to skin integrity and required assistance with turning and repositioning. Skin was to be evaluated on a daily and weekly basis. Geri sleeves to both arms were added on 07/22/2024 due to thin and fragile skin with discoloration and tears. Resident was on dexamethasone therapy (steroid) and at increased risk for bruising, bleeding, slow wound healing, thinning skin, red/purple spots on the skin. On 7/14/2024, potential impaired behavioral patterns were added (restlessness, agitation, movement onto the assist bar on left side of bed). Record review of Care Plan conference summary dated 08/14/2024 reflected a BIMS score of 0, which indicated severely impaired cognition. The facility reported that the internal investigation of the 07/14/2024 incident was unfounded. Surveyor requested copies of the facility's abuse/neglect investigations for Resident #1 for the past 60 days on 08/29/2024 at 11:45 AM but did not receive a copy of the 07/14/2024 internal investigation. The facility found the internal investigation of the 08/03/2024 incident to be inconclusive. Resident was alert to person, and able to answer yes or no questions. His BIMS score was 0. Resident #1 denied abuse but was unable to tell the source of the injury. SO/AP denied abuse, stated she had seen the bruise a few days ago, but was unable to recall the specific date and time. When asked why SO/AP did not report the bruise, SO/AP stated, I did not think twice about it. SO/AP admitted to covering the bruise with foundation make-up. Based on interviews and the extent of the injury no abuse or neglect was verified. Resident #1 took medications that contributed to skin fragility, and he did have spontaneous movement. During an interview on 08/29/2024 at 9:25 PM, the ADM had a copy of the police report and was aware of the allegations from four staff members who reported witnessing SO/AP assault Resident #1. The report revealed on 07/13/2024, staff observed SO/AP kick Resident #1 under the table in the dining room when they attempted to video record SO/AP interaction together while in the dining room. On 07/13/2024, staff observed SO/AP yell at Resident #1, grab his arms and shake him, and shove food in Resident #1's mouth, while he was lying flat on his back laying down, sleeping. Over the past month, staff had observed SO/AP punch Resident #1 in the chest with a closed fist and slap him in the face multiple times on different days. Staff had observed a burn on Resident #1's abdomen and reported they didn't know what caused the burn and that the resident would not have been able to cause it due to his mobility limitations. Staff reported that visitors had complained that they witnessed SO/AP slap Resident #1. Staff stated that they reported these allegations and concerns to their supervisor. Review on 08/30/2024 of Facility records in TULIP did not reveal a self-report that matched the allegations of physical abuse of Resident #1 on 07/13/2024 or other assault that occurred in June/July 2024. Record review of Resident #1's progress note dated 08/03/2024 by RN B, revealed nursing staff noticed the resident had the appearance of a left black eye around 5:30 AM. A maroon color bruise appropriately 1 cm in diameter below the resident's left eye around upper cheek. There were also some very small faint purple marks between his eye and nose. Also noted was the appearance of foundation makeup on his skin close to the left side of his nose as evidenced on cloth after wiping face. SO/AP was questioned by CNA B, RN and Director of Social Services and SO/AP reported seeing the bruise a couple of days ago and did not report it to staff. SO/AP admitted to putting the makeup on the bruise. The resident denied being hurt by the SO/AP. A BIMS interview was attempted, and the resident was unable to participate. The resident had difficulty talking and did not answer questions. Progress notes did not reflect that a head-to-toe assessment was done. Record review of Resident #1's change of condition evaluation dated 08/03/2024 revealed bruise/purple discoloration below left eye and in the corner of left eye. Record review of Resident #1's progress note dated 08/05/2024 by Director of Social Service, revealed SO/AP came to the facility to drop off clean laundry. Record review of Resident #1's progress note dated 08/05/2024, signed by the NP, revealed Resident #1 was alert and oriented to person, insight was impaired, and he was confused and forgetful. Record review of NP physical exam dated 08/05/2024 showed a diagnosis of contusion to left eyelid and periocular area and superficial injury to left upper arm. Notes stated that SO/AP observed bruise on 08/02/2024. Record review of Resident #1's progress note dated 08/08/2024 by Director of Social Services, revealed SO/AP was allowed back in the facility. New interventions were reviewed with SO/AP, including moving the resident closer to the nurse's station and having the resident's door always open for safety/monitoring when SO/AP was visiting the resident. Further review a Care conference took place on 08/14/2024 because SO was accused of being the AP in the 07/14/2024 and 08/03/2024 incident. Record revealed Resident #1's Care plan initiated 08/08/2024 included interventions to allow SO/AP to visit frequently, which included: move resident to room closer to nurse's station; SO/AP to notify staff immediately of any skin injury; resident's door to remain open during visits; and care plan conference with Ombudsman scheduled for 08/14/2024. Resident #1 was at risk for aspiration due to trouble swallowing and left sided weakness. Interventions included maintain appropriate, upright position during meals, remain upright for 1 hour after meals, order for puree/thin liquids diet, supervise or assist resident with oral intake as needed, 1:1 assist, monitor meal intake with each meal, encourage SO/AP compliance with diet order. SO/AP was non-compliant with texture diet orders and would order excessive quantities of food for the resident. Update on 08/13/2024, reflected that resident had delirium with changes to behavior, altered mental status, wide variation in cognition through the day, communication decline, disorientation, lethargy, restlessness and agitation, delusions, and hallucinations. Record review of Resident #1's orders dated 08/29/2024 revealed an order to keep the resident's door open when SO/AP was visiting alone with the resident. Record review of Resident #1's change of condition forms indicated the following: * dated 08/29/2024, revealed skin discoloration on the left side of resident's face at jawline, and behind left ear and red area. Area was better after pressure relieved from face on call control. * dated 08/30/2024 revealed a new skin tear to the right elbow. CNA witnessed SO/AP transport resident through bedroom doorway and bump the resident's elbow. Record review of Resident #1's skin integrity report dated 08/30/2024 revealed skin not intact. Discoloration, rash, abrasion, and skin tears in multiple different healing levels. The abrasion was a new skin issue and weekly wound data collection flow sheet was selected to be created. Record Review of facility sign in sheet for the month of August 2024, revealed SO/AP was at the facility 08/03/2024, 08/09/2024 to 08/30/24. SO/AP would arrive between 7:45 AM and would often not sign out. During an observation and attempted interview on 08/29/2024 at 12:24 PM, Resident #1 was in the dining room and SO/AP was observed trying to feed Resident #1 and said, I need your mouth open .this can be the last bite if you want .open your mouth. Resident #1 was observed in a wheelchair with pillows behind his head, back, under arms, and under his legs/feet. He was wrapped in Geri sleeves/bandages on both arms. Resident #1 wore a baseball cap that covered his head and forehead. Surveyor attempted to interview the resident in the dining room alone, but the resident did not respond to questions and closed his eyes and appeared to be asleep. During observations on 08/29/2024, revealed Resident #1's door was closed with SO/AP inside the room at the following times: 12:50 PM - 12:56 PM 1:06 PM - 1:10 PM 2:55 PM - 3:02 PM 4:36 PM - 4:45 PM During the above times of observations, six staff walked by the door and did not intervene to open the door. During an interview on 08/29/2024 at 12:11 PM, the DON stated that she had witnessed SO/AP trying to wake up Resident #1 by patting him on the cheek, shaking his chest. Staff had reported SO/AP force fed the resident. SO/AP put a lot of focus on eating and fed the resident all three meals daily. The DON stated the Medication Resident #1 took made him sleep and resident's skin got very thin and bruised a lot. The DON stated she did not think SO/AP was abusing the resident because SO/AP always said how much she loved the resident, and the SO/AP's intention was not to harm the resident. DON stated there was not any abuse to report. After the 08/03/2024 incident with the bruise on the resident's face, the facility set up a meeting with SO/AP and the Ombudsman on 08/08/2024. Facility's response was to move the resident to a room closer to the nurse's station to allow for line of sight, frequently monitoring, and the door to remain open. They have put padding on the resident's chair. The DON thought the marks on Resident #1 were due to positioning in the chair and/or bed. The DON had received in-service training on ANE this month and knew about reporting. During an interview on 08/29/2024 at 12:34 PM, RN C stated she was not aware of Resident #1's care plan about leaving the resident's door open. RN C had not been told what to do if the resident's door was closed. RN C had not told to do frequent rounds/monitoring on Resident #1. RN C did not know who the abuse coordinator was and had not received any recent training on ANE. During an interview on 08/29/2024 at 12:43 PM, CNA C stated that Resident #1 always had unexplained skin tears and bruises and SO/AP was told to visit the resident in public spaces. CNA C was not aware not aware of Resident #1's care plan about leaving the resident's door open. CNA C stated SO/AP wanted to the door closed and would close the door. CNA C had not been told what to do if the resident's door was closed. CNA C did not do anything when the door was closed. The resident only came out of his room to eat in the dining room and for therapy. They all stated they were not told to do frequent rounds/monitoring on Resident #1. CNA C observed SO/AP feed Resident #1 all meals in the dining room. During an interview on 08/29/2024 1:10 PM, CMA stated SO/AP fed Resident #1 all meals. CMA had not been told that Resident #1's door must stay open. CMA had not been told what to do if the resident's door was closed and CMA did not do anything when the door was closed. CMA stated the resident was moved closer to the nurse's station so that staff walking pass his door would keep an eye on him. During an interview on 08/29/2024 1:25 PM, NP stated that the marks on Resident #1's face, neck, and arms were clearly a result of the high dose steroid use and not abuse. The NP stated they (the marks on Resident #1) were not bruises. The NP believed skin tears were due to transfers, brushing up against the environment (chair/bed). The NP stated that staff (speech therapy, nurse, CMA/CNAs) had expressed their concerns about how SO/AP fed the resident. NP did not think SO/AP was intentionally trying to hurt the resident. The NP had no concerns about SO/AP visiting the resident and being alone in the facility with the resident with the door closed. The NP was not aware of any order to have Resident #1's door open or to do frequent monitoring. During an interview on 08/29/2024 at 1:38 PM, the MD stated that Resident #1 was taking a high dose of steroids due to brain cancer. The MD believed the discoloration on the resident's face was related to medical condition and medications. The MD had not observed any abuse. Staff have told the MD that SO/AP was persistent with feeding the resident but did not believe that would rise to the level to be abuse. They had not discussed any concerns about abuse or aggressive feeding in the monthly or weekly QAPI meetings. Surveyor told MD about the interviews from staff in the complaint report. The MD expressed surprise and stated, that is very concerning. The MD stated that Resident #1 did not have the cognition to be interviewed about the abuse. The MD was unaware of any interventions regarding Resident #1's door kept open during visits with SO/AP. During an interview on 08/29/2024 at 2:07 PM, LVN B had observed SO/AP on 7/14/2024, grabbing both (Resident #1's) shoulders and shaking him hard; slapping him in the face; hitting him in the chest with her fist; yelling him; threatening him to say she won't come visit him anymore if he doesn't wake up. LVN B intervened and told SO/AP to stop that it was dangerous to put food in the resident's mouth when he was asleep as he could choke. LVN B reported concerns to the DON, who called ADM, who did not want to report it. LVN B reported observing further abuse by SO/AP later that month and because of this, had not returned to work for this facility. During an interview on 08/29/2024, at 3:16 PM, LVN C stated she was unaware the Resident #1's care plan and interventions. She stated the DON was responsible for educating nursing staff and CNAs about the interventions in place and changes in a resident's care plan. LVN C had received in-service training on ANE recently and was aware to report ANE to the abuse coordinator. During an interview on 08/29/2024 at 3:28 PM, SO/AP denied hurting Resident #1. SO/AP was observed lying in bed on the right side of the resident while Resident #1 was asleep. SO/AP stated that the bruise of Resident #1's face was due to him sleeping on the call light button and reported the facility staff removed the call light at night. The AP/SO stated that was the only explanation for how the bruise occurred because SO/AP didn't do anything. Throughout the interview, SO/AP repeatedly stated she had nothing to hid and did not do anything and stated that she never noticed the bruise. It was a staff member that noticed the bruise, but SO/AP could not recall the staff member's name. When asked about the make-up, SO/AP originally denied it and then said she put make up on Resident #1's face a long time ago because SO/AP felt bad for the resident. SO/AP denied having a care plan meeting. When asked about keeping the door open, SO/AP confirmed she was asked to do that, but SO/AP kept the door cracked or closed because SO/AP did not want anyone looking into the room and the facility had blown that off. SO/AP wanted privacy. SO/AP denied staff coming to check on the resident or monitoring him. Surveyor attempted to interview Resident #1, but the resident remained asleep during the interview with SO/AP. During an interview and observation with LVN D on 08/29/2024 at 3:28 PM, LVN D was unaware of Resident #1's care plan interventions to keep door open. LVN D looked in Resident #1's electronic chart during the interview and could not find an order to have the resident's door open. LVN D walked off down the hallway. LVN D later returned as SO/AP was opening Resident #1's door and exiting the room with the resident. LVN D told SO/AP that the resident's door needed to stay open, and SO/AP responded, I don't care and continued to walk down the hallway pushing the resident in a wheelchair. LVN D stated she found a doctor's order in Resident #1's chart to keep the door open. LVN D told the charge nurse the care plan was not being followed and stated, I am sure the DON is aware. LVN D stated that all staff needed to be aware to keep the door open. During an interview on 08/29/2024 at 4:54 PM, Receptionist B had seen SO/AP be aggressive with Resident #1. Receptionist B observed SO/AP in the dining room grabbed his (Resident #1) jaw last month while trying to brush the resident's teeth. Receptionist B observed SO/AP grab Resident #1's arm and forced it down in a slapping motion when the resident reached out and grabbed hold of the dining room door frame. Receptionist B reported the incident to the police when they responded to the 08/03/2024 self-report and then reported it to her supervisor. Receptionist B received in-service training last month on ANE. Receptionist B had no knowledge of the resident's care plan or interventions nor if the facility had done an investigation regarding her concerns. During an interview on 08/29/2024 at 6:07 PM the ADM stated it was hard to say what the expectations were for staff not following Resident #1's care plan interventions to keep the resident safe because the facility's internal investigation revealed no abuse; the resident wanted SO/AP there and felt safe; the police had not done anything, and the Texas Health and Human Services Commission had cleared the first incident for 07/14/2024. The ADM stated that in general, when discussing other residents, the ADM's expectation was that staff follow the care plan. When surveyor asked again about expectations for Resident #1's care plan interventions and door being left open for safety and monitoring, ADM replied, that's hard to say. It is our findings that there has been no abuse. The ADM stressed there was no believe that any abuse had occurred and therefore, was not concerned about the closed door or staff not following the care plan interventions. During an interview on 08/29/2024 at 6:07 PM the DON stated it was care planned to have Resident #1's door kept open for line of sight. DON stressed that SO/AP would hurt the resident and therefore, we don't force the door if the door was closed. SO/AP was the POA and had been in a relationship with the resident for [AGE] years and the ADM and DON must respect that. The DON had known of concerns from staff that SO/AP force fed Resident #1 and that the AP/SO shakes his (Resident #1) shoulders to wake him up, but nothing the DON would consider abuse. The DON stressed that the AP/SO was intentionally trying to feed and wake Resident #1 but did not intend to cause harm. The DON stressed there was no believe that any abuse had occurred and therefore, was not concerned about the closed door or staff not following the care plan interventions. During an interview on 08/29/2024 at 7:28 PM, RN B stated that on 08/03/2024, a night CNA had reported to the night nurse that Resident #1 had a black eye around 5:30 AM. RN B did an assessment around 6:00 AM and did not think it was a bruise. RN B talked to the resident alone and the resident reported that he felt safe. RN B interviewed SO/AP and SO/AP had noticed the bruise a few days ago but had not reported it to the facility staff because she thought staff already knew. Resident #1 had fragile skin and due to medications, his skin would tear. RN B stated that the facility staff present that day had separated the resident and SO/AP and had the resident moved closer to nurse's station . RN B also called the police. RN B stated that the police officer had no concerns after interviewing the SO/AP. RN B was aware of the resident's care plan interventions to keep the door open while SO/AP visits. Staff had access to this information in the care plan. During an interview on 08/29/2024 at 7:43 PM, LVN A had observed SO/AP become impatient and frustrated with Resident #1. All staff have had to intervene because of SO/AP's behaviors. When SO/AP was not at the facility, Resident #1 was smiley and friendly with the staff. When SO/AP was at the facility, the resident was more upset and agitated. SO/AP got loud, bossy with him. On 8/3/2024, LVN A found the black eye with make-up put on Resident #1's face, which was highly suspicious. LVN A had heard that an agency nurse had seen SO/AP shake the resident in the dining room. LVN A stated Resident #1 would get skin tears on left side due to always leaning on left side. LVN A received in-service training on ANE and would report any concerns to the abuse coordinator. During an observation and interview on 08/30/2024 at 8:43 AM, Resident #1 was observed sitting in a wheelchair in the dining room and SO/AP was trying to feed the resident. Resident #1 appeared asleep as he had his eyes closed. Surveyor observed SLP intervene and crouch down to talk to the resident. Surveyor overhead SLP telling SO/AP, you can't feed him now .no, he's not awake enough and walked off. SLP stated he talked to SO/AP about not feeding the resident when the resident was asleep. The resident was not alert enough to eat and SO/AP needed to be educated to stop putting food in his month when the resident was asleep, which would collect in Resident #1 mouth and cause choking. SLP stated SO/AP got overzealous about feeding the resident but did not think it would be considered abuse. During an interview on 08/30/2024 at 11:37 AM, DCS stated that on 08/03/2024, Resident #1 was found to have a bruise on his face covered up by makeup. That was a big red flag. DCS reported it immediately to the previous ADM. The ADM was aware of the previous incident with SO/AP and told the DCS to call the police. Resident #1 was moved closer to the nurse's station on 08/03/2024 and then moved to another room on 08/10/2024 to keep an eye on the resident and provide frequent monitoring. ADM told DCS to remove SO/AP from the facility due to the situation. The SO/AP was still at the facility when the police arrive around 11:00 AM. Police responded to the facility on [DATE] around 11:00 AM and interviewed SO/AP and the resident. Police stated they could not do anything because there was no admission of guilt to the injury. DSC did not suspect SO/AP of any abuse. DCS had observed Resident #1's door being open but had been told that SO/AP liked to keep the door closed. DCS was in-serviced about keeping the resident's door open, the care plan interventions, and ANE about who was the abuse coordinator and about reporting when he arrived at the facility on 08/30/2024. The DCS stated the care plan was to ensure staff was providing proper care to the resident. The DCS expectation was that nursing staff follow the care plan. DCS would immediately report any allegations of ANE from staff. During an interview on 09/01/2024 at 9:50 AM, CNA A stated Resident #1 had unexplained bruises. Resident #1 was unable to communicate. An agency nurse had seen SO/AP smacking the resident and CNA A had seen SO/AP shaking the resident to wake him up a couple of month ago. We (the CNAs) had been suspicious of SO/AP for a while and could not believe no one believed it (the abuse) did not happen. During an interview on 09/01/2024 at 10:14 AM, CNA B had previously witnessed SO/AP shake (Resident #1) by the arms going back and forth. Resident #1 was sleepy, and SO/AP tried to put food in the resident's mouth. CNA B told SO/AP on 08/31/2024 not to feed Resident #1 soup with chucks of stuck in it because that could cause choking. During an interview on 09/01/2024 at 1:30 PM, LVN A had previously observed SO/AP be bossy and pushy where we as nursing staff would tell her that he has rights and we have always intervened. When asked if Resident #1 was safe at the facility, LVN A replied, I would hate to see him go home. During an interview on 09/01/2024 at 11:19 AM, RN A stated last week RN A observed SO/AP feed Resident #1 when he was not awake. Last week RN A observed SO/AP picking up Resident #1's head and holding it back. RN A intervened and explained to SO/AP that it was not appropriate to feed Resident #1 when he was asleep. Review of the Facility's Abuse, Neglect & Exploitation Policy, dated 07/2016 last revised 10/2022, reflected the facility will take necessary measures to prevent and protect residents from abuse. This policy will apply to potential abuse and injury of unknown source. Instances or allegations of abuse, neglect, mistreatment, or exploitation should be treated seriously and reported to the Administrator or the supervisor on duty for investigation and appropriate follow up. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and physical or chemical restraint not required to treat the resident's medical symptoms. The policy includes the definition of willful, as used in abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Prevention 1. Abuse prevention efforts should include, but are not limited to, the following: a. Providing residents and family information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution. b. Providing associates information on how and to whom they may report concerns, incidents and grievances without the fear or retribution. c. Identification, correction, and intervention in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur (this should include analysis or the physical environment that might make abuse and/or, neglect more likely to occur such as secluded areas of the community, deployment of associates on each shift to meet the needs of the residents; supervision or associates to identify inappropriate behaviors; and the assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict. mistreatment or neglect). Protection 1. Protection of Resident. Upon learning of alleged abuse, neglect, mistreatment or exploitation, the Administrator or supervisor on duty should attempt to take necessary steps to verify residents are protected from subsequent episodes of abuse, neglect, mistreatment or exploitation. Investigation of Potential Abuse, Neglect, and Exploitation Internal Investigation. Upon receipt of an allegation of resident abuse, neglect, mistreatment, or exploitation, the Administrator or designee should conduct a confidential internal investigation of the incident. Timing of Investigation. The investigation should be initiated as soon as practicable upon becoming aware of the incident. As required, the Administrator should provide a written report of the results of abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. External Reporting Alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property should be reported. As soon as practical, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Such alleged violations shall be reported to: I. The State Survey Agency; and II. Adult Protective Services. Internal Reporting Individuals observing an incident of resident abuse or suspecting resident abuse should immediately report such incident to the Administrator or Director of Clinical Services. The facility's policy on reporting abuse and neglect was requested on 08/29/2024 at 11:45 AM and 5:46 PM. It was not provided before exit. Attempted interview of Resident #1 on 08/30/2024, at 3:25 PM. Resident #1 was lying in bed in his room, awake and alert, and turned to look at surveyor when his name was called. The door was open, and a caregiver/sitter was sitting in a chair by the bed. SO/AP was lying in bed with the resident on the right side of the bed and surveyor was standing on the left side of the bed. Surveyor attempted to interview Resident #1, but SO/AP kept patting Resident #1's cheeks with her hands and turning the resident's face/head to the right and away from the surveyor when the surveyor tried to talk to the resident. This was determined to be an Immediate Jeopardy (IJ) on 08/30/2024 at 1:03 PM. The Administrator was notified. The Administrator was provided with the IJ template on 08/30/2024 at 1:30 PM. The following POR was accepted on 08/31/2024 at 2:23 PM: Plan of Removal Immediate Jeopardy On 08/30/2024, at 1:30PM, the facility was notified of an immediate jeopardy for F607 (implement their written policies and procedures to prohibit and prevent abuse) regarding: - The facility staff had failed to prevent Resident #1 from being abused. F607 Implement Policies to Prevent Abuse and Neglect One resident was identified as being affected by alleged deficient practice. On 08/30/2024, the HCA and DCS reminded SO of the care plan intervention

Based on observation, interviews, and record review, the facility failed to ensure each resident had the right to be free from abuse and neglect for one (Resident #1) of five residents reviewed for abuse and neglect, in that: The facility failed to ensure Resident #1 was free from abuse by his SO/AP when the facility neglected the interventions of Resident #1's care plan. The facility failed to follow the interventions in Resident #1's care plan, such as, keeping the Resident's door open during visits with SO/AP to keep the resident safe. This resulted in allegations that the SO/AP physically and verbally abused Resident #1. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/30/2024 at 1:30 PM. While the IJ was removed on 09/01/2024 at 01:41 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse, trauma, physical harm, pain, and/or psychosocial harm. Findings included: Record review of Resident #1's face sheet dated 08/10/2024, reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Glioblastoma (brain cancer), cerebral edema (swelling of the brain), muscle wasting and atrophy, seizures, hypertension (high blood pressure), and cognitive communication deficit (difficulty with speech). Resident #1 had also been diagnosed with difficulty swallowing and was a high risk for aspiration. Record review of Resident #1's MDS assessment, dated 05/21/2024, reflected a BIMS score of 12, which indicated moderate cognitive impairment. Resident was at risk of developing pressure ulcers but had no current pressure ulcers or injuries. Resident had skin tears, pressure reducing device for chair and bed. Negative for any behaviors. Resident was dependent for self-care and required maximal assistance to move from sitting to lying flat on bed. Record review of Resident #1's initial care plan initiated on 05/15/2024 revealed no behavioral problems. Resident required assistance with ADLs due to weakness, brain cancer, cognitive deficit, and history of seizures. Resident required two -person assistance for transfer. Resident had difficulty swallowing and had a puree/thin liquid diet with 1:1 assistance for eating, monitor meal intake with each meal, and monitor weights as ordered. SO/AP was non-compliant with texture modified diet order and ordered excessive quantities of food for the resident. Resident had impairment to skin integrity and required assistance with turning and repositioning. Skin was to be evaluated on a daily and weekly basis. Geri sleeves to both arms were added on 07/22/2024 due to thin and fragile skin with discoloration and tears. Resident was on dexamethasone therapy (steroid) and at increased risk for bruising, bleeding, slow wound healing, thinning skin, red/purple spots on the skin. On 7/14/2024, potential impaired behavioral patterns were added (restlessness, agitation, movement onto the assist bar on left side of bed). Record review of Care Plan conference summary dated 08/14/2024 reflected a BIMS score of 0, which indicated severely impaired cognition. The facility reported that the internal investigation of the 07/14/2024 incident was unfounded. Surveyor requested copies of the facility's abuse/neglect investigations for Resident #1 for the past 60 days on 08/29/2024 at 11:45 AM but did not receive a copy of the 07/14/2024 internal investigation. The facility found the internal investigation of the 08/03/2024 incident to be inconclusive. Resident was alert to person, and able to answer yes or no questions. His BIMS score was 0. Resident #1 denied abuse but was unable to tell the source of the injury. SO/AP denied abuse, stated she had seen the bruise a few days ago, but was unable to recall the specific date and time. When asked why SO/AP did not report the bruise, she stated, I did not think twice about it. SO/AP admitted to covering the bruise with foundation make-up. Based on interviews and the extent of the injury no abuse or neglect was verified. Resident #1 took medications that contributed to skin fragility, and he did have spontaneous movement. Record review of Resident #1's progress note dated 08/03/2024 by RN B, revealed nursing staff noticed the resident had the appearance of a left black eye around 5:30 AM. A maroon color bruise appropriately 1 cm in diameter below the resident's left eye around upper cheek. There were also some very small faint purple marks between his eye and nose. Also noted was the appearance of foundation makeup on his skin close to the left side of his nose as evidenced on cloth after wiping face. SO/AP was questioned by CNA B, RN and Director of Social Services and SO/AP reported seeing the bruise a couple of days ago and did not report it to staff. SO/AP admitted to putting the makeup on the bruise. The resident denied being hurt by the SO/AP. A BIMS interview was attempted, and the resident was unable to participate. The resident had difficulty talking and did not answer questions. Progress notes did not reflect that a head-to-toe assessment was done. Record review of Resident #1's change of condition evaluation dated 08/03/2024 revealed bruise/purple discoloration below left eye and in the corner of left eye. Record review of Resident #1's progress note dated 08/05/2024 by Director of Social Service, revealed SO/AP came to the facility to drop off clean laundry. Record review of Resident #1's progress note dated 08/05/2024, signed by the NP, revealed Resident #1 was alert and oriented to person, insight was impaired, and he was confused and forgetful. Record review of the NP physical exam dated 08/05/2024 showed a diagnosis of contusion to left eyelid and periocular area and superficial injury to left upper arm. Notes stated that SO/AP observed bruise on 08/02/2024. Record review of Resident #1's progress note dated 08/08/2024 by Director of Social Services, revealed SO/AP was allowed back in the facility. New interventions were reviewed with SO/AP, including moving the resident closer to the nurse's station and having the resident's door always open for safety/monitoring when SO/AP was visiting the resident. Further review a Care conference took place on 08/14/2024 because SO was accused of being the AP in the 07/14/2024 and 08/03/2024 incident. Record revealed Resident #1's Care plan initiated 08/08/2024 included interventions to allow SO/AP to visit frequently, which included: move resident to room closer to nurse's station; SO/AP to notify staff immediately of any skin injury; resident's door to remain open during visits; and care plan conference with Ombudsman scheduled for 08/14/2024. Resident #1 was at risk for aspiration due to trouble swallowing and left sided weakness. Interventions included maintain appropriate, upright position during meals, remain upright for 1 hour after meals, order for puree/thin liquids diet, supervise or assist resident with oral intake as needed, 1:1 assist, monitor meal intake with each meal, encourage SO/AP compliance with diet order. SO/AP was non-compliant with texture diet orders and would order excessive quantities of food for the resident. Update on 08/13/2024, reflected that resident had delirium with changes to behavior, altered mental status, wide variation in cognition through the day, communication decline, disorientation, lethargy, restlessness and agitation, delusions, and hallucinations. Record review of Resident #1's orders dated 08/29/2024 revealed an order to keep the resident's door open when SO/AP was visiting alone with the resident. Record Review of Resident #1's skin integrity report dated 08/22/2024 revealed skin tear on left arm. Record review of Resident #1's change of condition forms indicated the following: * dated 08/29/2024, revealed skin discoloration on the left side of resident's face at jawline, and behind left ear and red area. Area was better after pressure relieved from face on call control. * dated 08/30/2024 revealed a new skin tear to the right elbow. CNA witnessed SO/AP transport resident through bedroom doorway and bump the resident's elbow. Record review of Resident #1's skin integrity report dated 08/30/2024 revealed skin not intact. Discoloration, rash, abrasion, and skin tears in multiple different healing levels. The abrasion was a new skin issue and weekly wound data collection flow sheet was selected to be created. Record review of facility sign in sheet for August 2024, revealed SO/AP was at the facility 08/03/2024, 08/09/2024 to 08/30/2024. During an observation and attempted interview on 08/29/2024 at 12:24 PM, Resident #1 was in the dining room and SO/AP was observed trying to feed Resident #1 and said, I need your mouth open .this can be the last bite if you want .open your mouth. Resident #1 was observed in a wheelchair with pillows behind his head, back, under arms, and under his legs/feet. He was wrapped in Geri sleeves/bandages on both arms. Resident #1 wore a baseball cap that covered his head and forehead. Surveyor attempted to interview the resident in the dining room alone, but the resident did not respond to questions and closed his eyes and appeared to be asleep. During observations on 08/29/2024, revealed Resident #1's door was closed with SO/AP inside the room at the following times: 12:50 PM - 12:56 PM 1:06 PM - 1:10 PM 2:55 PM - 3:02 PM 4:36 PM - 4:45 PM During the above times of observations, six staff walked by the door and did not intervene to open the door. During an interview on 08/29/2024 at 12:11 PM, the DON stated that she had witnessed SO/AP trying to wake up Resident #1 by patting him on the cheek, shaking his chest. Staff had reported SO/AP force fed the resident. SO/AP put a lot of focus on eating and fed the resident all three meals daily. The DON stated the Medication Resident #1 took made him sleep and resident's skin got very thin and bruised a lot. The DON stated she did not think SO/AP was abusing the resident because SO/AP always said how much she loved the resident, and the SO/AP's intention was not to harm the resident. DON stated there was not any abuse to report. After the 08/03/2024 incident with the bruise on the resident's face, the facility set up a meeting with SO/AP and the Ombudsman on 08/08/2024. Facility's response was to move the resident to a room closer to the nurse's station to allow for line of sight, frequently monitoring, and the door to remain open. They have put padding on the resident's chair. The DON thought the marks on Resident #1 were due to positioning in the chair and/or bed. The DON had received in-service training on ANE this month and knew about reporting. During an interview on 08/29/2024 at 12:34 PM, RN C stated she was not aware of Resident #1's care plan about leaving the resident's door open. RN C had not been told what to do if the resident's door was closed. RN C had not told to do frequent rounds/monitoring on Resident #1. RN C did not know who the abuse coordinator was and had not received any recent training on ANE. During an interview on 08/29/2024 at 12:43 PM, CNA C stated that Resident #1 always had unexplained skin tears and bruises and SO/AP was told to visit the resident in public spaces. CNA C was not aware not aware of Resident #1's care plan about leaving the resident's door open. CNA C stated SO/AP wanted to the door closed and would close the door. CNA C had not been told what to do if the resident's door was closed. CNA C did not do anything when the door was closed. The resident only came out of his room to eat in the dining room and for therapy. They all stated they were not told to do frequent rounds/monitoring on Resident #1. CNA C observed SO/AP feed Resident #1 all meals in the dining room. During an interview on 08/29/2024 1:10 PM, CMA stated SO/AP fed Resident #1 all meals. CMA had not been told that Resident #1's door must stay open. CMA had not been told what to do if the resident's door was closed and CMA did not do anything when the door was closed. CMA stated the resident was moved closer to the nurse's station so that staff walking pass his door would keep an eye on him. During an interview on 08/29/2024 1:25 PM, NP stated that the marks on Resident #1's face, neck, and arms were clearly a result of the high dose steroid use and not abuse. The NP stated they (the marks on Resident #1) were not bruises. The NP believed skin tears were due to transfers, brushing up against the environment (chair/bed). The NP stated that staff (speech therapy, nurse, CMA/CNAs) had expressed their concerns about how SO/AP fed the resident. NP did not think SO/AP was intentionally trying to hurt the resident. The NP had no concerns about SO/AP visiting the resident and being alone in the facility with the resident with the door closed. The NP was not aware of any order to have Resident #1's door open or to do frequent monitoring. During an interview on 08/29/2024 at 1:38 PM, the MD stated that Resident #1 was taking a high dose of steroids due to brain cancer. The MD believed the discoloration on the resident's face was related to medical condition and medications. The MD had not observed any abuse. Staff have told the MD that SO/AP was persistent with feeding the resident but did not believe that would rise to the level to be abuse. They had not discussed any concerns about abuse or aggressive feeding in the monthly or weekly QAPI meetings. Surveyor told MD about the interviews from staff in the complaint report. The MD expressed surprise and stated, that is very concerning. The MD stated that Resident #1 did not have the cognition to be interviewed about the abuse. The MD was unaware of any interventions regarding Resident #1's door kept open during visits with SO/AP. During an interview on 08/29/2024 at 2:07 PM, LVN B had observed SO/AP on 7/14/2024, grabbing both (Resident #1's) shoulders and shaking him hard; slapping him in the face; hitting him in the chest with her fist; yelling him; threatening him to say she won't come visit him anymore if he doesn't wake up. LVN B intervened and told SO/AP to stop that it was dangerous to put food in the resident's mouth when he was asleep as he could choke. LVN B reported concerns to the DON, who called ADM, who did not want to report it. LVN B reported observing further abuse by SO/AP later that month and because of this, had not returned to work for this facility. During an interview on 08/29/2024, at 3:16 PM, LVN C stated she was unaware the Resident #1's care plan and interventions. She stated the DON was responsible for educating nursing staff and CNAs about the interventions in place and changes in a resident's care plan. LVN C had received in-service training on ANE recently and was aware to report ANE to the abuse coordinator. During an interview on 08/29/2024 at 3:28 PM, SO/AP denied hurting Resident #1. SO/AP was observed lying in bed on the right side of the resident while Resident #1 was asleep. SO/AP stated that the bruise of Resident #1's face was due to him sleeping on the call light button and reported the facility staff removed the call light at night. The AP/SO stated that was the only explanation for how the bruise occurred because SO/AP didn't do anything. Throughout the interview, SO/AP repeatedly stated she had nothing to hid and did not do anything and stated that she never noticed the bruise. It was a staff member that noticed the bruise, but SO/AP could not recall the staff member's name. When asked about the make-up, SO/AP originally denied it and then said she put make up on Resident #1's face a long time ago because SO/AP felt bad for the resident. SO/AP denied having a care plan meeting. When asked about keeping the door open, SO/AP stated she was asked to do that, but SO/AP kept the door cracked or closed because SO/AP did not want anyone looking into the room and the facility had blown that off. SO/AP wanted privacy. SO/AP denied staff coming to check on the resident or monitoring him. Surveyor attempted to interview Resident #1, but the resident remained asleep during the interview with SO/AP. During an interview and observation with LVN D on 08/29/2024 at 3:28 PM, LVN D was unaware of Resident #1's care plan interventions to keep door open. LVN D looked in Resident #1's electronic chart during the interview and could not find an order to have the resident's door open. LVN D walked off down the hallway. LVN D later returned as SO/AP was opening Resident #1's door and exiting the room with the resident. LVN D told SO/AP that the resident's door needed to stay open, and SO/AP responded, I don't care and continued to walk down the hallway pushing the resident in a wheelchair. LVN D stated she found a doctor's order in Resident #1's chart to keep the door open. LVN D told the charge nurse the care plan was not being followed and stated, I am sure the DON is aware. LVN D stated that all staff needed to be aware to keep the door open. During an interview on 08/29/2024 at 4:54 PM, Receptionist B had seen SO/AP be aggressive with Resident #1. Receptionist B observed SO/AP in the dining room grabbed his (Resident #1) jaw last month while trying to brush the resident's teeth. Receptionist B observed SO/AP grab Resident #1's arm and forced it down in a slapping motion when the resident reached out and grabbed hold of the dining room door frame. Receptionist B reported the incident to the police when they responded to the 08/03/2024 self-report and then reported it to her supervisor. Receptionist B received in-service training last month on ANE. Receptionist B had no knowledge of the resident's care plan or interventions nor if the facility had done an investigation regarding her concerns. During an interview on 08/29/2024 at 6:07 PM the ADM stated it was hard to say what the expectations were for staff not following Resident #1's care plan interventions to keep the resident safe because the facility's internal investigation revealed no abuse; the resident wanted SO/AP there and felt safe; the police had not done anything, and the Texas Health and Human Services Commission had cleared the first incident for 07/14/2024. The ADM stated that in general, when discussing other residents, the ADM's expectation was that staff follow the care plan. When surveyor asked again about expectations for Resident #1's care plan interventions and door being left open for safety and monitoring, ADM replied, that's hard to say. It is our findings that there has been no abuse. The ADM stressed there was no believe that any abuse had occurred and therefore, was not concerned about the closed door or staff not following the care plan interventions. During an interview on 08/29/2024 at 6:07 PM the DON stated it was care planned to have Resident #1's door kept open for line of sight. DON stressed that SO/AP would hurt the resident and therefore, we don't force the door if the door was closed. SO/AP was the POA and had been in a relationship with the resident for [AGE] years and the ADM and DON must respect that. The DON had known of concerns from staff that SO/AP force fed Resident #1 and that the AP/SO shakes his (Resident #1) shoulders to wake him up, but nothing the DON would consider abuse. The DON stressed that the AP/SO was intentionally trying to feed and wake Resident #1 but did not intend to cause harm. The DON stressed there was no believe that any abuse had occurred and therefore, was not concerned about the closed door or staff not following the care plan interventions. During an interview on 08/29/2024 at 7:06 PM, the DON stated SO/AP was told to leave the building and would not be allowed in the facility again if Resident #1's door did not remain completely open during visits. SO/AP was encouraged to stay in public/common areas. The DON would start in-service training with staff about the care plan interventions. During an interview on 08/29/2024 at 7:28 PM, RN B stated that on 08/03/2024, a night CNA had reported to the night nurse that Resident #1 had a black eye around 5:30 AM. RN B did an assessment and did not think it was a bruise. RN B talked to the resident alone and the resident reported that he felt safe. RN B interviewed SO/AP and SO/AP had noticed the bruise a few days ago but had not reported it to the facility staff because she thought staff already knew. Resident #1 had fragile skin and due to medications, his skin would tear. RN B stated that the facility staff present that day had separated the resident and SO/AP and had the resident moved closer to nurse's station . RN B also called the police. RN B stated that the police officer had no concerns after interviewing the SO/AP. RN B was aware of the resident's care plan interventions to keep the door open while SO/AP visits. Staff had access to this information in the care plan. During an interview on 08/29/2024 at 7:43 PM, LVN A had observed SO/AP become impatient and frustrated with Resident #1. All staff have had to intervene because of SO/AP's behaviors. When SO/AP was not there, Resident #1 was smiley and friendly with the staff. When SO/AP was at the facility, the resident was more upset and agitated. SO/AP got loud, bossy with him. LVN A found the black eye with make-up put on Resident #1's face, which was highly suspicious. LVN A had heard that an agency nurse had seen SO/AP shake the resident in the dining room. LVN A stated Resident #1 would get skin tears on left side due to always leaning on left side. LVN A received in-service training on ANE and would report any concerns to the abuse coordinator. During an interview on 08/29/2024 at 9:25 PM, the ADM had a copy of the police report and was aware of the allegations from four staff members who reported witnessing SO/AP assault Resident #1. The report revealed on 07/13/2024, staff observed SO/AP kick Resident #1 under the table in the dining room when they attempted to video record SO/AP interaction together while in the dining room. On 07/13/2024, staff observed SO/AP yell at Resident #1, grab his arms and shake him, and shove food in Resident #1's mouth, while he was lying flat on his back laying down, sleeping. Over the past month, staff had observed SO/AP punch Resident #1 in the chest with a closed fist and slap him in the face multiple times on different days. Staff had observed a burn on Resident #1's abdomen and reported they didn't know what caused the burn and that the resident would not have been able to cause it due to his mobility limitations. Staff reported that visitors had complained that they witnessed SO/AP slap Resident #1. Staff stated that they reported these allegations and concerns to their supervisor. During an observation and interview on 08/30/2024 at 8:43 AM, Resident #1 was observed sitting in a wheelchair in the dining room and SO/AP was trying to feed the resident. Resident #1 appeared asleep as he had his eyes closed. Surveyor observed SLP intervene and crouch down to talk to the resident. Surveyor overhead SLP telling SO/AP, you can't feed him now .no, he's not awake enough and walked off. SLP stated he talked to SO/AP about not feeding the resident when the resident was asleep. The resident was not alert enough to eat and SO/AP needed to be educated to stop putting food in his month when the resident was asleep, which would collect in Resident #1 mouth and cause choking. SLP stated SO/AP got overzealous about feeding the resident but did not think it would be considered abuse. During an interview on 08/30/2024 at 11:37 AM, DCS stated that on 08/03/2024, Resident #1 was found to have a bruise on his face covered up by makeup. That was a big red flag. DCS reported it immediately to the previous ADM. The ADM was aware of the previous incident with SO/AP and told the DCS to call the police. Resident #1 was moved closer to the nurse's station on 08/03/2024 and then moved to another room on 08/10/2024 to keep an eye on the resident and provide frequent monitoring. ADM told DCS to remove SO/AP from the facility due to the situation. The SO/AP was still at the facility when the police arrive around 11:00 AM. Police responded to the facility on [DATE] around 11:00 AM and interviewed SO/AP and the resident. Police stated they could not do anything because there was no admission of guilt to the injury. DSC did not suspect SO/AP of any abuse. DCS had observed Resident #1's door being open but had been told that SO/AP liked to keep the door closed. DCS was in-serviced about keeping the resident's door open, the care plan interventions, and ANE about who was the abuse coordinator and about reporting when he arrived at the facility on 08/30/2024. The DCS stated the care plan was to ensure staff was providing proper care to the resident. The DCS expectation was that nursing staff follow the care plan. DCS would immediately report any allegations of ANE from staff. During an interview on 09/01/2024 at 9:50 AM, CNA A stated Resident #1 had unexplained bruises. Resident #1 was unable to communicate. An agency nurse had seen SO/AP smacking the resident and CNA A had seen SO/AP shaking the resident to wake him up a couple of month ago. We (the CNAs) had been suspicious of SO/AP for a while and could not believe no one believed it (the abuse) did not happen. During an interview on 09/01/2024 at 10:14 AM, CNA B had previously witnessed SO/AP shake (Resident #1) by the arms going back and forth. Resident #1 was sleepy, and SO/AP tried to put food in the resident's mouth. CNA B told SO/AP on 08/31/2024 not to feed Resident #1 soup with chucks of stuck in it because that could cause choking. During an interview on 09/01/2024 at 1:30 PM, LVN A had previously observed SO/AP be bossy and pushy where we as nursing staff would tell her that he has rights and we have always intervened. When asked if Resident #1 was safe at the facility, LVN A replied, I would hate to see him go home. During an interview on 09/01/2024 at 11:19 AM, RN A stated last week RN A observed SO/AP feed Resident #1 when he was not awake. Last week RN A observed SO/AP picking up Resident #1's head and holding it back. RN A intervened and explained to SO/AP that it was not appropriate to feed Resident #1 when he was asleep. Review of the Facility's Abuse, Neglect & Exploitation Policy, dated 07/2016 last revised 10/2022, reflected the facility will take necessary measures to prevent and protect residents from abuse. This policy will apply to potential abuse and injury of unknown source. Instances or allegations of abuse, neglect, mistreatment, or exploitation should be treated seriously and reported to the Administrator or the supervisor on duty for investigation and appropriate follow up. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and physical or chemical restraint not required to treat the resident's medical symptoms. The policy includes the definition of willful, as used in abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Prevention 1. Abuse prevention efforts should include, but are not limited to, the following: a. Providing residents and family information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution. b. Providing associates information on how and to whom they may report concerns, incidents and grievances without the fear or retribution. c. Identification, correction, and intervention in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur (this should include analysis or the physical environment that might make abuse and/or, neglect more likely to occur such as secluded areas of the community, deployment of associates on each shift to meet the needs of the residents; supervision or associates to identify inappropriate behaviors; and the assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict. mistreatment or neglect). Protection 1. Protection of Resident. Upon learning of alleged abuse, neglect, mistreatment or exploitation, the Administrator or supervisor on duty should attempt to take necessary steps to verify residents are protected from subsequent episodes of abuse, neglect, mistreatment or exploitation. An attempted interview of Resident #1 on 08/30/2024, at 3:25 PM. Resident #1 was lying in bed in his room, awake and alert, and turned to look at surveyor when his name was called. The door was open, and a caregiver/sitter was sitting in a chair by the bed. SO/AP was lying in bed with the resident on the right side of the bed. Surveyor attempted to interview Resident #1, but SO/AP kept patting Resident #1's cheeks with her hands and turning the resident's face/head to the right and away from the surveyor when the surveyor tried to talk to the resident. This was determined to be an Immediate Jeopardy (IJ) on 08/30/2024 at 1:03 PM. The Administrator was notified. The Administrator was provided with the IJ template on 08/30/2024 at 1:30 PM. The following POR was accepted on 08/31/2024 at 2:23 PM and included: Immediate Jeopardy On 8/30/2024, at 1:30 PM, the facility was notified of an immediate jeopardy for F600 (Free from abuse and neglect) regarding: - The facility failed to implement interventions in Resident #1's care plan to keep Resident #1 free from abuse by his SO. F600 Abuse and Neglect 1. One resident was identified as being affected by alleged deficient practice. On 08/30/2024, the HCA and DCS reminded SO of the care plan intervention that the resident's door is to remain open during the SO's visits, except at such times staff is present providing personal care. SO was advised of risks associated with non-compliance to include limitations on or restrictions of visitation. SO verbalized her understanding and agreement. On 08/30/2024, the DCS/designee re-educated the current and on-coming staff on the following: current care plan intervention that the resident's door is to remain open during visits with SO, except at such times staff is present providing personal care; actions to take in the event the SO refuses or prevents the staff from keeping the door open or is otherwise non-compliant; and the location of care plan information to include the Kardex and care plan and how to access the same. Staff not available will be re-educated prior to the next shift by the DCS or designee. On 08/30/2024, a head-to-toe skin assessment on Resident #1 was performed by the Interim RAI Coordinator and DCS with no significant findings. On 08/3020/24, a psychosocial assessment was performed on Resident #1 by the HCA and DCS with no significant findings, and a Trauma Informed Care Screen was performed by the Interim RAI Coordinator. The resident verbalized trauma related to a diagnosis of brain cancer earlier this year but denied any recent associated emotional distress. Care plan and Kardex updated as indicated. 2. On 08/30/2024, DCS and/or designee conducted interviews with current interviewable residents regarding potential abuse and/or neglect. No additional allegations of abuse or neglect were identified. Skin assessments were conducted by DCS and/or designee on non-interviewable residents. No concerns were noted. To identify others with the potential of being affected by the alleged deficient practice, by 08/31/2024, all care plans, including tasks and interventions, were reviewed, and validated the DCS and RAI coordinator or designee for implementation. Any con [TRUNCATED]

Based on interviews, and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2(Residents #14, and # 58) of 16 residents reviewed for care plans. The facility failed to ensure Resident #14's comprehensive care plan was updated when wound care was ordered to his left knee. The facility failed to ensure Resident # 58's comprehensive care plan was updated when the external feeding was discontinued. This failure could place residents at risk of receiving inadequate or unnecessary interventions not individualized to their health care needs. The Findings included: Record review of Resident # 14's Quarterly MDS dated [DATE] revealed an [AGE] year old male admitted to the facility on [DATE] and 08/13/2020 with diagnoses that included Acquired Absence of Kidney (surgical removal of Kidney), Epilepsy ( a brain condition that causes recurring seizures due to abnormal electrical signals) Dementia ( long term brain disorder causing personality changed and impaired memory, reasoning, and social function) and a BIMS score of 15 (cognitively intact). No R wounds were coded as the wound were found after the assessment and submission date. Record review of Resident # 14's Physician's orders dated 7/10/2024 revealed an order for clean left knee wound with wound cleaner, pat dry, and cover with padded dressing on Monday, Wednesday, Friday and as needed. Record review of Resident #14's Physician progress noted dated 7/9/2024 read: small abrasion today-no sign of infection, cover with padded dressing on shower days. Record review of Resident #14's Care plan updated on 07/05/2024 revealed no indication of wound to left knee. Record review of Resident # 58 Quarterly MDS dated [DATE] section A revealed a [AGE] year-old male admitted [DATE]. Section I revealed diagnoses that include unspecified nondisplaced fracture of sixth cervical vertebra (a break in the bones of the spinal cord), Dysphagia Pharyngoesophageal phase (difficulty with the swallowing reflex and squeezing down into the throat). Section C revealed a BIMS score of 13 (Cognitively intact). Section K revealed no feeding tube present. Resident # 58's Physician's orders printed 7/31/2024 revealed Bolus feeding Peptamen 1.5-250 ml bolus x 5 per day discontinued on 5/7/2024. Regular diet started on 5/3/2024. Record review of Resident # 58's Nurse Practitioner Notes dated 7/5/2024 read, resident was tolerating regular diet. Record review Resident # 58's care plan revised on 5/18/2024 revealed focus for nutritional risk need for tube feeding. Interventions were updated with diet and dc of feedings. Interview on 07/31/24 at 09:45 AM with LVN C stated the nurses do have the ability to update care plans in the computer system but she does not do that. She stated if she had an order to remove a line/tube, she would remove it and document in the notes that she had removed it. She stated for new wounds she was responsible for the order and the wound care. She stated she would not update the care plan. She stated the MDS nurse or DON was responsible for updating care plans. 07/31/24 09:54 AM MDS Nurse, stated she was responsible for care plans, but the clinical supervisors and other nurses also help. But ultimately, she was responsible for the CPs. She stated when a line/tube is removed, the care plan should be updated at that time, or any change that requires a care plan update. She stated she tried to update CPs as soon as she was aware of a change. She stated if a there was a change in the resident condition, the CP should be updated the same day or at least the next day. She stated they have clinical team meetings weekly - the team includes DON A Clinical supervisor, and herself. Not updating the CP, resident may not get needed care. She stated the IDT -dietary, DON MDS, SS, DC planners, Act. Dir review care plans and orders. It does not meet her expectations that a PEG tube that was removed in May was still on the Care Plan on July 30th. Regarding a new wound not on the care plan, it should be reflected on the care plan. Adverse/negative outcome? - Don't get proper care. Interview on 07/31/24 at 02:22 PM with DON B said when MDS got notified of changes in the resident care the care plan it should be updated. When orders reviewed it should have come off the chart. Morning meeting, Care plans not reflecting the actual care doesn't meet expectations as they wouldn't receive the care they needed. Interview with the ADM on 07/31/24 at 03:04 PM, the ADM stated the care plans not reflecting the residents need does not meet expectation. The care plan should be updated as soon as possible but at least at the weekly clinical meeting. The MDS nurse updates and the IDT over sees the process. Residents cannot receive the care they need or deserve if the care plan was not updated. Review of the Policy Comprehensive Care Plan - SOM revised 08/2009 5. The Care Plan process assesses and is developed to meet the resident's medical, nursing, mental and psychosocial needs. 9. Care plans will be revised as information about the resident and the resident's condition changes.

Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for food storage and labeling in that: The facility failed to ensure foods were safely stored, labeled, and dated in the refrigerator. This failure could place residents at risk of foodborne illness. The findings include: Observation on 7/29/2024 at 9:13 am in the kitchen of the refrigerator revealed an unsealed Ziploc bag containing food items that resembled croutons. This item was labeled and dated but unsealed. Observation on 7/29/2024 at 9:15 am in the kitchen of the refrigerator revealed an unsealed Ziploc bag containing food items that resembled romaine lettuce. This item was labeled and dated but unsealed. Observation on 7/29/2024 at 9:16 am in the kitchen of the refrigerator revealed a large, unsealed, clear, plastic bag containing food that resembled uncooked bacon This food item was not labeled or dated. Interview on 7/31/2024 at 2:20pm with DC-F revealed they had been employed by the facility for two years. They stated every person working in the kitchen was responsible to ensure that food was stored and labeled properly. They stated they were trained by the previous Dietary Manager and had read the facility's policy for Labeling and Storage. They identified potential adverse outcomes for the residents as infection, intoxication (DC-F speaks Spanish) and illness. Interview on 7/31/2024 at 2:30pm with DC-G revealed they had been employed by the facility for two years. They stated the cook was responsible for labeling the items when they used the food. They stated they used to be a Dietary Manager on the assisted living side of the facility. They stated they had read the facility's policy for Labeling and Storage. They identified potential adverse outcomes for the residents as bacteria, diarrhea and vomiting in the elderly. Interview on 7/31/2024 at 2:10pm with the CD revealed they had been employed with the facility or two years. They stated everyone in the kitchen was responsible to ensure food was stored and labeled properly. They identified potential adverse outcomes could have been illness for the residents and spoiled food. They stated their expectation was that items should be sealed properly. Interview on 7/31/2024 at 3:00 pm with DON-B revealed the CD supervised the staff who were responsible for ensuring food was stored properly. They identified potential adverse outcomes for the residents could have been exposure to bacteria or gastrointestinal (digestion) issues. They stated their expectation was that items should be sealed properly. Interview on 7/31/2024 at 3:20 pm with the ADM revealed it was the responsibility of all kitchen staff to store items properly and the monitoring was done by dining leadership. They identified potential adverse outcomes could have been gastrointestinal (digestion) issues for the residents, food contamination, spoiled food and/or the food not tasting good. Review of the facility's policy titled Labeling - DS-04.02, effective date 2005, last revised 5/10 revealed. Category/Sub-Function: Safety and Sanitation. Policy Overview: All food items must be labeled and dated before storing.

Based on observation, interviews and record reviews, the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #56) of 5 residents reviewed for unnecessary medications. The facility failed to ensure Resident #56 had a preexisting mental illness for which an antipsychotic medication (Seroquel) would be warranted. This failure could place residents at risk for unnecessary psychotropic drug use. Findings included: Review of Resident #56's admission MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including hypertension (high blood pressure), urinary tract infection, hyperlipidemia (abnormally high level of fats in the blood), thyroid disorder, non-Alzheimer's dementia, anxiety disorder (intense and excessive worry and fear), depression, and metabolic encephalopathy (a group of conditions that cause brain dysfunction). Section C (Cognitive Patterns) reflected a BIMS score of 3 indicating severely impaired cognition. This section also reflected disorganized thinking was continuously present. Section E (Behavior) reflected no hallucinations or delusions. This section also reflected no physical, verbal, or other behavioral symptoms present and there was no rejection of care or wandering. Section N (Medications) reflected the resident was taking antipsychotic and antidepressant medications. Review of Resident #56's physician's orders reflected an order dated 07/09/24, Seroquel oral tablet 25mg give 1 tablet by mouth two times a day for behaviors. Review of Resident #56's MAR and TAR for July 2023, reflected nursing administered the Seroquel as ordered. The MAR and TAR reflected nursing monitored the resident each shift for side effects. From 07/09/24 through 07/31/24, nursing documented confusion as a side effect on three shifts. The MAR and TAR reflected nursing monitored the resident each shift for behaviors. From 07/09/24 through 07/31/24, nursing documented behaviors on two shifts. Review of Resident #56's comprehensive care plan initiated on 07/09/24, reflected in part, Focus: Resident has impaired cognitive function/dementia or impaired thought process. Goal: Resident will maintain current level of cognitive function through the review date. Interventions/Tasks: Communicate with Resident/family/caregivers regarding resident capabilities and needs. Explain care and procedures to resident prior to beginning. Focus: Resident uses psychotropic medications. Goal: Resident will be/remain free of drug related complications . Interventions/Tasks: Administer medications as ordered. Monitor/document for side effects and effectiveness. Discuss with MD, family of ongoing need for use of medication. Monitor/record/report to MD side effects and adverse reactions of psychoactive medications . On 07/27/24, a problem was initiated, Focus: Resident is/has potential to demonstrate verbally abusive behaviors r/t dementia . Goal: Resident will demonstrate effective coping skills through review date. Interventions/Tasks: Assess and anticipate needs . Assess resident's coping skills and support system. Assess resident's understanding of the situation . Review of Resident #56's nurse practitioner note dated 07/25/24, reflected in part, 3. Cognitive impairment: Patient likely has dementia - BIMS 3- severe range. Refer to behavioral services. Currently on Seroquel - easily agitated, refusing labs, refusing to wear c-collar at times per staff report. Review of the Pharmacist Consultation Report dated 07/10/24, reflected in part, Resident was recently admitted with an order for an antipsychotic medication Quetiapine 25mg po bid. Antipsychotics have a BOXED WARNING (a safety warning required by the FDA due to serious side effects) for increased risk of mortality in older adults with psychosis related to dementia. Additionally, they are associated with other potentially serious adverse effects including movement disorders, metabolic abnormalities, and orthostatic hypotension. Please provide a diagnosis for use . Rationale for recommendation: CMS requires the resident's medical record include documentation of adequate indications for medication use and the diagnosed condition for which a medication is prescribed. On the form, the doctor provided the diagnosis of acute encephalopathy. An observation and interview on 07/29/24 at 10:45 AM revealed Resident #56 sitting quietly in a wheelchair in her room. She stated she thinks she had been at the facility for about a month. She stated the staff treated her well, but she hoped to go home soon. During an interview on 07/31/24 at 2:22 PM, interim DON B stated when there was an order for a psychotropic medication, they ensured there was consent for the medication and they monitored the resident for behaviors and side effects. She stated nursing documented the behaviors and side effects on the TAR. She stated all medications needed an indication for why it was given. She stated the diagnosis of behaviors was not an appropriate diagnosis for an antipsychotic medication. She stated the pharmacy consultant monitored psychotropic medications monthly. She stated they coordinated with the nurse practitioner to determine the need for psychotropic medications. DON B stated the pharmacy recommendations were given to the providers and the clinical supervisor was responsible to monitor the process. She stated giving unnecessary antipsychotic medications could cause lethargy or movement disorders. During an interview on 07/31/24 at 3:07 PM, interim DON A stated the clinical supervisor was mostly responsible for monitoring the pharmacy recommendations. She stated neither behaviors or acute encephalopathy was a proper diagnosis for an antipsychotic medication. She stated residents were given the lowest dose necessary of psychotropic medications to reduce the risk of side effects. During an interview on 07/31/24 at 4:41 PM, the Clinical Supervisor provided documentation of Resident #56's behaviors. She stated on one occasion the resident was yelling and screaming. On another occasion the resident refused lunch and refused to wear her c-collar. She stated the nurse practitioner notes reflected a diagnosis of dementia with severe agitation. She stated the resident did not have a specific diagnosed condition for an antipsychotic medication, but the resident was admitted already on the medication. Review of the Psychotropic Drug Management Policy, revised October 2022, reflected in part, Policy Overview .To avoid the use of unnecessary drugs and their associated adverse drug effects, psychotropic medications will be used only after non-drug interventions alone have failed to manage behavioral symptoms associated with dementia and a medication is used to treat a specific condition as diagnosed and documented in the clinical record . Policy Detail . 2. The psychotropic medication order shall include the following information: a. Appropriate diagnosis for the medication. B. Manifestations of the disorder treated (e.g., auditory hallucinations, hitting others) . 3. The health care provider shall write a progress note describing the behaviors and the reason for ordering the psychotropic drug and include a risk versus benefit statement .Nursing Responsibilities . 2. The nurse shall implement non-drug interventions to help modify the resident's behavior in accordance with the care plan . Interdisciplinary Team 1. The resident's interdisciplinary care plan shall include the reason for the medication and describe the behaviors the medication was prescribed to treat . 2. The interdisciplinary team will review psychotropic medications as needed in the collaborative care meeting - appropriate diagnosis of medication - manifestations for the medication .

Based on interview and record review, the facility failed to ensure a resident who entered the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates the catheterization is necessary for 1 of 5 residents (Resident #22) reviewed for incontinent and catheter care. The facility failed to obtain physician orders for Resident #22's indwelling catheter, catheter care, and maintenance. This failure could place residents at risk of infection or accidental dislodgement. Findings included: Review of Resident #22's 5-day MDS assessment, dated 07/13/24, Section A (Identification Information) reflected an [AGE] year-old male originally admitted to the facility 04/18/24 and readmitted on [DATE]. Section I (Active Diagnoses) reflected his current diagnoses included cancer, iron deficiency anemia due to blood loss - chronic (lack of red blood cells in the blood), coronary artery disease (the blood vessels supplying blood to the heart are blocked), end stage renal disease (loss of function of the kidneys), and obstructive uropathy (urine cannot drain due to blockage). Section C (Cognitive Patterns) reflected a BIMS score of 14 indicating intact cognition. Section GG (Functional Abilities) reflected he was able to feed himself and perform his own oral hygiene but was dependent for all other ADL care. Section H (Bladder and Bowel) reflected an indwelling catheter. Review of Resident #22's comprehensive care plan revised 05/08/24, reflected in part, Focus: Resident has indwelling catheter r/t obstructive uropathy. Goal: Resident will be/remain free from catheter-related trauma through review date. Interventions/Tasks: Catheter care per policy. Change catheter as per MD orders. Check tubing for kinks. Monitor and document intake and output as ordered .Secure catheter to reduce friction. Review of Resident #22's Bladder Continence task from 07/18/24 to 07/30/24 reflected 12 entries of Continence not rated due to indwelling catheter. Review of Resident #22's clinical physicians orders printed 07/29/24 reflected no orders for an indwelling catheter and no orders for indwelling catheter care or maintenance. During an interview on 07/31/24 at 9:45 AM, LVN C stated Resident #22 had an indwelling catheter. She stated she had provided catheter care and placed the drainage bag inside a privacy bag before she sent the resident to the acute hospital on 07/30/24. She stated she expected to see physician orders for anyone with an indwelling catheter. She stated there were batch orders for catheters that included catheter care and maintenance. She stated the orders appeared on the TAR (treatment administration records) where the nurses recorded the care provided. LVN C pulled up the electronic medical record for Resident #22 but was not able to locate an order for the indwelling catheter or for the care and maintenance of the catheter. She stated, Maybe the orders fell off the record when he recently returned from the acute hospital. She stated if there was not an order for the catheter or for care of the catheter, staff may not have known he had a catheter and then not provided proper care. She stated not caring for a catheter could lead to infection. During an interview on 07/31/24 at 9:54 AM, the MDS Nurse stated, there needed to be a physician order for and indwelling catheter. She stated if there was a resident with a catheter but no order, the physician should have been contacted to clarify if the catheter should remain or removed. If the catheter remained, there should have been orders for care and maintenance. She stated the admitting nurse was responsible to clarify the order. During an interview on 07/31/24 at 10:20 AM, MA H stated she had assisted Resident #22 many times. She stated the resident had an indwelling catheter and he had recently told her the catheter was pulling a little bit. She stated she reported the pulling to the nurse. During an interview on 07/31/24 at 10:41 AM, CNA D stated Resident #22 had a catheter, and he always used the drainage bag as he did not like to use a leg beg. She stated she provided catheter care and documented it in the electronic medical record in the ADL charting. She stated the resident always used a stabilization device to keep the catheter from pulling. She stated she had to wear PPE when providing care to Resident #22 because he had a catheter. She stated not wearing PPE or not providing catheter care could lead to the spread of infection. During an interview on 07/31/24 at 2:22 PM, interim DON B stated it was her expectation that orders for catheters were in place and the care documented on the TAR. It did not meet her expectation that there was no order for Resident #22's indwelling catheter. She stated that both her and the other interim DON should have monitored for physician orders. She stated without catheter orders and proper care, residents were at risk of infection. During an interview on 07/31/24 at 3:04 PM, the ADM deferred clinical questions to interim DON A. During an interview on 07/31/24 at 3:07 PM, interim DON A stated it was her expectation that there was an order for an indwelling catheter that included the size of the catheter and the care required. She stated if there was not an order for the catheter, staff may not have known it was present and not provided the correct care. She stated if proper care were not provided, it could have led to infection. She stated all orders should have been reviewed in the supervisor huddle meetings. Review of the facility policy Procedure: Urinary Catheter Care revised August 2023, reflected in part, General Guidelines: 1. Determine if the resident is on intake or output before discarding urine. 2. Check urine for unusual appearance. Record findings. 3. Maintain a daily record of resident's daily fluid intake and output, as indicated. Preparation: 1. Verify that there is a healthcare provider's order for this procedure . Documentation: The following information should be recorded in the resident's medical record: 1. The date catheter care was given. 3. How resident tolerated the procedure .

Based on observation, interview, and record review the facility failed to ensure the nurse staffing information was posted on a daily basis and included the total number and the actual hours worked by licensed and unlicensed nursing staff for 3 of 5 days (07/26/24, 07/27/24, and 07/28/24) reviewed for nurse staffing and the facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months. 1 The facility failed to ensure the Daily Staffing log contained the total number and actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift for registered nurses, licensed practical or vocational nurses, and certified nurse aides on 07/26/24, 07/27/24, and 07/28/24. 2 The facility failed to maintain the nurse staffing data from February 2023 through July 31, 2024. These failures could place residents and visitors at risk of not knowing the current staffing and not being able to request the daily nurse staffing data record for the last 18 months. Findings included: An observation on 07/29/24 at 9:01 AM revealed the staffing information posted at the reception desk. The date on the posted information was 07/25/24. The form did not contain the number of actual hours worked by licensed and unlicensed nursing staff. During an interview on 07/31/24 at 12:30 PM, the ADM stated she had some staffing sheets for the last 18 months, but they did not have all of the forms. She stated some of the forms had been lost or maybe thrown out. She provided documents they had for the last 18 months. During an interview on 07/31/24 at 1:37 PM, the Scheduler stated she had been in her current position since late June, and she was responsible for posting the staffing information. She stated she posted the forms daily. She stated she initiated the documents in advance for the weekends and the receptionist was responsible for ensuring to display the correct form to match the date. She stated she did not know why the form for 07/25/24 was posted on 07/29/24. She stated she was responsible to update the actual hours worked on the form depending on the shift. After hours, the charge nurse was supposed to update the hours worked. She stated the director of clinical services monitored the posted staffing. She stated it the forms were not posted daily the families would not know how many staff were on hand and how their loved ones were cared for. During an interview on 07/31/24 at 2:22 PM, interim DON B stated she expected the staffing to be posted with the correct information at the start of the day. She stated the actual hours worked would have been updated each shift. She stated the scheduler was responsible to post the information. Interim DON B stated the nursing supervisor was responsible to post the information. She stated it did not meet her expectations that the posting on 07/29/24 was dated 07/25/24 and the actual hours worked were not updated. She stated it was important to post the information so visitor and family would know how many staff were working. During an interview on 07/31/24 at 2:54 PM, the Receptionist stated she was aware of the staffing numbers because they were in a frame on the reception desk. She stated the plan was to have the prepared staffing sheets in the frame then on the weekends the receptions would display the form to match the current date. The receptionist stated she worked on 07/27/24 and 07/28/24. She stated she had not changed the form over the weekend because she did not have any prepared forms available. During an interview on 07/31/24 at 03:04 PM, the ADM stated she expected the staffing was posted daily in a visible location. She expected the scheduler reviewed the forms for changes and updated as needed. She expected the forms to be retained, in one location, for at least 18 months. She stated knowledge is power and residents and visitor should have the staffing information available for understanding of staffing. Review of retained posted staffing documents for the last 18 months reflected, from 02/01/24 through 06/30/24, there were forms for only 25 days. Review of the policy titled Benefits Improvement Protection Act Daily Associate Posting, revised 02/23, reflected in part, 1. On a daily basis, a designated associate should post the community-specific number of direct caregivers scheduled for each shift in a 24-hour period by categories of nursing associates employed by the community . 5. Data from the forms must be retained for 18 months.

Based on observation, record review, and interview, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 6 residents (Resident #28) reviewed for pain management in that: Resident #28 requested pain medication from staff and had to wait 2 hours and 45 minutes for a nurse to assess her for pain and administer pain medications. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life. The findings included: Record review of Resident #28's face sheet, dated 6/7/23 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] and 6/6/23 with diagnoses that included acute and chronic respiratory failure, congestive heart failure, muscle weakness, age-related physical debility, and chronic pain syndrome. Record review of Resident #28's most recent admission MDS assessment, dated 4/27/23 revealed the resident was cognitively intact for daily decision-making skills, received pain medications as needed, and had pain frequently. Section G revealed the resident required extensive assistance with med mobilty and transfers, required two + person physical assisst, and used a wheelchair. Record review of Resident #28's comprehensive care plan, revision date 6/9/23 revealed the resident experienced pain and interventions included to administer pain medication as ordered and the resident was able to call for assistance when in pain, ask for medication, tell how much pain was experienced and what could increase or alleviate pain. Record review of Resident #28's Order Summary Report, dated 6/8/23 revealed the following: -Pain Observation and Non-Pharmacological Interventions every shift, Intervention Codes: 0=Denied pain, 1=Redirect, 2=1:1, 3=See nurses notes -Gabapentin 600 mg, 1 tablet every 6 hours as needed for nerve pain with order date 6/6/23 and no end date -Norco 5-325 mg (hydrocodone-acetaminophen), 1 tablet every 4 hours as needed for pain with order date 6/6/23 and no end date -Norco 5-325 mg (hydrocodone-acetaminophen), 2 tablets every 4 hours as needed for pain with order date 6/7/23 and no end date. Record review of Resident #28's medication administration record for 6/9/23 revealed LVN E had marked under pain observation/pain level as 0, which indicated the resident had denied pain. Further review of Resident #28's medication administration record revealed the resident had not received Gabapentin as needed since the order date, had not received Norco 5-325 mg 1 tablet every 4 hours as needed since the order date and had last received Norco 5-325 mg 2 tablets every 4 hours as needed on 6/8/23 during the morning shift. Observation and interview on 6/9/23 at 9:36 a.m., during the medication pass, LVN E revealed, Resident #28 was to receive a narcotic and 2 pills, hydrocodone, for pain. As the Surveyor stood outside of Resident #28's room with LVN E, the resident could be heard loudly saying, I'm in pain and Please give me my pain medication. Resident #28 rated her pain level at an 8 out of 10, was yelling, making crying noises without tears, and was apologizing over and over for yelling. Resident #28 stated she was in so much pain and had been asking for pain medication since that morning. During an interview on 6/9/23 at 9:36 a.m., Resident #28 revealed she had been asking for pain medication since before breakfast, but nobody ever gave her a pain medication. Resident #28 revealed she had told an aide, and another person that she was in pain and needed pain medication. Resident #28 revealed she was unable to identify who the aide or other person she talked to about wanting pain medication. During an interview on 6/9/23 at 9:41 a.m., LVN E revealed her shift started at 6:00 a.m. and made quick rounds. LVN E did not reveal if she had assessed Resident #28 for pain, only that the CNA's go into each room to obtain the vital signs and then would review them. During a follow up interview on 6/9/23 at 9:42 a.m., Resident #28 stated she had not seen LVN E at all this morning until just now (during the medication pass with the Surveyor at 9:36 a.m.) Resident #28 revealed once again, she had told an aide earlier in the morning about wanting pain medication, was not sure what time, but indicated it was before breakfast. Resident #28 described the pain as neck and shoulder pain from a previous surgery to that area. During an interview on 6/9/23 at 9:58 a.m., CNA F revealed her shift started at 6:00 a.m. and recalled Resident #28 was asking for pain medications. CNA F revealed she went into Resident #28's room and the resident told her she had been asking for pain medications. CNA F revealed she went into the resident's room at approximately 6:45 a.m. CNA F revealed she told LVN E Resident #28 was asking for pain medication and was told by LVN E she would check on the resident. During an interview on 6/9/23 at 10:14 a.m., CNA G revealed she was distributing breakfast trays at approximately 8:00 a.m. when Resident #28 activated the call light. CNA G revealed she went into Resident #28's room and the resident complained about having pain and wanting pain medication. CNA G revealed, after she de-activated the call light, she sent to LVN E to tell her Resident #28 was in pain and was requesting pain medication. CNA G revealed, LVN E said she would be in Resident #28's room soon. CNA G stated, I actually went into Resident #28's room and told her that I had notified the nurse. During an interview on 6/9/23 at 2:53 p.m., the DON revealed she had asked LVN E about Resident #28 and revealed LVN E told her an aide notified her via text at 8:44 a.m. that Resident #28 was requesting pain medication. The DON determined, when reviewing documentation in Resident #28's electronic record, LVN E documented at 9:27 a.m. the resident was given pain medication and documented at 10:11 a.m. the resident had a pain level of 0, which was after the resident received pain medication. The DON determined from the electronic record, the last time the resident was assessed for pain was on 6/9/23 at 4:24 a.m. by the night nurse. Record review of the facility's policy titled Medical Management Overview, dated 07/2015, last revised 03/2019, stated policy overview: the community will adopt pharmacy services and procedure manual for skilled nursing communities for medication and pharmacy related policies and procedures, unless otherwise indicated. Additional company policy this year may be added as needed or required for safety federal regulations. Medicine shall be administered as prescribed by the health care provider

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 3 of 6 Residents (Resident #28, Resident #142 and #146) reviewed for medication administration in that: 1. Resident #142 was observed with 4 pills in a medication cup, an open box of over-the-counter allergy pills, a container of nasal spray and an open package with a lidocaine patch at the bedside. 2. Resident #146 was observed with a prescription box of Ondansetron (prescribed to prevent nausea/vomiting) and a prescription bottle of Trazadone (prescribed for treatment of depression and used as a sedative) at the bedside. 3. Resident #28's breathing treatments were documented as administered at 9:21 a.m. The order was to administer them at 7:00 a.m. These deficient practices could affect residents who received medication and place them at risk of not receiving the appropriate amount of medication and could result in an adverse reaction or a decline in health. The findings included: 1. Record review of Resident #142's face sheet, dated 6/7/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included type 2 diabetes with foot ulcer (a chronic, long-lasting health condition that affects how your body turns food into energy), end stage renal disease (condition in which the kidneys cease functioning on a permanent basis), cirrhosis of liver (scarring of the liver caused by long-term liver damage) , dependence on renal dialysis, heart disease, hypertension (high blood pressure) and muscle weakness. Record review of Resident #142's comprehensive care plan, dated 5/21/23 revealed the resident experienced pain with interventions that included to administer pain medication as per orders. Record review of Resident #142's Order Summary Report, dated 6/8/23 revealed the following: -Lidocaine External Patch 4%, apply to area of pain topically one time a day for pain, remove after 12 hours of application, with order date 5/20/23 and no end date. -Melatonin 3 mg, give 3 tablets by mouth at bedtime for insomnia, with order date 5/20/23 and no end date. -Protonix 40 mg delayed release one time daily for GERD (gastroesophageal reflux- occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach/esophagus) with order date 5/20/23 and no end date. -Fluticasone Propionate Suspension 50 mcg, 1 spray in each nostril one time a day for allergic rhinitis, with order dated 6/6/23 and no end date. -Resident #142 did not have a physician's order for allergy pills Observation on 6/6/23 at 11:11 a.m., during initial tour, revealed Resident #142 with an open box of over-the-counter allergy pills and a container of nasal spray in a half open drawer attached to the bedside table on the right of the bed. Further observation revealed an open package with a lidocaine patch (a local anesthetic used to relieve pain) on top of the same bedside table. The lidocaine patch was marked with a black marker and, Call for help! was written on the package with a smile drawn on the package. During an interview on 6/6/23 at 11:11 a.m., Resident #142 revealed he had taken a dose of the over-the-counter allergy pills the night before and administered the nasal spray the night before last. Resident #142 revealed the lidocaine patch had been on the bedside table about a week and he was unable to put the patch on without help. Resident #142 revealed the lidocaine patch was supposed to be placed over his liver or on the back by staff. Resident #142 could not identify which staff had left the lidocaine patch at the bedside. Observation the following day on 6/7/23 at 11:10 a.m. revealed Resident #142 with a medication cup with 4 pills in it on the bedside table to the right of the resident's bed, and the same open box of over-the-counter allergy pills, the same container of nasal spray and the same open package with the lidocaine patch observed on 6/6/23. During an interview on 6/7/23 at 11:10 a.m., Resident #142 revealed the pills in the medication cup were from the other day. Resident #142 revealed he was given pills by an unidentified nursing staff and took the big pills first then fell asleep. Resident #142 revealed he still planned on taking the pills from the medication cup later. During an observation and interview on 6/7/23 at 11:18 a.m., CMA A revealed she was able to identify the pills in the medication cup as a melatonin pill and a protonix pill. CMA A could not identify 2 of the 4 pills in the medication cup. CMA A revealed, Resident #142 was not supposed to have any medications at the bedside, including the pills in the medication cup, the lidocaine patch, the box of over-the-counter allergy pills and the container of nasal spray. CMA A revealed, medications left at the bedside could result in the resident double dosing or overdosing. During an interview on 6/7/23 at 11:25 a.m., RN B revealed Resident #142 should not have had medications left at the bedside because the person dispensing the medication had to ensure the resident took the medications. RN B revealed an order had to be obtained for over-the-counter medications. RN B revealed, medications left at the bedside could results in the resident taking the medication incorrectly, possibly overdosing, could be taking more than the recommended dose, and could be contraindicated with other prescribed medications. 2. Record review of Resident #146's face sheet, dated 7/7/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included fracture of left lower leg, depression, anxiety, pain, age-related physical debility, and unsteadiness on feet. Record review of Resident #146's comprehensive care plan, revision date 6/3/23 revealed the resident experienced pain with interventions that included to administer pain medication as per orders. Record review of Resident #146's Order Summary Report, dated 6/8/23 revealed the following: -Ondansetron 4 mg, give 1 tablet every 12 hours as needed for nausea and vomiting, with order date 5/29/23 and no end date. -Trazadone 50 mg, give 1 tablet at bedtime for insomnia, monitor for agitation, lethargy, with order date 5/29/23 and no end date. During an observation and interview on 6/6/23 at 10:48 a.m. during initial tour, revealed Resident #146 with a box of Ondansetron with a pharmacy label stored in an open top drawer of the resident's nightstand on the left of the bed. Resident #146 revealed staff were aware of the box of Ondansetron. Resident #146 could not reveal when she had last taken the Ondansetron stored in the open top drawer of the resident's nightstand and had complained that she had not been receiving pain medications. During an observation and interview the following day on 6/7/23 at 9:45 a.m., Resident #146 with the same box of Ondansetron with a pharmacy label stored in an open top drawer of the resident's nightstand on the left side of the bed. Resident #146 revealed she had taken the Ondansetron several days ago and again revealed staff were aware of the box of Ondansetron. During an observation and interview on 6/7/23 at 11:42 a.m., CMA A was summoned into Resident #146's room and identified the box of Ondansetron in an open top drawer of the resident's nightstand on the left of the bed. CMA A then pulled on the same top drawer and a large prescription bottle of Trazadone was observed at the back of the drawer. CMA A revealed, Resident #146 was not supposed to have medications at the bedside because it could result in the resident double dosing or overdosing. Resident #146 stated, go ahead and take it, I haven't used the Trazadone. During an interview on 6/7/23 at 11:31 a.m., the LVN Clinical Services Manager revealed, leaving medications at a resident's bedside was unacceptable and if the resident did not take the medications as prescribed, such as blood pressure medications, it could have caused the resident's blood pressure to elevate. The LVN Clinical Service Manager stated, we are not doing our job. During an interview on 6/7/23 at 5:24 p.m., the DON revealed, medications left at the bedside was a hazard and other residents could possibly wander into the resident's room and take medications not prescribed to them. 3. Record review of Resident #28's face sheet, dated 6/7/23 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] and 6/6/23 with diagnoses that included acute and chronic respiratory failure, congestive heart failure, muscle weakness, age-related physical debility, and chronic pain syndrome. Record review of Resident #28's most recent admission MDS assessment, dated 4/27/23 revealed the resident was cognitively intact for daily decision-making skills. Record review of Resident #28's comprehensive care plan, revision date 6/9/23 revealed Resident #28 had impaired airway clearance. COPD, recent acute respiratory failure with history of chronic respiratory failure. Interventions include Nebulizer as ordered Inhalation Nebulization Ipratropium Albuterol Solution 0.5-2.5 (3) MG/3ML Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation)). Record review of Resident #28's Order Summary Report, dated 6/8/23 revealed the following: Brovana Inhalation Nebulization Solution 15 MCG/2ML (Arformoterol Tartrate) 2 ml inhale orally two times a day for SoB/Wheezing -Start Date- 06/07/2023 0700 and Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation)) 2 ml inhale orally two times a day for SoB/Wheezing -Start Date- 06/07/2023 0700. Record review of Resident #28's MAR, dated 06/09/23, revealed LVN E marked both nebulizer treatments as administered at 7 a.m. on 06/09/23. During an observation/interview at 9:10 a.m. this surveyor observed LVN E at a medication cart in a hallway. This surveyor asked LVN E if she had any medications to administer that morning. LVN E stated she was done passing medications and had no more medications to administer that morning. This surveyor asked LVN E if she had access to the eMAR to see who or if any residents had medications due that morning. LVN E stated this surveyor should ask the medication aide because she did not have access to see the eMAR. During an observation on 06/09/23 at 9:24 a.m. LVN E was observed at a nursing cart dispensing narcotics in front of Resident #28's room. This surveyor asked to observe LVN E administer the medications. LVN E stated she would like a 2nd person to witness the medication pass. Another surveyor came moments later to the area to observe the medication pass. LVN E stated she had pain medication and antianxiety medication ready to administer to Resident #28. The top of the nursing cart contained 3 plastic vials of nebulizer treatments. This surveyor requested to see the package the vials came from. LVN E declined to show this surveyor and stated she planned to administer the nebulizer breathing treatments to Resident #28 after she administered the other medications to Resident #28. LVN E then entered the room to administer the pain and antianxiety medications to Resident #28. Resident #28 expressed she had waited all morning for her medications. LVN E stated she was sorry it took her forever to bring her medications. During an interview on 06/09/23 at 9:41 a.m. Resident #28 stated she had not seen LVN E at all that morning until the medication pass observed by the surveyors. The resident stated she had asked other staff for pain medication all morning but had not seen LVN E until the medication pass at 9:36 a.m. During an interview on 06/09/23 at 2:53 p.m., the DON stated LVN E had spoken with her about the situation and stated she had woken Resident #28 up that morning to give her the breathing treatments. This surveyor informed the DON 3 vials of breathing treatments were observed on the nursing cart at 9:24 a.m. and LVN E stated she planned to administer them after administering the pain medications. The DON stated she would need to get her laptop to access the times the medications were given. At 3:24 p.m. the DON returned with her computer. The DON's computer showed LVN E documented the breathing treatments as administered at 9:21 a.m. and 9:22 a.m. The breathing treatment scheduled at 11 am was documented as administered at 10 a.m. The DON stated she guessed LVN E was just late on her documentation. The DON stated staff was expected to document at the time the medication was administered, and they were able to enter a note for late documentation. During a follow up interview on 06/09/23 at 4:20 p.m. Resident #28 stated she received her breathing treatments that morning from LVN E a short time after LVN E provided her pain medications while the surveyors were observing medication pass (After 9:36 a.m. on 06/09/23). Resident #28 revealed she usually gets two breathing treatments, the first one in the morning, and the second one is given usually after supper. Resident #28 stated the breathing treatment consisted of the nurse putting several vials, double sometimes triple, depending on the need. Record review of the facility's policy titled Medical Management Overview, dated 07/2015, last revised 03/2019, stated policy overview: the community will adopt pharmacy services and procedure manual for skilled nursing communities for medication and pharmacy related policies and procedures, unless otherwise indicated. Additional company policy this year may be added as needed or required for safety federal regulations. Medicine shall be administered as prescribed by the health care provider . Record review of the facility's admission agreement, dated 10/2020, stated I. Parties. This Admission Agreement is made this . Attachment F Medication: no medications or drugs may be brought into the provider unless the medications or drugs are labeled accordingly to the requirements of state and federal law. Packaging of medications must be compatible with the provider medication distribution system no drugs or medications may be brought into the provider unless they are delivered directly to the nurse's station. All over the counter medications including, but not limited to, the following are prohibited in the Resident's room . 45857

Based on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions for 1 of 7 residents (Resident #192) reviewed during the medication pass for medication labeling, and the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 3 of 4 medication carts (nursing cart 1, medication cart 2, and nursing cart 3) medication storage in that: 1. The pharmacy label on Resident #192's insulin pen did not match the dosage prescribed by the physician. 2. Nursing cart 1, medication cart 2, and nursing cart 3 were unlocked and unattended at various times. These failures could place residents at risk for not receiving the therapeutic effects of their medications and receiving the wrong amount of medication. The findings included: 1. Record review of Resident #192's face sheet, dated 6/7/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included cellulitis (inflammation) of left lower limb and muscle weakness. Record review of Resident #192's comprehensive care plan, initiated 6/5/23 revealed the resident had diabetes with interventions that included diabetes medication as ordered by doctor. Record review of Resident #192's Order Summary Report, dated 6/8/23 revealed the following: -Insulin Lispro 200 units/ml, inject 8 units subcutaneously with meals for diabetes care with order date 6/6/23 and no end date. Observation during the medication pass on 6/8/23 at 4:44 p.m. revealed LVN C removed Resident #192's insulin Lispro from the medication cart. Resident #192's insulin Lispro had a pharmacy label that indicated to inject 5 units with meals which did not match the physician's order to inject 8 units. The insulin Lispro had an open date of 6/4/23. During an interview on 6/8/23 at 5:13 p.m., LVN C revealed, the insulin Lispro prescribed to Resident #192 had been used since the open date indicated on the insulin pen. LVN C revealed the order did not match the label on the insulin Lispro and there should have been a label attached to indicate the order had been changed. LVN C revealed, the label to indicate there was an order change was to avoid a medication error. LVN C stated, somebody could just look at the label (on the insulin Lispro), see that it says 5 units, but the order is for 8 units. LVN C revealed, Resident #192 could be under dosed, and it could result in his sugar to continue to elevate because he did not get enough insulin and could show signs and symptoms of hypoglycemia (low blood sugar). During an interview on 6/8/23 at 5:59 p.m., the DON stated, we look at the label for the resident's name, date, name of drug and expiration date, but not the actual dosage for the insulin. We go by the order that's in the computer because insulin orders change all the time. We go by the orders in the computer. The DON further revealed, if LVN C had under dosed the resident it would have been a medication error. During an interview on 6/9/23 at 9:08 a.m., the RN Corporate Nurse revealed, Resident #192 had his insulin dosage changed and there should have been a change of order sticker on the insulin Lispro to avoid a medication error. The RN Corporate Nurse revealed, if Resident #192 was not getting enough insulin he could have become hypoglycemic. 2. During an observation on 06/07/2023 at 9:04 a.m. Medication cart 2 was observed unlocked and no staff is near the cart. During an observation on 06/07/2023 at 9:05 a.m. Nursing cart 1 was left unlocked and unattended. Staff is observed walking by the cart. During an observation and interview on 06/07/23 at 9:11 a.m. CMA A return to medication cart 2. CMA A stated she can open the drawers and the cart was unlocked. CMA A stated she was standing across the hall and was getting ready to administer medications. During an observation and interview on 06/07/23 at 9:15 a.m. RN B was informed by this surveyor nursing cart 1 in hallway 3 was left unlocked. RN B walked out from behind the nurses' station and over to the cart. RN B stated it was a cart she was used and had unlocked if for unknown staff to remove supplies. RN B stated she did not recall who she unlocked it for, but she will unlock it for the medication aides to get what they need out and they forgot to lock it. RN B stated it should stay locked so residents and anyone else can not get into the cart. During an interview on 06/07/23 at 5:26 p.m. the DON stated she did an in service on locking carts. The DON stated staff was expected to lock carts whenever they are away from the cart. The DON stated if they were standing with in arms distance it is ok to be unlocked. The DON stated the carts should be locked when they leave the carts, so residents don't grab items from it. During an observation on 06/08/23 at 8:26 a.m. a nursing cart 3 was unlocked near hallway 1. LVN E was observed exiting a resident's room and approached the cart. LVN E was asked if the cart was unlocked. LVN E pushed the lock on the cart into the locked position and stated it was half locked. LVN E confirmed the draws could still open in the half-locked position. LVN E stated she went to talk to a resident quickly so he could enjoy his breakfast. LVN E stated she called in the day before and did not receive the in-service on keeping carts locked. LVN E stated the cart should be locked to keep things secure. LVN E then walked away ending the interview. Record review of the facility policy and procedure titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, revision date 1/1/13 revealed in part, .3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . 45857

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 facility reviewed for dietary sanitation in that: The facility failed to ensure the emergency water storage was located at least 6 inches above the ground. The facility failed to ensure the emergency food storage was located at least 6 inches above the ground and 18 inches below the ceiling of the storage room. The facility failed to ensure 2 ice makers were maintained for cleanliness. The facility failed to remove expired food found within 3 of 6 unit refrigerators. The facility failed to ensure 2 of 6 unit refrigerators operated below 41 degrees Fahrenheit. The facility failed to ensure 1 of 6 unit refrigerators maintained complete temperature logs. The facility failed to ensure all food contained a label and a date for 2 of 6 unit refrigerators. These failures could place residents at risk for cross-contamination and foodborne illnesses. The findings included: Observation and interview on [DATE] at 11:09 AM of the emergency water storage revealed approximately 28 5-gallon water containers located on the floor of a shower in a vacant resident room that was utilized as a staff office. The DM stated she was aware of the water storage being in that room but was not aware it was not at least 6 inches off the ground and stated the emergency water storage was the responsibility of maintenance. Observation and interview on [DATE] at 11:14 AM of the emergency food storage revealed the location to be within an electrical support room of the nearby building adjacent to the facility with the food been stored on wire shelving racks ,d+[DATE] inches above the ground and an air duct >,d+[DATE] inches above the food storage. The DM stated the emergency food storage was moved several months ago because of flood history in the facility. The DM stated the maintenance of the room that the emergency food storage was in was the responsibility of maintenance. Observation and interview on [DATE] at 11:41 AM of the downstairs kitchen ice maker revealed a black substance buildup inside of the equipment. The Dietary Manager stated the dietary department completed a documented monthly cleaning of the ice makers in both kitchens. In addition, the maintenance department completed a monthly undocumented interior cleaning of the ice makers. The Dietary Manager stated the black substance inside the ice maker was unidentifiable but would have been cleaned during the maintenance portion of the ice maker cleaning. The Dietary Manager stated the risk associated with not maintaining the cleanliness of the ice makers would be the potential for foodborne illness and macrobacteria afflicting residents. Observation on [DATE] at 11:47 AM of the upstairs kitchen ice maker revealed a black substance buildup inside of the equipment. Observation on [DATE] at 9:14 AM of Hall ,d+[DATE] unit refrigerator revealed: one unit of fruit yogurt with a best by date of [DATE], and a pint of dairy ice cream without a listed expiration date or use by date apart from an identifiable date of [DATE]. Observation on [DATE] at 9:19 AM of Hall ,d+[DATE] unit refrigerator revealed: an internal temperature of 44 degrees Fahrenheit, an undated sandwich for room [ROOM NUMBER], and an undated and unlabeled green produce. Observation on [DATE] at 9:24 AM of Hall ,d+[DATE] unit refrigerator revealed: a container of red fruit produce with a sell by date of [DATE], 2 units of dairy milk with best by dates of [DATE], and the unit refrigerator temperature log sheet on [DATE] was not completed. Observation on [DATE] at 9:46 AM of Hall ,d+[DATE] unit refrigerator revealed: an internal temperature of 48 degrees Fahrenheit, a single unit of dairy milk with a best by date of [DATE], and single unit of dairy yogurt with a best by date of [DATE]. Interview on [DATE] at 10:47 AM, the MS stated he was responsible for repairing inoperable essential equipment at the facility. The MS stated he was not aware of the unit refrigerators operating outside of expected temperatures or the cleanliness of the kitchen ice makers. The MS stated the frequency of cleaning the ice makers was every other month and that he just cleaned the ice makers in April. The MS stated the cleaning of the ice maker is recorded digitally. Interview and observation on [DATE] at 1:54 PM, the ADON stated she was not aware of the failures observed within the unit refrigerators. The ADON stated the unit refrigerators were inspected daily by the nursing night shift and when items were in the unit refrigerators for more than 3 days, they should have been disposed of regardless of listed date. The ADON stated all items within the unit refrigerators were expected to be dated and labeled and that best by dates are treated as expiration dates. The ADON stated the risk associated with the failures identified within the unit refrigerators would be a potential for foodborne illness in residents. During the interview, the ADON observed the unit refrigerators with the surveyor and confirmed the findings. Interview on [DATE] at 5:37 PM, the ADM stated it was her expectation that food served to residents be maintained in properly operating refrigerators and outdated items be disposed of immediately. The ADM stated she was not aware of the failures identified within the unit refrigerators and expected nursing night staff to complete the temperature logs accurately and inform Maintenance immediately either in a paper work-order or notify the Maintenance Supervisor directly. The ADM stated she was aware of the emergency food and water storage but not the location of them with respect to their distance to the floor or ceiling and expected them to be stored properly. The ADM stated she was unaware of the cleanliness of the ice makers and expected them to be cleaned on their routine basis. The ADM stated the failures have a risk to residents of potentially causing foodborne illness. Record review of the Ice Machine Cleaning Log reflected the last date of cleaning date for the Downstairs ice maker to be ,d+[DATE][23]. Record review of the nutritional policy titled Storage of Non Perishable Food, dated 2005, reflected 1. All non perishable foods shall be dated upon delivery indicating (month/day/year) product was received. 2. All non perishable foods shall be stored on storeroom shelving that is no less than 6 [inches] from the floor and 18 [inches] from the ceiling or according to state regulations. All new products shall be placed behind existing stock to assure utilization of current stock first (first in/first out.) 3. The storeroom shall be maintained free from dirt, dust, insects, rodents or any potential sources of contamination. The storeroom should be maintained as close to optimal temperature (70 [degrees] Fahrenheit) as possible. The storage area should be well ventilated. 4. Dry storage must have a thermometer placed towards the rear of the storeroom. 5. Open boxes or cans shall be stored, sealed, labeled and dated. Dry goods should be stored according to dry storage guidelines. Record review of US Food Code, dated 2017, revealed (F) MEAT and POULTRY that is not a READY-TO-EAT FOOD and is in a PACKAGED form when it is offered for sale or otherwise offered for consumption, shall be labeled to include safe handling instructions as specified in LAW, including 9 CFR 317.2(l) and 9 CFR 381.125(b). Record review of US Food Code, dated 2017, revealed The shelf life of ROP foods is based on storage temperature for a certain time and other intrinsic factors of the food (pH, aw, cured with salt and nitrite, high levels of competing organisms, organic acids, natural antibiotics or bacteriocins, salt, preservatives, etc.). Each package of food in ROP must bear a use-by date. In some cases such as cook chill or sous vide processing when none of these intrinsic factors are present, a temperature lower than 3 C (38 F) must be the controlling factor for C. botulinum and L. monocytogenes growth and/or toxin formation. This use by date cannot exceed the number of days specified in one of the ROP methods in Section ,d+[DATE].12 or must be based on laboratory inoculation studies. The date assigned by a retail repacker cannot extend beyond the manufacturer's recommended expiration or pull date for the food. The use-by date must be listed on the principal display panel in bold type on a contrasting background for any product sold to consumers. Any label on packages intended for consumer sale must contain a combination of a sell-by date and use-by instructions which makes it clear that the product must be consumed within the number of days determined to be safe as specified under Section ,d+[DATE].12 of the Food Code. Foods, especially fish, that are frozen before or immediately after packaging and remain frozen until use should bear a label statement, Important, keep frozen until used, thaw under refrigeration immediately before use. Raw meat and poultry packaged using ROP methods must be labeled with safe handling instructions found in 9 CFR 317.2(l) and 9 CFR 381.125(b)

Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 2 of 15 Residents (Resident #142 and Resident #193) reviewed for accidents and hazards, in that: 1. The facility failed to prevent Resident #142 from having cigarettes and a lighter in a drawer attached to the bedside table next to the resident's bed and over the counter medications on the bedside table. 2. The facility failed to prevent Resident #193 from having a box cutter in his room. These deficient practices could place residents at risk of harm or injury and contribute to avoidable accidents. The findings included: 1. Record review of Resident #142's face sheet, dated 6/7/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included type 2 diabetes with foot ulcer (a chronic, long-lasting health condition that affects how your body turns food into energy), end stage renal disease (condition in which the kidneys cease functioning on a permanent basis), cirrhosis of liver (scarring of the liver caused by long-term liver damage) , dependence on renal dialysis, heart disease, hypertension (high blood pressure) and muscle weakness. Record review of Resident #142's comprehensive care plan, dated 5/21/23 revealed the resident was at risk for complications/injury related to smoking with interventions that included to retrieve cigarettes and lighter when resident is done smoking. Record review of Resident #142's Admission Smoking Data Collection document, dated 5/22/23 revealed the resident required direct supervision with smoking and retrieve cigarettes and lighter when resident is done smoking. Observation on 6/7/23 at 11:10 a.m. revealed Resident #142 with an open box of over-the-counter medication allergy pills and container of nasal spray in the half open drawer attached to the bedside table next to the resident's bed. Observation and interview on 6/7/23 at 11:18 a.m. revealed CMA A, when summoned to Resident #142's room, pulled the half open drawer attached to the bottom of Resident #142's bedside table and revealed, in addition to the open box of over-the-counter medication allergy pills and the container of nasal spray, a package of cigarettes and a lighter. CMA A revealed, the package of cigarettes and the lighter were not supposed to be in Resident #142's possession and those items were supposed to be locked and kept by nursing staff. CMA A revealed, cigarettes and lighters kept at the bedside was dangerous because Resident #142 could have decided to light up in the room and the lighter was a hazard because it could start a fire. The CMA A revealed medications on the bedside should not be left because he could overdose or double dose. During an interview on 6/7/23 at 11:31 a.m., the LVN Clinical Services Manager revealed, cigarettes and lighters must be locked up at the nurse's station because Resident #142 might have the temptation to smoke in his room and could start a fire or burn himself or another resident. During an interview on 6/7/23 at 5:24 p.m., the DON revealed Resident #142 was supposed to get his cigarettes and the lighter from nursing and after the smoke break the cigarettes and the lighter were locked and kept by the nurses. The DON revealed the resident was not supposed to have cigarettes and the lighter in his room due to safety concerns to others and it was a fire hazard. 2. Record review of Resident #193's face sheet, dated 6/7/23 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses that included muscle weakness, included type 2 diabetes without complications (a chronic, long-lasting health condition that affects how your body turns food into energy), anxiety disorder, other idiopathic peripheral autonomic neuropathy, hypertension (high blood pressure), and primary generalized arthritis. Record review of Resident #142's comprehensive care plan, dated 5/31/23 revealed, the resident had an ADL self-care deficit performance deficit and required a mechanical aide for transfer and other assistive devices. During an observation on 06/09/23 at 11:30 a.m. Resident #193 was sitting on his bed with an open cardboard box next to him. On the bed was a red box cutter. During an interview on 06/09/23 at 11:43 a.m., CMA H stated she saw the box cutter in the resident's room, and she thought he may have just received it in the mail. CMA H stated she would let the nurse know. LVN C stated Resident #193 did not have special permission to have a box cutter and no one was allowed to have a box cutter. Record review of the facility's admission agreement, dated 10/2020, stated I. Parties. This Admission Agreement is made this .VI .6. Smoking. Smoking is not permitted in any of the provider facilities except in the designated outdoor areas. 7. Weapons. Weapons as defined by us are not allowed in the provider or on property. Weapons include but are not limited to firearms, explosive materials, knives, chemical weapons, and collectible or antique weapons . Attachment F Medication: no medications or drugs may be brought into the provider unless the medications or drugs are labeled accordingly to the requirements of state and federal law. Packaging of medications must be compatible with the provider medication distribution system no drugs or medications may be brought into the provider unless they are delivered directly to the nurse's station. All over the counter medications including, but not limited to, the following are prohibited in the Resident's room . 45857