Every finding on record at Wisteria Place

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (LVN A and CNA B) of 4 staff reviewed for hand hygiene. The facility failed to ensure LVN A and CNA B performed hand hygiene and changed gloves at the appropriate time while providing resident care for Resident #3. These failures could affect the residents by placing them at risk for spread of infection. Findings include: Record review of Resident #3's electronic face sheet revealed [AGE] year-old female who was admitted the facility on 03.25.2026 with diagnoses that included Hypertension (high blood pressure), End stage heart failure (severe phase of heart failure), Type 2 Diabetes Mellitus (chronic medical condition where the body cannot use insulin properly). Record review of Resident #3's Significant change MDS dated 06.20.2026 revealed Section C-Cognitive Patterns-BIMS score =05 (severely impaired). Section GG-Functional Abilities Toileting hygiene 02 reflected the resident required Substantial/Maximal assistance. Section H Bowel and Bladder 3 reflected the resident was always incontinent. Record review of Resident #3's Care Plan revised 04.07.2026 revealed the resident has a history of Urinary Tract Infection. Interventions include to monitor/document/report to MD signs and symptoms of UTI: frequency, urgency, foul smelling urine, flank pain, altered mental status. Resident #3 has a urinary tract infection (07.23.2026) and interventions reflected to give antibiotic therapy as ordered, and obtain and monitor labs ordered. Record review of Resident #3's physician's orders dated 08.03.2026 revealed no current antibiotic therapy orders. During an observation on 08.03.2026 at 12:22 pm in Resident #3's room, revealed LVN A and CNA B were wearing gloves and a gown. Resident #3 was transferred via mechanical lift (battery powered device used to tranfer resident from bed to chair using a sling) from wheelchair to bed. LVN A and CNA B did not change gloves or perform hand hygiene between transferring Resident #3 to bed and providing incontinent care. LVN A opened the brief and cleaned Resident #3's peri-area with wipes. CNA B cleaned Resident #3's buttocks with wipes. LVN A and CNA B removed their gloves and put on clean gloves. LVN A and CNA B did not perform hand hygiene between glove changes. LVN A applied barrier cream to Resident #3's buttocks area and secured the clean brief. LVN A did not change gloves or perform hand hygiene after applying barrier cream and securing Residet #3's brief. During an interview on 08.03.2026 at 12:40 pm CNA B stated she did not bring in enough gloves prior to beginning the mechanical transfer and incontinent care. She stated that was why the failure occurred. CNA B stated not changing gloves properly could have caused a resident to get an infection. CNA B stated hand hygiene should have been performed between glove changes and the failure occurred due to not having any hand sanitizer in the resident's room. During an interview on 08.03.2026 at 1:00 pm LVN A stated she should have changed gloves after using the mechanical lift and before providing incontinent care for Resident #3. LVN A stated she should have changed gloves and used hand sanitizer after incontinent care and before placing sheet over Resident #3. LVN A stated she just forgot to get enough gloves prior to providing care for Resident #3. LVN A stated not using proper handwashing and not changing gloves between tasks could have resulted in a resident getting an infection. During an interview on 08.04.2026 at 2:30 pm RN C (Infection Preventionist) stated her expectations were that all staff would have used standard precautions on all residents and brought adequate supplies to the resident's room for the tasks to be performed. RN C stated gloves should have been changed between tasks and if gloves were soiled. RN C stated hand hygiene should have been performed after taking off gloves and before putting on clean gloves. RN C stated the potential harm to the residents could have been UTI or spread of an infection. RN C stated she was responsible for monitoring skills once a month. RN C stated a different skill was monitored each month with the nurses and CNAs. RN C stated she felt the failure occurred due to the staff being nervous. During an interview on 08.04.2026 at 2:42 pm the DON stated her expectation was the nurses and CNAs used gloves anytime they were providing care to a resident. The DON stated her expectations were that hand hygiene would be used before entering a resident room and after exiting a resident room. The DON stated gloves should be changed between tasks and when gloves were soiled. The DON stated hand hygiene should be performed between glove changes. The DON stated she felt like failure occurred due to the staff being nervous. The DON stated she conducted random checks two times a month with staff who were providing incontinent care. Record review of the facility's policy titled Hand Hygiene dated 4.2025 revealed: PolicyIt is the policy of this facility to provide the necessary supplies, education and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on acceptable standards. Residents, family and visitors will be encouraged to practice hands hygiene. DefinitionsHand hygiene is a general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub. Hand washing is the vigorous, brief rubbing together of all surfaces of hands with soap and water, followed by rinsing under a stream of water. Alcohol-based hand rub is a 60-95 percent ethanol or isopropyl alcohol-containing preparation base designated for application to the hands to reduce the number of viable microorganisms. Procedure Wash hands with soap and water for the following situations: When hands are visibly soiled (blood, body fluids). After caring for a resident with known or suspected Clostridioides (C.) difficile or Norovirus infection during an outbreak, or if infection rates of C. difficile infection are high. Use alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap and water for the following situations. Before and after direct contact with residents.Before performing any non-surgical invasive procedures.Before and after handling an invasive device (such as uringary catheter, IV access sites) Before donning sterile gloves. Before moving from a contaminated body site to a clean body site during resident care.After contact with a resident's intact skin. After contact with blood or bodily fluids.After contact with objects (such as medical equipment). After removing gloves. After removing and disposing of personal protective equipment.Washing hands Vigorously lather hands with soap and water and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. Hot water is unnecessarily rough on hands.Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not tough fingertips to inside of sink.Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel.Discard towels into trash.Use lotions throughout the day to protect the integrity of the skin. Using Alcohol-Based Hand Rubs Apply generous amount of product to palm of hand and rub hands together.Cover all surfaces of hands and fingers until hands are dry, about 20 seconds.Follow manufacturers' directions for volume of product to use.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 3 (Resident #5) residents observed for oxygen management. The facility failed to post an oxygen in use sign indicating Resident #5 received oxygen.This failure could place residents at risk of receiving incorrect or inadequate oxygen support; decline in health; and at risk of fire hazards.Findings Included:Record review of Resident #5's electronic face sheet dated 05/19/2026 reflected an [AGE] year-old female with an admission date of 03/17/2026 and diagnosis including COPD (chronic respiratory disease that obstructs the airways and interferes with breathing).Record review of Resident #5's admission MDS, dated [DATE] reflected a BIMS score of 15 indicating the resident was cognitively intact. Further review of the MDS reflected Resident #5 utilized oxygen therapy continuous prior to admission and while she was a resident.Record review of Resident #5's comprehensive care plan, dated 03/20/2026, reflected Resident #5 had COPD with intervention that included give oxygen therapy as ordered by the physician. Record review of Resident #5's electronic physician orders, dated 03/17/2026 reflected an order for oxygen via nasal cannula at 1-4 LPM continuously to keep saturation greater than 92%. Record review of Resident #5's medical record, accessed on 05/19/2026, reflected resident did change rooms on 05/11/2026. During an observation and interview on 05/19/2026 at 11:00 a.m., Resident #5 was sitting in a wheelchair in her room. She was wearing a nasal cannula, and an oxygen concentrator was on administering oxygen at 2LPM. Resident #5 stated she had been on oxygen since she was admitted into the facility. There was no oxygen in use sign posted outside the residents' room. During an interview on 05/19/2026 at 11:17 a.m., LVN C stated there should have been an oxygen in use sign outside of Resident #5's room. LVN C stated the resident had moved rooms recently and the sign may not have gotten moved with her. LVN C stated she was responsible for making sure the residents with oxygen use had the oxygen in use sign outside of their rooms. She stated the DON monitored that the signs were outside of residents' room also. She stated the signs were to inform visitors and residents that there was oxygen in use in the room. She stated the facility was non-smoking so no one should have been smoking near the room no matter if there was a sign or not.During an interview on 05/19/2026 at 12:10 p.m., the DON stated best practice was for residents who used oxygen to have a sign outside of their room stating oxygen in use. She stated all staff were responsible for making sure those signs were present outside of the rooms of the residents who used oxygen. She stated she monitored that those signs were present. She stated Resident #5 had moved rooms on 05/11/2026 due to construction on another hall where her room was and the sign must have not been moved with her. The DON stated whoever moved her from the previous room should have moved the sign as well. She did not feel any negative impact would occur from the sign not being present due to the facility was a non-smoking facility. She stated in an emergency situation, staff or other emergency professionals would not be looking for those signs, and Resident #5 would not be in anymore danger than residents who did not utilize oxygen. She stated she would ask corporate if the facility had a policy on oxygen administration or oxygen in use signs. During a follow-up interview on 05/19/2026 at 2:45 p.m., the DON stated the facility did not have a policy for oxygen administration or oxygen in use signs and the nurses would go off of orders for oxygen administration.During an interview on 05/20/2026 at 9:11 a.m., CNA A stated the nurses were responsible for making sure residents had an oxygen in use sign outside of their rooms when they used oxygen. She stated she did not have anything to do with those signs. She stated the signs were needed to let people know someone was wearing oxygen even though the facility was a non-smoking facility. She stated she would know to check on residents in an emergency who used oxygen to make sure the canisters were full or the concentrator was plugged into an outlet that the generator would supply electricity to if she saw an oxygen in use sign outside of their rooms.During an interview on 05/20/2026 at 10:15 a.m., the ADMN stated she expected for oxygen in use signs to be posted outside of residents rooms who used oxygen therapy. She stated the signs made sure everyone was aware of oxygen being in use inside of the room. She stated everyone who handles resident care was responsible for making sure the oxygen in use signs were posted. She stated nursing and department heads should be monitoring that those signs were posted during their weekly inspection of the resident room. She stated Resident #5 moved rooms on 05/11/2026 and she felt that the sign did not get moved with her. She stated she knew that prior to the move, Resident #5 had a sign posted outside of her room. She stated not having the sign could put residents at risk for any kind of hazard that could occur with oxygen including chemical reaction or smoking. She stated the signs were the first alert for people to be aware of the oxygen in use. At the time of exit on 05/20/2026 at 11:30 p.m., the facility did not provide a policy for oxygen administration or oxygen in use sign posting.

Based on interview and record review the facility failed to ensure medical records were maintained on each resident that were complete and accurately documented for 1 of 6 (Resident #6) residents reviewed for accurate records. The facility failed to include oxygen administration on Resident #6's MAR. The facility failed to document oxygen saturation levels in the vital signs when oxygen utilized to keep saturation levels greater than 90% for Resident #6. These failures could place residents of an accurate depiction of care in the facility.Findings included: Record review of Resident #6's electronic face sheet, dated 05/19/2026, reflected an [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Resident #6 had a diagnosis which included OSA (common sleep disorder where your airway becomes temporarily blocked during sleep, causing you to stop breathing for short periods) and pulmonary hypertension (high pressure in the arteries that carry blood from the heart to the lungs making the heart work harder and reducing oxygen flow to the body). Record review of Resident #6's quarterly MDS, dated [DATE], reflected a BIMS score of 05, which indicated severe cognitive impairment. Further review reflected Resident #6 used oxygen while a resident. Record review of Resident #6's comprehensive care plan, dated 12/03/2025, reflected Resident #6 had altered respiratory status and difficulty breathing related to OSA and pulmonary hypertension with interventions that included provide oxygen as ordered.monitor / document changes in orientation, increased restlessness, anxiety, and air hunger.monitor / document report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring. Record review of Resident #6's electronic physician order reflected an record by LVN B with start date of 01/17/2026 for O2 high flow, 6-10 LPM via nasal cannula PRN for SOB to maintain O2 saturation above 90%. Record review of Resident #6's MAR, May 2026, reflected no evidence that oxygen was being administered or oxygen saturation levels were being checked. Record review of Resident #6's progress notes for May 2026 reflected there was no oxygen saturation level recorded and the reason for administering the oxygen: 05/02/2026 at 1:47 a.m., Resident #6 remained on high flow O2 at 6 LPM via nasal cannula. 05/02/2026 at 2:56 p.m., Resident #6 was on 3 LPM on high flow via nasal cannula. 05/03/2026 at 2:22 a.m., Resident #6 remained on high flow O2 at 6 LPM via nasal cannula. 05/03/2026 at 12:51 p.m., Resident #6 was on 3 LPM on high flow via nasal cannula. 05/04/2026 at 2:16 a.m., Resident #6 remained on high flow O2 at 6 LPM via nasal cannula. 05/05/2026 at 12:11 p.m., Resident #6 was on 3 LPM on high flow via nasal cannula. 05/06/2026 at 12:12 a.m., Resident #6 was on high flow O2 at 6 LPM via nasal cannula. 05/06/2026 at 4:37 p.m., Resident #6 was on 3 LPM on high flow via nasal cannula. 05/07/2026 at 1:24 a.m., Resident #6 was on 3 LPM on high flow via nasal cannula. 05/08/2026 at 1:16 a.m., Resident #6 remained on high flow O2 at 6 LPM via nasal cannula. 05/08/2026 at 11:55 p.m., Resident #6 was on high flow O2 at 6 LPM via nasal cannula. 05/09/2026 at 4:32 p.m., Resident #6 was on O2 at 3 LPM via nasal cannula. 05/09/2026 at 11:56 p.m., Resident #6 was on high flow O2 at 6 LPM via nasal cannula. 05/10/2026 at 11:58 p.m., Resident #6 was on high flow O2 at 6 LPM via nasal cannula. 05/11/2026 at 11:00 p.m., Resident #6 remained on high flow O2 at 5 LPM via nasal cannula. 05/12/2026 at 4:58 a.m., Resident #6 remained on high flow O2 at 5 LPM via nasal cannula. 05/12/2026 at 1:25 p.m., Resident #6 was on high flow O2 at 6 LPM via nasal cannula. 05/13/2026 at 3:19 a.m., Resident #6 remained on high flow O2 at 5 LPM via nasal cannula 05/13/2026 at 11:43 p.m., Resident #6 was on high flow O2 at 6 LPM via nasal cannula. 05/14/2026 at 5:24 p.m., Resident #6 was on O2 at 3 LPM via nasal cannula. 05/14/2026 at 11:52 p.m., Resident #6 was on high flow O2 at 6 LPM via nasal cannula. 05/15/2026 at 1:40 p.m., Resident #6 was on high flow O2 at 6 LPM via nasal cannula. 05/16/2026 at 3:03 a.m., Resident #6 was on high flow O2 at 6 LPM via nasal cannula. 05/16/2026 at 1:33 p.m., Resident #6 was on high flow O2 at 6 LPM via nasal cannula. 05/17/2026 at 2:18 a.m., Resident #6 was on high flow O2 at 6 LPM via nasal cannula. 05/17/2026 at 11:46 a.m., Resident #6 was on high flow O2 at 6 LPM via nasal cannula. 05/18/2026 at 2:25 p.m., Resident #6 was on O2 at 3 LPM via nasal cannula. 05/18/2026 at 11:39 p.m., Resident #6 was on high flow O2 at 6 LPM via nasal cannula. 05/19/2026 at 2:29 p.m., Resident #6 was on O2 at 3 LPM via nasal cannula. Record review of Resident #6's vital signs records in May 1st - May 19th 2026 reflected oxygen saturation level was recorded only on the following dates: 05/02/2026 at 2:05 p.m. 98% with oxygen being administered. 05/07/2026 at 10:21 a.m. 95% with oxygen being administered. 05/09/2026 at 10:26 a.m. 97% on room air. 05/10/2026 at 9:32 a.m. 96% on room air. 05/14/2026 at 9:49 a.m. 96% on room air. 05/16/2026 at 9:02 a.m. 95% with oxygen being administered. 05/18/2026 at 9:01 a.m. 92% on room air. 05/19/2026 at 9:09 a.m. 97% on room air. During an interview on 05/20/2026 at 8:55 a.m., LVN B stated she checked on Resident #6 every two hours and took her oxygen saturation level during those checks. LVN B stated she documented saturation level in the MAR when she obtained the oxygen saturation levels. She stated she obtained Resident # 6's oxygen saturation this morning before breakfast and showed where she wrote it down on a paper document. She had Resident #6's oxygen saturation was 97% on 3 LPM canister. She stated when Resident #6 used the canister she got 3 LPM and when she used the concentrator, she got 6 LPM. She stated she had not documented the oxygen saturation in the system yet. She did not know why there were days without any readings being documented for Resident #6. She stated she was unsure if she was supposed to do something in the physician orders when she obtained them to populate the saturation and or reason the resident was put on PRN oxygen. She stated PRN meant that Resident #6 did not need oxygen all the time. She stated she had gotten the order from the hospice provider and had put it into the electronic medical record as it was given to her. She did not know if anyone monitored the oxygen saturation levels or reason why oxygen was administered. She stated she would have to ask the DON who was responsible for putting something in the order to make it show on the MAR. She verified that Resident #6's MAR did not have a space for oxygen saturation or oxygen orders.During an interview on 05/20/2026 at 9:16 a.m., the DON stated she expected for all residents to have their vital signs checked once a day on the day shift. She stated that if a resident was on PRN oxygen, she expected for the MAR to have a place for the oxygen saturation level or SOB symptoms to be documented. She stated she reviewed the new orders by running a report and then made sure the orders were transferred onto the MAR as needed. She stated she had missed that Resident #6's orders for PRN oxygen did not have a spot on the MAR for oxygen saturations or SOB symptoms to be documented. She stated if the nurses did not document symptoms or oxygen saturation levels on the MAR, she expected for them to document in the progress notes. She stated she did not have a time frame for when the nurse should document the symptoms and oxygen saturation levels but that they should document be the end of the nurses shift. She stated she did not monitor the documentation in the computer system but she did ask the nurses during morning verbal rounds about resident vital signs. She stated she had not noticed that there were days when the documentation did not occur for Resident #6. She stated she could not verify that the vital signs were taken on those days but she stated they should have been documented in the vital sign section of the medical record if they were taken. She stated giving a resident oxygen when they did not need it per physician orders could cause CO2 retention that could lead to the resident not wanting to breath. During an interview on 05/20/2026 at 10:15 a.m., the ADMN stated her expectation would be for the nurses to document whatever they did in the medical record. She stated if the symptoms or oxygen saturation was not documented, then there was no way to prove it was don. She stated she would defer to the DON for specific order questions and in-service questions on oxygen administration.Review of facility policy, titled Licensed Nurse Procedures: Clinical Documentation, no date, reflected Services provided to the resident's changes in their residence condition shall be documented in the residence medical record. Procedure: 1. Medications administered should be documented in the resident's clinical records. 2. Incidents, accidents, or changes in the residents' condition should be documented. 3. Documentation of treatments shall be documented in the clinical record.

Based on interview, observation and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for accuracy and completeness. The facility failed to completely and accurately document Hydrocodone was being given to Resident #1 from 2/21/26 to 2/27/26. This deficient practice could put residents at risk of not receiving needed services.Findings include: Record review of Resident #1's detailed summary report/face sheet, dated 2/27/26, reflected a [AGE] year-old female who was admitted to facility on 2/18/26. Resident #1 had diagnoses which included Unilateral primary osteoarthritis-left knee (is the most common degenerative joint disease, caused by the gradual breakdown of protective cartilage that cushions joints, leading to pain, swelling, and reduced mobility), aftercare following joint replacement surgery-left knee, and anxiety disorder (a group of common, treatable mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry that impairs daily functioning). Record review of Resident #1's Quarterly MDS, dated [DATE], reflected the BIMS score of 9, which indicated the resident was moderately cognitively impaired. Record review of Physician orders, dated 2/27/26, reflected Resident #1's HYDROcodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen), Give 1 tablet by mouth every 4 hours as needed for Moderate to Severe Pain (4-10). Record review of Resident #1's MAR, dated 2/27/26, reflected missing sign out dates for the hydrocodone medication from 2/21/26 through 2/27/26. Record review of Narcotics Sign out sheet, dated for the month of February 2026, indicated sign out dates with signatures and hydrocodone pill counts for the dates of 2/21/26 through 2/27/26. During an interview on 2/27/26 at 12:55 PM, Resident #1 stated she had not missed any of her hydrocodone medication. She stated the nurses made sure to got it to her anytime she needed it. She stated the pain was still high considering she just had knee replacement, but the facility did a good job of getting her pain medication. During an interview on 2/27/26 at 1:15 PM, the DON stated she had no idea why the MAR for Resident #1 was blank. She stated there must be an issue with the electronic tracking system. She stated because if the boxes were blank that indicated either the medication was not given or staff were not clicking out of the system. During an interview on 2/27/26 at 2:15 PM, RN A stated she had been working with Resident #1 on her pain everyday she worked because Resident #1 was on her hall. She stated every morning she would go down and ask Resident #1 her pain level and give Resident #1 her hydrocodone anytime she needed it following the physician order. She stated Resident #1 never refused her pain medications. She stated once Resident #1 indicated she needed her pain medication; she would go to the electronic system and pull the medication for Resident #1. She stated she would sign out the medication out of the narcotics sign out log for Resident #1. During an observation on 2/27/26 at 3:05 PM revealed RN A administer the medication of hydrocodone to Resident #1. RN A went to Resident #1 asked Resident #1's pain level. Resident #1 indicated a level 6. RN A went to the medication cart to pull hydrocodone for Resident #1. No infection control issues noted, medication was pulled, correct dosage was verified, and medication was given to Resident #1. RN A then signed out medication from Narcotics document. During interview on 2/27/26 at 3:30 PM, the DON stated based on the previous MAR was blank and now the new stamp at 3:05 pm by RN A meant her nurses were not clicking the medication out of the electronic system. She stated this would be fixed. She stated this was important because this was the facility's way of tracking Resident #1 was receiving her pain medication. She stated without documentation being completed properly, Resident #1 could get to much or too little of her medications and possibly cause harm. Record review of new MAR dated 2.27.26 indicated that hydrocodone was administered to Resident #1 at 1504 by RN A. Record review of the facility's, undated, Policy titled: Controlled Medications-Storage and Reconciliation reflected:6. When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: Date and time of administration. Amount administered. Signature of the nurse administering the dose, completed after the medication is actually administered.

Based on interview and record review, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical status for 1 of 4 resident (Resident #1) reviewed for resident rights. The facility failed to notify the physician on [DATE] of a resident's change in condition of Resident #1's passing large amounts of watery fluids through his ileostomy and the resident expired on [DATE]. Resident #1's death certificate listed cause of death as Coronary Artery Thrombosis (blood clot). An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place the residents at risk of a delay in medical intervention, decline in health, serious injury, harm, impairment, or death. Findings include:Review of a Comprehensive assessment dated [DATE], revealed Resident #1 was an [AGE] year-old male, admitted to the facility on [DATE]. He had a primary diagnosis of [NAME] Syndrome (paralysis of colon - colon acts like it is blocked but nothing is blocking it). Additional diagnoses of ileostomy status (stoma of the small intestine), hypokalemia (low potassium in blood serum), atherosclerotic heart disease of native coronary artery without angina pectoris (the arteries supplying blood to the heart become narrowed due to the accumulation of plaque), congestive heart failure (the heart's ability to pump blood well). The resident had a BIMS score of 03 (severe cognitive impairment). A record review of Resident #1's Medication Administration Record revealed the resident received losartan potassium 25 mg for hypertension on [DATE] at 7:00 am. The physician order indicated to hold medication if systolic blood pressure was less than 120 and diastolic blood pressure was less than 70. Resident's #1 recorded blood pressure at the time of medication administration was 110/76 with a pulse of 100. The medication was given outside of the parameters. A record review of Resident #1's blood pressure revealed on [DATE] at 10:19 pm, Resident #1's blood pressure was 95/62 with a pulse of 100. Further review revealed there was no other documentation in the electronic record until 4:05 am. A record review of a progress note by LVN C dated [DATE] at 4:05 am, documented Resident #1 was found on the floor unresponsive and CPR initiated. EMS arrived at 4:20 pm and continued CPR. The resident was pronounced dead at 4:50 am. In an interview on [DATE] at 11:40 am, Resident #1's Family Member D said she visited Resident #1 every day. Family Member D said on [DATE] at 4:00 pm she visited Resident #1 and noticed he was breathing differently, looked pale and was weaker. She went and got Nurse A and expressed her concerns. At that time, Nurse A said Resident #1 had been having lots of fluids today in his ileostomy bag and it had to be changed several times already today. Resident #1 Family Member D requested Resident #1's vitals be taken. Nurse A took Resident #1's vitals which revealed a blood pressure of 98/50 with a pulse of 100. Nurse A said his blood pressure was low but not critical and he would be alright. Resident #1's Family Member D said she expressed concerns to Nurse A about the resident having the same symptoms in the hospital and he was dehydrated, and his potassium was low. Nurse A said she would get labs in the morning. Resident #1's Family Member D went and got the resident some Gatorade and then went home. She received a call on [DATE] at 5:00 am saying he had passed. In an interview on [DATE] at 11:55 am, Nurse A said Resident #1's Family Member D came and got her stating Resident #1's breathing was different, and he did not look good. Nurse A stated she told Resident #1's Family Member D that Resident #1 had lots of fluids that day (passing watery stools) and had to change his ostomy bag several times. She said she took his vital signs but could not remember them exactly, but his vitals were low but not extremely low. Nurse A said she did not see that his breathing was different, it was not labored, and he was talking to me and did not express any complaints. She said the resident passing lots of fluids was a new symptom for Resident #1 that had started on that day, [DATE] and had not had that symptom in the past. Resident #1's Family Member D asked about getting labs. Nurse A stated I told her I would get them in the morning. Nurse A was asked if she notified the doctor of the resident passing large amounts of fluids which was a different symptom for him, she said she could not recall if she did notify the doctor but did not see any documentation in the resident's chart when she looked in Resident #1's electronic record. When asked about the medication error, she said Resident #1 should not have received the Losartan due to his blood pressure outside of the parameters. When asked why the resident was given the medication, she said I don't know. In an interview on [DATE] at 12:25 pm, Physician B said the facility did not contact her concerning Resident #1 on [DATE]. She said she should have been contacted due to the resident's change in condition of having large watery stools, which he did not have before, and for his low blood pressure. She would have ordered labs stat and would have sent the resident to the ER. She said she also was not notified of the medication error but did not think the medication error contributed to his death but could have been the reason his blood pressure was low on [DATE] when the nurse took it at 4:00 pm. She said it was her expectation for the facility to contact her for a resident's change in condition. In an interview on [DATE] at 1:00 pm, the DIT said she had not received any notification of Resident #1's medication error. She said Resident #1 normally had green loose stools. She said if Resident #1 had a large amount of watery stools that was different from his baseline, Nurse A should have contacted the physician about the resident's change in condition. In an interview on [DATE] at 1:10 pm, Resident #1's Family Member E said Nurse A should have taken action for the resident's change in condition. Family Member E said Family Member D texted on [DATE] around 4:00 pm and said that Resident #1 was breathing differently, he was not his normal self. Family Member E told Family Member D to go and get the nurse, and she did. She said she told the nurse that Resident #1 was breathing differently and was not himself, but Nurse A did not think so. Nurse A told Family Member D that Resident #1 had been gushing fluids in his ostomy bag today which was different for him. Resident #1's Family Member E told her to have the nurse take his blood pressure and it was 98/50 with a pulse 100. I texted her back and said it sounds like the same symptoms when he was in the hospital which was dehydration and low potassium. Resident #1's Family Member D told Nurse A that and said she would get labs in the morning. That was all that was done. Resident #1's Family Member E requested a copy of Resident #1's records from the facility and there was nothing reflecting in his notes that addressed his change in condition or that he was gushing fluids or that the doctor was notified of the medication error. The facility did not even give Resident #1 a fighting chance and send him to the ER. His change in condition was not addressed. In an interview on [DATE] at 3:34 pm, LVN C said she cared for Resident #1 on the evening of [DATE] and on the morning of [DATE] and initiated CPR when she found Resident #1 unresponsive. She said on that evening, [DATE], Resident #1 was at his baseline but was acting more tired than normal, and his ostomy bag had to be changed because it busted. She could not remember the reason the bag was busted but said he had trouble with the seal. She could not remember if Resident #1 was having watery stools in his ileostomy bag. She said she did not contact anyone about Resident #1 that evening prior to finding him on the floor. Record review of the facility policy Significant Change of Condition, Response, dated as revised 12/2023 revealed the following [in part]:Policy: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care.Procedure: 1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. 2. The nurse will perform and document an assessment of the resident and identify any additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider to obtain new orders or interventions. Record review of the facility policy Pharmacy Services: Medication Errors and Adverse Reactions, dated as revised 12/2019, revealed the following [in part]: Policy: It is the policy of the facility that medication errors and adverse drug reactions must be reported to the resident's attending physician.Procedures:1. Adverse drug reactions and medication errors with adverse clinical consequences must be reported to the resident's attending physician immediately. 5. The medical director, director of nursing services, and consultant pharmacist must be informed of all medication errors and adverse reactions.This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator was notified and the IJ template was provided to the facility on [DATE] at 3:40 p.m. and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on [DATE] at 2:12 pm and included the following:PLAN OF REMOVAL, F580, [DATE]Underlying cause deficiency: The facility failed to notify MD and Resident #1's caregivers about change of condition whose records were reviewed for Resident's Rights. This deficient practice has the potential to affect all residents of the facility.1. Address how staff will accomplish corrective action for those residents found to have been affected by the deficiency1a. Review of all residents for any identified change of conditions by DON, Director of Nurses in Training (DIT), and ADON for change of condition completed [DATE]-and identified change of condition were documented with appropriate interventions* DON and Director of Nurses in Training (DIT) performed grand rounds of all residents going room to room with licensed nurses initiated on [DATE] and completed on [DATE]. Additionally, DON and DIT reviewed progress notes and change of condition documentation* No other residents were found to be affected after review on [DATE]. Address how staff will identify other residents who have the potential to be affected by the same deficiency 2a. Review of all residents for any identified change of conditions by DON, Director of Nurses in Training (DIT), and ADON for change of condition completed [DATE]-and identified change of condition were documented with appropriate interventions* DON and Director of Nurses in Training (DIT) performed grand rounds of all residents going room to room with licensed nurses initiated on [DATE] and completed on [DATE]. Additionally, DON and DIT reviewed progress notes and change of condition documentation* No other residents were found to be affected after review on [DATE]b. DON, DIT, or designee will review change of condition, hot rack charting, 24-hour summary report that includes progress notes, and all orders in the order listing report to ensure that residents aren't affected by this deficiency* This practice was initiated on [DATE] and will be monitored ongoing by DON or designee* Results will be reported in QAPI 3. Address the measures that will be put in place or the systemic changes that will be made to ensure that the deficiency will not recur 3a. Education initiated with all nursing staff on:* Change of condition and reporting & monitoring* Initiated today, [DATE] in person or via phone and was completed [DATE] at 10:00am* This was initiated by the DON and Director of Nursing in Training (DIT) and will be ongoing for new hires.3b. All licensed nursing staff will complete competency on change of condition* Initiated today and will be completed by [DATE] for all scheduled staff * DON and DIT will ensure competency is completed prior to shift and ongoing for new hires.3c. Staff will not be allowed to work unless they have completed the education and competency checks. This education will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and competency check. For those that do not pass the competency check, they will not be permitted to work until they are re-educated and pass the competency check. The DON and Operations Manager will verify that the competency and education have been completed by all new staff and current staff. 4. Indicate how the provider plans to monitor staff to ensure that solutions are sustained 4a. DON/ADON will ensure licensed nurses identify, and document all change of condition on the change of condition log and will not be removed until change of condition is resolved. This practice was initiated on [DATE] and will be ongoing. * DON and/or designee will be part of shift-to-shift report to help identify residents with change of condition, notification, and documentation 5. The actions the facility will take to ensure the violation will not reoccur5a. Nurse A received written counseling on [DATE] and Nurse A was educated on [DATE] on the following:* Change of condition* Resident rights* The rights of medication administration following orders for blood pressure parameters5b. Education initiated with all nursing staff on change of condition, identification, reporting, and documentation* Done [DATE] in person or via phone* This process was initiated [DATE] by DON, DIT, or designee and completed on [DATE].5c. All staff will complete competency on change of condition* Done [DATE] in person or via phone and or prior to shift.* This process was initiated and monitored by DON, DIT, or designee.6. Indicate when corrective action will be: initiated on [DATE] and will be ongoing6a. Interdisciplinary team (DON, Operations Manager, or Designee) are tracking notification of changes in condition, treatment, room assignment, or rights to ensure compliance with F5806b. Review tracking of change of condition as an interdisciplinary team (DON, Operations Manager, MDS, or designee) daily during clinical meeting6c. Interdisciplinary team (DON, ADON, MDS, Operations Manager, or designee) will review change of condition in standard of care (SOC) meeting weekly and report in QAPI monthly6d. Ad Hoc QAPI was completed [DATE] regarding IJ template with all interdisciplinary team members and medical director signatures.On [DATE] review of the Plan of Removal was initiated to confirm Immediate Jeopardy (IJ) could sufficiently be removed by:Verification of #1In an interview on [DATE] at 3:28 pm, the DON and DIT stated all residents had been reviewed. No other concerns identified. A record review on [DATE] at 4:06 pm revealed all residents were evaluated. Verification #22a: In an interview on [DATE] at 3:20 pm, the DON and DIT said all residents have been reviewed for change in condition including conducting ground rounds of all residents by going room and were completed on [DATE]. No other residents were found to be affective after review. 2b: In an interview on [DATE] at 3:30 pm, the DON and DIT said the process was initiated on [DATE] that includes daily reviewing change of condition documentation, charting in the electronic record, 24-hour summary report and physician orders. This process is being conducted by DON, DIT or designee. Results will be reported in QAPI meetings. A record review on [DATE] at 4:12 pm, revealed documentation completed for Order Listing Report and 24-hour summary communications, dated [DATE] and [DATE]. Verification #33a. In an interview on [DATE] at 3:32 pm, the DON and DIT said all nursing staff have completed in-services on change in condition and reporting and monitoring. In addition, all nurses have completed in-services on blood pressures and Resident Rights. In-services were initiated on [DATE] and were completed on [DATE]. In a record review on [DATE] at 4:15 pm documentation of in-services revealed, including staff sign-in sheets for F580 Change in Condition and Resident rights for all staff including Nurses, CNAs and Physical Therapy. Nurses completed in-services on Administration Medications - being aware of blood pressure parameters and reporting errors. Nurses and CMAs. All staff have completed. 3b. In an interview on [DATE] at 3:33 pm, DON and DIT said all nursing staff have completed and passed the change in condition competency evaluations, except for a few PRN staff. Those staff will not be able to work until they have completed the evaluation. In a record review on [DATE] at 4:15 pm, the Change in Condition Competency Evaluations were reviewed. All PRN staff were identified. 3c. Interviews on [DATE] with the following nursing staff stated they had received training on Change in Condition, Resident Rights, Medication Administration/Errors and blood pressure parameters. All said they have completed a competency evaluation. 1. [DATE] at 2:20 pm, LVN F 2. [DATE] at 2:25 pm, LVN G 3. [DATE] at 2:30 pm, LVN H 4. [DATE] at 2:35 pm. ADON5. [DATE] at 2:45 pm, LVN I 6. [DATE] at 3:00 pm, LVN J 7. [DATE] at 3:30 pm, RN K8. [DATE] at 5:45 pm, LVN L9. [DATE] at 6:00 pm, RN M10. [DATE] at 6:15 pm, CMA NVerification of #4In an interview on [DATE] at 3:35 pm, the DON and DIT said how the facility plans to monitor staff to ensure that solutions are sustained is a condition report that is to be reviewed at every shift change and documentation logged. In a record review on [DATE] at 4:28 pm, the documentation Change in Condition report documentation was called Order [NAME] Report. Logged completed for [DATE] and [DATE]. Verification #55a: In an interview on [DATE] at 3:36 pm, the DON and DIT said Nurse A received education and counseling on change in condition, resident rights, and the rights of medication administration following orders for blood pressure parameters. In an record review on [DATE] at 4:29 pm, revealed documentation of Counseling/Disciplinary Notice for Nurse A. Completed and signed on [DATE]. 5b: In an interview on [DATE] at 3:37 pm, the DON and DIT said all staff have completed training on change in condition and resident rights except for a few PRN staff on [DATE]. Those staff will not be allowed to work until they have completed training. A record review on [DATE] at 4:15 pm, revealed documentation of in-service and signs in sheets for Change in Condition and Resident Rights were completed by all staff except for the identified PRN staff. 5c: Interview with staff on [DATE] verifying they had completed training on change in condition and resident rights.11. [DATE] at 2:22 pm, CNA O12. [DATE] 2:27 pm, CNA P13. [DATE] at 2:32 pm, CNA Q14. [DATE] at 2:37 pm, Housekeeping Supervisor. She also said all 5 of her staff have completed training. 15. [DATE] at 2:42 pm, Dietary Manager. She also said all of her kitchen staff have completed training. 16. [DATE] at 3:05 pm, Maintenance Manager.17. [DATE] at 3:10 pm, Director of Rehabilitation. She also said all of her staff have completed training. 18. [DATE] at 3:13 pm, Receptionist R19. [DATE] at 3:15 pm, CNA S20. [DATE] at 3:17 pm, Physical Therapist T21. [DATE] at 3:20 pm, Rehabilitation Student U22. [DATE] at 3:22 pm, Speech Therapist V23. [DATE] at 3:25 pm, Community Resident Liaison24. [DATE] at 3:30 pm, CNA W25. [DATE] at 5:47 pm, CNA X26. [DATE] at 5:50 pm, CNA Y27. [DATE] at 5:53 pm, CNA Z28. [DATE] at 5:56 pm, CNA AA29. [DATE] at 5:59 pm, CNA BB30. [DATE] at 6:03 pm, CNA CC31. [DATE] at 6:10 pm, CNA DDVerification #6In an interview on [DATE] at 3:39 pm, the DON and DIT said a change in condition log was implemented on [DATE] and is reviewed daily by the Interdisciplinary Team in the morning meeting and reviewed weekly in QAPI. In a record review on [DATE] at 4:34 pm, an ad hoc QAPI meeting was held on [DATE]. Sign in sheet revealed all required members attended. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 5 residents (Resident #1) reviewed for medication errors in that: RN A gave Resident #1's blood pressure medication Losartan Potassium 25 mg needed for hypertension, outside of the ordered parameters. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medication by receiving too much or not enough. Findings Included: Record review of a Comprehensive assessment dated [DATE] revealed Resident #1 was an [AGE] year-old male, admitted to the facility on [DATE] and expired on [DATE]. He had a primary diagnosis of [NAME] Syndrome (paralysis of colon - colon acts like it is blocked but nothing is blocking it). Additional diagnoses included ileostomy status (stoma of the small intestine), hypokalemia (low potassium in blood serum), atherosclerotic heart disease of native coronary artery without angina pectoris (the arteries supplying blood to the heart become narrowed due to the accumulation of plaque), congestive heart failure (the heart's ability to pump blood well). The resident had a BIMS score of 03 (severe cognitive impairment). Record review on [DATE] of Resident #1's Physician's Order Summary Report, dated for active orders as of [DATE], revealed an order for Losartan Potassium 25 MG Tablet, Give 1 tablet by mouth one time a day for Hypertension, HOLD IF SBP IS LESS THAN 120 OR DBP LESS THAN 70. Start date of [DATE]. A record review on [DATE] of Resident #1 Medication Administration Record revealed the resident received losartan potassium 25 mg for hypertension on [DATE] at 7:00 am. The physician order instructed to hold medication if systolic blood pressure is less than 120 and diastolic blood pressure is less than 70. Resident's #1 recorded blood pressure at the time of medication administration was 110/76 with a pulse of 100. The medication was given outside of the parameters. Nurse A failed to notify the DON and Physician of a medication error. In an interview with Resident #1's Family Member D on [DATE] at 11:40 am, said they visited Resident #1 every day. On [DATE] at 4:00 pm Family Member D visited Resident #1 and noticed he was breathing differently, looked pale and was weaker. Family Member D went and got Nurse A and expressed their concerns. Family Member D requested Resident #1's vitals be taken. Nurse A took Resident #1's vitals which revealed a blood pressure of 98/50 with a pulse of 100. Nurse A said his blood pressure was low but not critical. A record review of Resident #1's blood pressures revealed on [DATE] at 10:19 pm, Resident #1's blood pressure was 95/62 with a pulse of 100. In an interview with Nurse A on [DATE] at 11:55 am, she said Resident #1's Family Member D came and got her stating Resident #1's breathing was different, and he didn't look good and requested his vitals be taken. She said she took his vital signs but could not remember them exactly, but his vitals were low but not extremely low. Nurse A said did not see that his breathing was different, it was not labored, and he was talking to me and did not express any complaints. When asked about the medication error, she said Resident #1 should not have received the Losartan due to his blood pressure outside of the parameters. When asked why the resident was given the medication, she said I don't know. In an interview with Physician B on [DATE] at 12:25 pm, she said the facility did not contact her concerning Resident #1 on [DATE]. She said she should have been contacted due to the resident's low blood pressure. She also said she was not notified of the medication error but did not think the medication error contributed to his death but could have been the reason his blood pressure was low on [DATE] when the nurse took it at 4:00 pm. In an interview with the DIT on [DATE] at 1:00 pm, she said she had not received any notification of Resident #1's medication error. She said a potential negative outcome of receiving blood pressure medications outside of the parameters would be the resident's blood pressure could bottom out. Record review of the facility policy Pharmacy Services: Medication Errors and Adverse Reactions, dated as revised 12/2019, revealed the following [in part]: Policy: It is the policy of the facility that medication errors and adverse drug reactions must be reported to the resident's attending physician.Procedures:1. Adverse drug reactions and medication errors with adverse clinical consequences must be reported to the resident's attending physician immediately. 5. The medical director, director of nursing services, and consultant pharmacist must be informed of all medication errors and adverse reactions.

Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 3 (Resident #7, Resident #8, and Resident #77) of 18 residents reviewed for unnecessary medications. The facility failed to ensure Resident #7's PRN Alprazolam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. The facility failed to ensure Resident #8's PRN Xanax (Alprazolam) (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. The facility failed to ensure Resident #77's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications.Findings included: Resident #7 Review of Resident #7's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, delusional disorders, and psychosis. Review of Resident #7's quarterly MDS assessment dated [DATE], revealed a BIMS score was not completed. Review of Section N: Medications revealed Resident #7 was receiving anti-anxiety medications. Review of Resident #7's Comprehensive Care Plan revised on 06/25/2025, revealed: Focus: Resident has anti-anxiety medication use r/t anxiety, agitation, and restlessness .Interventions: Give anti-anxiety medication ordered by physician, monitor/document side effects and effectiveness. Review of Resident #7's electronic Physicians Orders revealed: Alprazolam Oral Tablet 0.5 mg Give 1 tablet by mouth every 6 hours as needed for Anxiety, start date 03/06/2025 with no stop date. Review of Resident #7's July 2025 MAR revealed a dose of Alprazolam was administered on 07/10/2025 at 3:31 pm. Review of Resident #7's June 2025 MAR revealed no doses of Alprazolam were administered. Review of Resident #7s physician progress notes revealed no evidence of documented rationale to order PRN Alprazolam for more than 14 days. Review of Drugs.com for Xanax/ Alprazolam accessed on 07/30/2025 at https://www.drugs.com/xanax.html revealed: Xanax is used to treat anxiety disorders and anxiety caused by depression. Xanax can slow or stop your breathing, especially if you have recently used an opioid medication or alcohol. Resident #8 Review of Resident #8's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: fractured leg, liver disease, and heart failure. Review of Resident #8's significant change MDS assessment dated [DATE], revealed a BIMS score of 00 which indicated severe cognitive impairment. Review of Section N: Medications revealed Resident #8 was not receiving anti-anxiety medications. Review of Resident #8's Comprehensive Care Plan revised on 06/21/2025, revealed: Focus: Resident has anti-anxiety medication use r/t anxiety, agitation, and restlessness .Interventions: Give anti-anxiety medication- Xanax ordered by physician, monitor/document side effects and effectiveness. Review of Resident #8's electronic Physicians Orders revealed: Xanax Oral Tablet 0.25 mg Give 1 tablet by mouth every 12 hours as needed for Anxiety, start date 07/09/2025 with no stop date. Review of Resident #8's July 2025 MAR revealed doses of Xanax were administered on 07/12/2025 at 7:34 pm and 07/13/2025 at 11:30 pm. Review of Resident #8's physician progress notes revealed no evidence of documented rationale to order PRN Xanax for more than 14 days. Resident #77 Review of Resident #77's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: high blood pressure, urinary tract infection, and lung disease. Review of Resident #77's admission MDS dated [DATE], revealed a BIMS score of 12 which indicated moderate cognitive impairment. Review of Section N: Medications revealed Resident #77 was not receiving anti-anxiety medication. Review of Resident #77's Comprehensive Care Plan revised on 06/27/2025 revealed; Focus: Resident has antianxiety medication r/t anxiety disorder.Interventions: Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. Review of Resident #77's electronic Physicians Orders revealed: Lorazepam Oral Tablet 0.5 mg give 1 tablet by mouth every 8 hours as needed for anxiety start date 07/03/2025 with no stop date. Review of Resident #77's July2025 MAR revealed doses of Lorazepam were administered on 07/19/2025 at 7:00 pm and 07/27/2025 at 7:47 am. Review of Resident #77's physician progress notes revealed no evidence of documented rationale to order PRN Lorazepam for more than 14 days. Review of Drugs.com for Lorazepam accessed on 07/30/2025 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. During an interview on 07/30/2025 at 2:31 PM, the DON-IT stated all PRN psych medications should have had a 14 day stop date. After the 14 days the resident needed to be reevaluated for the need to continue the medication. She stated it was ultimately her and her nurse manager's responsibility to monitor the orders when they were entered to ensure that stop dates were entered. She stated the failure occurred just by being overlooked. She stated she did not see any negative harm or outcome. Review of the facility's policy titled; Psychotropic Drug Use revised 08/2017 revealed in part: Policy: It is the policy of this facility 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. Based on a comprehensive assessment of a resident, the facility will ensure that: . 4. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and describes the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 18 residents (Resident #68, Resident #07, Resident #65, Resident #30) reviewed for comprehensive person-centered care plans. The facility failed to develop a comprehensive care plan for Resident #68, Resident #07, Resident #65, and Resident #30 that included advance directive information. This deficient practice could place residents in the facility at risk of not being provided the necessary care or services and not having a personalized plan of care developed to address their specific needs.The findings include: Resident #68 Record review of Resident #68's Face sheet, dated [DATE], revealed an [AGE] year-old female, with an admission date into the facility of [DATE]. Resident #68's diagnoses included Metabolic Encephalopathy (a condition where brain function is disrupted due to chemical imbalances in the body, often resulting from illnesses or organ dysfunction) and Acute Kidney Failure (a sudden and rapid decrease in kidney function). Record review of Resident #68's Annual MDS, dated [DATE], revealed Resident #68's BIMS score was 10, which indicated moderate impairment. Record review of Resident #68's doctor orders, dated [DATE], revealed Resident #68 had standing orders of, Full Code: Use AED (Automated External Defibrillator) with CPR during sudden cardiac arrest. Record review of Resident #68's Care Plan, with recent review of [DATE], revealed the information in the area of advance directives and Resident #68's desire to be resuscitated in the event of sudden cardiac arrest was not included in Resident #68's care plan. During an interview on [DATE] at 9:56 a.m., Resident #68 said if she had a heart attack, Resident #68 wanted the staff to do everything they could to keep her alive. Resident #68 said she had not discussed the decision during her care plan meeting that she could remember. Resident #07 Record review of Resident #07's Face sheet, dated [DATE], revealed a [AGE] year-old female, with an admission date into the facility of [DATE]. Resident #07's diagnoses included Unspecified Atrial Fibrillation (a common heart condition where the heart's upper chambers beat irregularly and often too fast disrupting the normal heart rhythm), Cognitive Communication Deficit (difficulties in communication that arise from impairments in cognitive processes rather than problems with speech or language), and Delusional Disorders (a mental illness characterized by one or more delusions lasting for at least one month without other prominent psychotic symptoms like hallucinations or disorganized thinking). Record review of Resident #07's Quarterly MDS, dated [DATE], revealed Resident #07's BIMS score was not calculated. Section C0100, Should Brief Interview for Mental Status (C0200 - C0500) be Conducted was left blank. Record review of Resident #07's doctor orders, dated [DATE], revealed Resident #07 had standing orders of, Full Code: Use AED (Automated External Defibrillator) with CPR during sudden cardiac arrest. Record review of Resident #07's Care Plan, with recent review of [DATE], revealed the information in the area of advance directives and Resident #07's desire to be resuscitated in the event of sudden cardiac arrest was not included in Resident #07's care plan. During an interview on [DATE] at 10:11 a.m., Resident #07 said she wanted the staff at the facility to perform CPR on her because she did not want to die. Resident #07 was unable to state if the choice was discussed at her care plan meeting. Resident #65 Record review of Resident #65's Face sheet, dated [DATE], revealed an [AGE] year-old female, with an admission date into the facility of [DATE]. Resident #65's diagnoses included Parkinson's Disease (a progressive neurodegenerative disorder that primarily affects movement), and Dementia (a broad term for a decline in mental ability severe enough to interfere with daily life), moderate, with psychotic disturbance. Record review of Resident #65's Quarterly MDS, dated [DATE], revealed Resident #65's BIMS score was not calculated. Section C0100, Should Brief Interview for Mental Status (C0200 - C0500) be Conducted was coded 0 for No - resident was rarely/never understood; therefore, BIMS score was not determined. Record review of Resident #65's doctor orders, dated [DATE], revealed Resident #65 had a standing order of, DNR - Do Not Resuscitate. Record review of Resident #65's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order, dated and notarized [DATE], revealed Resident #65 had a DNR in place to be used as needed prior to admission into the facility on [DATE]. Record review of Resident #65's Care Plan, with recent review of [DATE], revealed the information in the area of advance directives and Resident #65's presence of a formal DNR was not included in Resident #65's care plan. During an observation on [DATE] at 10:21 a.m., Resident #65 was observed as she sat in her wheelchair in the common area of the facility. She was observed to be unable to respond to interview questions. Resident #30 Record review of Resident #30's Facesheet, dated [DATE], revealed a [AGE] year-old male, with an admission date into the facility of [DATE]. Resident #30's diagnoses included Heart Failure (the heart cannot pump enough blood to meet the body's needs, not that it stopped beating), unspecified and Unspecified Dementia (a broad term for a decline in mental ability severe enough to interfere with daily life) without behavioral disturbance. Record review of Resident #30's Quarterly MDS, dated [DATE], revealed Resident #30's BIMS score was not calculated. Section C0100, Should Brief Interview for Mental Status (C0200 - C0500) be Conducted was left blank. Record review of Resident #30's doctor orders, dated [DATE], revealed Resident #30 had a standing order of, DNR - Do Not Resuscitate. Record review of Resident #30's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order, dated and notarized [DATE], revealed Resident #30 had a DNR in place to be used as needed. Record review of Resident #30's Care Plan, with recent review of [DATE], revealed the information in the area of advance directives and Resident #30's presence of a formal DNR was not included in Resident #30's care plan. During an interview on [DATE] at 11:00 a.m., Resident #30 said his advance directive was not discussed during his care plan meeting. Resident #30 said he discussed his signed DNR when he first came into the nursing facility. During an interview on [DATE] at 2:28 p.m., the MDS Coordinator said the advance directives were not required to be in the care plans. The MDS Coordinator said he would consider the information and decision making involved in the advance directives as a major importance to a person and their rights. The MDS Coordinator said the information involved during the discussion of advance directives would be good information to have in the resident's care plans. The MDS Coordinator said at admission, the facility discussed the residents' preference in the area of advance directives and anything that might warrant further discussion. The MDS Coordinator said he could see the benefits of discussing advance directives during the care plan meetings especially to ensure the residents' rights were not violated. During an interview on [DATE] at 3:00 p.m., the Operations Manager said the advance directives were not part of the care planning because the process was not required. The Operations Manager said the residents' status was kept in a binder at the nurses' station and updated as needed. During an interview on [DATE] at 3:41 p.m., the DON said advance directives were not required to be care planned and she did not think the information should be in the residents' care plan. The DON said the code status was not on the hospital discharge paperwork as an order and did not become an order upon admission if the resident was unable to produce documentation that a DNR was in place. Record review of the facility's policy, Comprehensive Person-Centered Care Planning, dated 01/2022, revealed, 4. The facility IDT would develop and implement a comprehensive person-centered care plan for each resident and will include resident's needs identified in the comprehensive assessment and resident's goals and desired outcomes, preferences for future discharge and discharge plans. 5. The resident has the right to refuse or discontinue treatment. In the event that a resident refuses certain services posing a risk to resident's health and safety, the comprehensive care plan will identify care or service declined, the associated risks, IDT's effort to educate the resident and resident representative and any alternate means to address risk. Record review of the facility's policy, Resident Rights, Code Status Listing, dated 11/2007, revealed, IDT team will discuss advanced directives with resident/responsible party during annual care plan conference.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure kitchen staff used proper hand washing and sanitation procedures when handling and serving food. These failures could place residents who received food from the kitchen at risk of cross contamination and food borne illness.The findings include: During an observation on 07/28/2025 at 11:05 a.m., [NAME] E, who was wearing gloves, put a pair of oven mitts on and removed a pan of oven cooked chicken from the oven. [NAME] E removed the oven mitts and picked up and placed a thermometer into a piece of chicken. [NAME] E covered the pan of chicken with tin foil, put the oven mitts on and placed the pan into the oven. [NAME] E was observed as he removed a pan of spinach from the oven and placed it on the prep table. [NAME] E removed the oven mitts and picked up and placed a thermometer into the spinach. [NAME] E covered the pan of spinach, put the oven mitts on and placed the pan into the oven. [NAME] E was observed as he removed a pan of mashed potatoes from the oven and placed it on the prep table. [NAME] E removed the oven mitts and picked up and placed a thermometer into the mashed potatoes. [NAME] E covered the pan of mashed potatoes, put the oven mitts on and placed the pan into the oven. [NAME] E did not change gloves or wash his hands prior to donning or doffing the oven mitts. During an observation on 07/28/2025 at 11:19 a.m., the Assistant Dietary Supervisor, who was wearing gloves, was observed as she picked up a spoon by the eating surface and placed it on a cloth napkin. The Assistant Dietary Supervisor proceeded to pick up a knife by the blade end and a fork by the tines. The Assistant Dietary Supervisor rolled the silverware up in the napkin and placed it in a bin. The Assistant Dietary Supervisor laid a napkin on the table and picked up another spoon by the eating surface, a knife by the blade end, and fork by the tines and placed them on the napkin. The Assistant Dietary Supervisor rolled the napkin and placed it in the bin. The Assistant Dietary Supervisor was observed as she rubbed the side of her nose with her right hand and the placed a napkin on the table. The Assistant Dietary Supervisor picked up a knife by the blade end, a spoon by eating end, and a fork by the tines and placed them on the napkin. The Assistant Dietary Supervisor did not change her gloves or wash her hands during the observation. During an observation on 07/28/2025 at 11:26 a.m., Dietary Aide G was observed to exit the kitchen by the back exit door and enter the storage refrigerator/freezer unit located in the outside area behind the kitchen. Dietary Aide G entered the storage unit, retrieved the dessert premade for lunch, exited the unit, and reentered the kitchen by the back door. Dietary Aide G picked up the pan with his hands that had not been washed. Dietary Aide G placed the pan on the prep table and immediately began placing small bowls on a serving tray. Dietary Aide G retrieved a serving scoop with his bare hands and began to put the dessert in the bowls. Dietary Aide G did not wash his hands upon entering the kitchen from outside, prior to stacking the cups on the tray or serving the dessert into the bowls. During an observation on 07/28/2025 at 12:01 p.m., Dietary Aide H was observed as she stood by the steam station and rubbed the back of her neck with her left hand. Dietary Aide H did not wash her hands during the observation. Dietary Aide H stood by the steam station until the Dietary Manager said it was time to begin to serve. During an observation on 07/28/2025 at 12:10 p.m., Dietary Aide H held a plate as she scooped mashed potatoes onto the eating surface. Observed Dietary Aide H's thumb touched the eating surface of the plate, and the tip of the thumb touched the mashed potatoes. Dietary Aide H did not wear gloves and had not washed her hands prior to serving. Dietary Aide H picked up another plate and touched approximately 1 1/2 inches of eating surface of the plate with her thumb and her thumb brushed against the biscuit on the plate. Observed Dietary Aide H hand to be shaky. Observed Dietary Aide H as she picked up a third plate and spooned spinach onto the plate with her thumb across the top of the plate touching the eating surface of the plate. Observed juice from the spinach touched Dietary Aide H's fingers. Observed Dietary Aide H wiped her right hand on the side of her pant leg. Dietary Aide H did not wash her hands during the observation. During an interview on 07/29/2025 at 1:25 p.m., the Assistant Dietary Supervisor said she knew she was not supposed to grab the silverware by the eating end surfaces of the utensils. The Assistant Dietary Supervisor said she should not touch the end that would go into the residents' mouth. The Assistant Dietary Supervisor said she had been trained in the proper way to handle utensils and knew her action could cause cross contamination. The Assistant Dietary Supervisor said cross contamination could cause germs that could make the residents or anyone who ate from the kitchen sick. During an interview on 07/29/2025 at 1:40 p.m., [NAME] E said he knew he should have washed his hands and changed gloves in between using the oven mitts that had been used by other staff in the kitchen and in between temping food. [NAME] E said the fact that the oven mitts were not washed or sanitized between use by others could cause cross contamination. [NAME] E said the action could have a negative impact on the residents by causing cross contamination and the residents could become ill. During an interview on 07/29/2025 at 1:50 p.m., Dietary Aide H said she was trained on the need to not touch the eating surfaces of plates and said the fact that she did could cause cross contamination. Dietary Aide H said the negative outcome of her action could cause germs to get into the food, which could make the residents ill. Dietary Aide H said she knew she was not supposed to touch food with her bare hands and said she was trained on the need to wash her hand when she touched surfaces, such as wiping her hand on her jeans. Dietary Aide H said she was aware that she should have washed her hands prior to serving the food and after she touched the food, but she was nervous and forgot. During an interview on 07/29/2025 at 1:59 p.m., Dietary Aide G said he was trained that when he left the kitchen and returned, he should wash his hands every time. Dietary Aide G said when he went outside to retrieve the dessert and returned, he should have washed his hands prior to serving. Dietary Aide G said this was important for the safety of the residents because his hands could have germs on them. Dietary Aide G said the residents who ate from the kitchen could become ill from eating food with germs. During an interview on 07/30/2025 at 1:53 p.m., the Dietary Manager said the issues related to not washing hands did not meet her expectations. The Dietary Manager said the negative outcomes specifically to the staff not washing his hands when he left the kitchen to go outside were food poisoning and sickness. The Dietary Manager said [NAME] E who used gloves and did not change them or wash his hands between use of the oven mitts between tasks did not meet her expectation as he could cause cross contamination. The Dietary Manager said she would increase monitoring to avoid future occurrences to ensure the residents were not exposed to cross contamination or illness. During an interview on 07/30/2025 at 3:00 p.m., the Operations Manager said the issues related to hand washing and sanitation in the kitchen did not meet her expectations. The Operations Manager said she expected staff to abide by policy. The Operations Manager said touching the end of the silver ware could cause a negative outcome and introduce what was on the staffs' hands to the residents. The Operations Manager said the staffs' actions could cause cross contamination and cause the residents to become ill. Record review of the facility's policy, Employee Sanitary Practices, dated 2021, revealed, food and nutrition services employees will practice good personal hygiene and safe food handling procedures. 2. Wash hands before handling food using Posted hand washing procedures. 6. Use utensils to handle food, avoiding bare hand contact with food. Disposable gloves are a single use item and should be discarded after each use. Hands must be washed prior to using gloves and after removing gloves. 7. Avoid touching mouth or face while preparing food (And wash hands if contaminated.). 10. Equipment and work areas should be cleaned and sanitized after use. 11. Use these sidelines in handling clean dishware, glassware, and flatware:a. Use clean hands.b. Pick flatware and cups up by their handles.c. Pick dishes up by the rims. Record review of the facility's policy, Hand Washing, dated 2021, revealed, Employees will wash hands as frequently as needed throughout the day using proper hand washing procedures. Hands and exposed portions of arms should be washed immediately before engaging in food preparation. 1. When to wash hands:a. When entering the kitchen at start of the shift.b. After touching bare human body parts other than clean hands and wrists.f. After handling soiled equipment or utensils.g. During food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks.i. Before donning disposable gloves for working with food and after gloves are removed.j. After engaging in activities that contaminate the hands.

Based on interview and record review, the facility, with a capacity of more than 120 beds, failed to employ a qualified social worker on a full-time basis. The facility failed to ensure the facility had a full-time social worker between the time of 6/25/2025 to 07/30/2025. This failure could affect all residents of the facility by placing them at increased risk of psychosocial decline and poor quality of life. The findings included: Review of facility provided employee list provided on 07/28/2025 revealed no social worker on staff. During an interview on 07/30/2025 at 2:10 PM the OM stated they did not currently have a social worker. The OM stated the previous social worker's last day was on June 25, 2025. The OM stated she posted the position on June 11th but had not received applications from licensed social workers, until this past Monday, 07.29.2025. The OM stated she had raised the salary last week and added a sign on bonus. The OM stated her expectation was to have a full-time licensed social worker. The OM stated she did not feel like there was a negative effect to the residents, because staff were covering the duties of the social worker. The OM stated the facility did not have a policy for social services. The OM stated what led to the failure was the availability of licensed social workers in the area and possibly the salary. Record review of CMS Form 3740 titled Bed Classification dated 07/28/2025 revealed the facility had a licensed capacity of 123 resident beds.

Based on interviews and record review, the facility failed to ensure the development of comprehensive care plan that meets allof a residnt's need for 1 of 18 residents (Resident #37) reviewed for advance directives. The facility failed to ensure that Resident #37's advanced directive preference was included in care plan or stored in DNR binder at the nurses' station. The facility failed to have the advanced directive in the binder and failed to implement their policies for implementing advance directives This failure could place residents at risk of receiving treatments that go against their personal preferences and does not allow them to make an informed decision about their care. Finding included: Record review of the Resident #37's face sheet dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: cerebral infarction stroke), presence of cardiac pacemaker, and metabolic encephalopathy (brain swelling). Further investigation of face sheet revealed that resident resided on unit 3 (300 hall). Record review of Resident #37's admission MDS dated [DATE] revealed: no BIMS score, and Resident #37 was rarely or never understood. Record review of Resident #37's care plan dated [DATE] revealed no evidence of advanced directive code status. Record review of Resident #37's electronic physician orders dated [DATE] revealed DNR-DO NOT RESUSCITATE. Record review of Resident #37's OOH-DNR dated [DATE] revealed adult child signed and dated form, two witnesses signed form, and physician signed form. During an interview on [DATE] at 2:49 PM, the DON stated the facility ensures direct care nurses are notified of resident's code status by locating information in DNR binder. She stated the facility does not add code status to resident's care plans. During an observation on [DATE] at 2:58 PM, DNR binder observed at nurses' station for 300 hall and no information about Resident #37's advanced directive wishes observed inside of binder. During an interview on [DATE] at 3:08 PM, RN B stated direct care staff would look in the DNR binder at nurses' station to see if resident had a DNR code status. She stated nurses' station on 400 halls housed DNR binder for residents that resided on 400 hall and nurses' station on 300 halls housed DNR binder for residents that resided on 300 hall of nursing facility. During an interview on [DATE] at 3:20 PM, LVN C stated typically residents DNR status would be identified on admission by the admission nurse. She stated admission nurse was responsible for placing resident's information in DNR binder at nurses' station. She stated she did not know why Resident #37's information was not in DNR binder on 300 halls. She stated Resident #37 was admitted on [DATE] and her DNR status should have been placed in DNR binder. During a follow up interview on [DATE] at 3:26 PM, the DON stated she expected for a resident that was a DNR to be identified by admission nurse on admission and the admission nurse should add resident's information to DNR binder at nurses' station. She stated nurses monitor code status information by performing chart audits including ADON and DON. She did not know why Resident #37's information was not in DNR binder or why is had not been identified prior to [DATE]. She stated the effect of information being left out of the binder could lead to delay of resuscitation. She stated nurses could look into electronic medical record to see information on code status as well. During an interview on [DATE] at 4:03 PM, the ADMN stated her expectation was for DNR binders to be updated when a change in code status occurred. She stated she expected facility policy to be followed. She stated the facility policy stated social worker or designee would monitor advanced directive information in DNR binders at nurses' stations were up to date. She stated she did not know why information was not present in DNR binder for Resident #37. She stated the effect of not having information in the DNR binder could potentially lead to advanced directive not being followed in an emergency. During a phone interview on [DATE] at 4:20 PM, Resident #37's son stated he expected the facility to follow their advanced directive wishes. He stated he expected for her wishes to be honored and no CPR to be performed. Record Review of facility policy titled Code Status Listing revised date ,d+[DATE] revealed: 1. All residents will be informed of their opportunity to file advanced directives upon admission and at least annually. 2. The residents with code status will be kept in a binder at each nurse's station. 3. Social Serviced, or designee, will keep the code status list current and updated whenever a change occurs. 4. ID team will discuss advanced directives with resident/responsible party during annual care plan conference and update as necessary.

Based on observations, interviews, and record review, the facility failed to ensure no expired medication/treatment products were not on 1 of 1 Treatment cart reviewed for medication storage. The facility failed to remove expired box of collagen dated ,d+[DATE] from treatment cart. This failure could result in delayed healing of wound. Findings included: During an observation on [DATE] at 1:00 PM wound treatment supplies and products being set up for a treatment, LVN A observed expired box of collagen (a protein in the body that encourages wounds to heal quickly and effectively) sheets. The expiration date: ,d+[DATE]. During an interview on [DATE] at 1:01 PM LVN A stated the expired supplies should not have been left on the cart. She stated that using expired wound care products (collagen sheet) could have caused the treatment to not be as effective due to the matrix of product. She stated she did not know why expired collagen was on the cart. LVN A stated she had checked the cart earlier in the day but did not see that this dressing was expired at that time. During an interview on [DATE] at 1:50 PM the DON stated her expectations was expired treatment products should not have been applied to resident, and the treatment nurse should have checked expiration dates prior to using and discard any expired products immediately. The DON stated the treatment nurse audits their cart weekly and nursing management monitors as well. She stated treatment products were to promote healing and if expired product was used it could have interfered with the healing process and could have delayed healing of resident wound. She stated she did not know what had caused the failure. During an interview on [DATE] at 2:15 PM the ADMN stated the expectation would have been that treatment products or medications were used on/or before the expiration date. She stated it was the responsibility of treatment nurse to ensure products and medications were not expired and should have been double checked by nursing management. She stated possible harm to the resident could have been the potency of treatment could have been decreased if not used prior to or by the expiration date. She stated the facility had been training new staff on wound care and it could have possibly been missed due to this. Record review of facility's policy titled, Care and Treatment Subject: Medication Access and Storage, dated ,d+[DATE] revealed: 13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists.

Based on interviews, record reviews the facility failed to ensure that the quality assessment and assurance committee developed and implemented appropriate plans of actions to correct deficiency of having a full time Social Worker on staff for Residents social needs for all resident. The facility failed to ensure the QAPI committee, which included the Administrator, DON, Medical Director, had followed the facility's plan of correction dated 04/12/2023. This failure could place all residents at risk for unmet social services and psychosocial needs. Findings included: Review of the facility's CMS 2567/facility-submitted Plan Of Correction (POC) dated 05/05/2023 which was submitted in response to the 04/12/2023 SSA recertification survey revealed Facility has contracted a licensed social worker who is licensed by the Texas State Board of Social Worker Examiners to oversee work of social services designee . Facility has contracted a licensed social worker to assist in meeting the needs of residents. Completion Date 05/15/23. Record review of Social Services Manager's employee file revealed Social Services Manager was not a licensed social worker. During an interview on 06/26/24 at 3:30 PM the ADMN stated the Social Services Manager had a Bachelor of Arts degree in Human Services. The ADMN stated she had an interview with licensed social worker approximately one year ago and candidate declined due to not wanting to relocate. The ADMN stated she did not feel that any resident had been harmed or denied any services that a Licensed Social Worker could have provided. The ADMN stated the facility discussed the POC from 04/12/2023 at every monthly QAPI meeting. The ADMN stated she felt that she had followed the POC actions. She stated she considered the QAPI Plan was the policy that facility had for QAPI. Per review of facility's QAPI Plan on 06/26/2024 at 3:45 PM revealed: c. To serve the whole facility: The resident, resident's family, caregiver, employee, and other service providers all working towards a common goal of providing the best care possible. B. Core Values: a. Celebration: Celebrate successes and make work fun b. Accountability: Being held to highest standards of care and Professionalism c. Passion for Learning: On-going training d. Love One Another: Strive to treat each other as we would our Family. e. Intelligent Risk Taking: Trusting each other's judgment. f. Customer Second, We put our employee's first g. Ownership: We reward and support our employees who treat this facility as if they owned it. C. Guiding Principles pertaining to quality assurance and performance improvement. a. Guiding Principle #1: The use of QAPI will be prominent in how we manage our operation on a daily basis b. Guiding Principle #2: The facility will use QAPI to assist us in making. decisions for improvement in the facility and facility functions in order to guide our day-to-day operations c. Guiding Principle #3: QAPI will be at the core for all resident care to help ensure the residents receive quality of care. d. Guiding Principle #4: QAPI includes all of our employees, all departments and all services provided. e. Guiding Principle #5: QAPI in this facility focuses on systems and processes and the improvement in those systems and processes when a flaw is discovered. The QAPI plan for this facility helps us to provide guidance for overall quality improvement in our care. Decisions will be made based on the QAPI that will help to improve quality of care, quality of life, resident choice, person directed care and resident transitions. The Executive Director will assure that the QAPI plan is reviewed on an annual basis by the QA committee. Revisions will be made based on on-going assessment of resident needs and as the need arises to help to reestablish good quality care. QAPI activities will be integrated across all the care and services of our facility. Each discipline will have a representative on the QAA committee. A facility assessment will be conducted to include an overview of the services and care areas that are provided. Any new service areas or changes in population or service areas identified during the facility assessment will be included in our QAPI plan. [Facility] current care areas: The QAA committee includes the executive director, director of nursing, infection control officer, medical director, dietary director, rehabilitation director, social worker, activities director, plant operations manager, assistant director of nursing, MDS director, housekeeping/laundry supervisor, business office manager, central supply and a CNA. The QAA committee will meet monthly. The committee will monitor progress, provide input, and ensure the individuals involved in the project have the resources they need. QAPI activities and outcomes will be shared with staff at staff meetings and with residents through the resident council meetings at least quarterly. Quality Improvement Projects (QITS) are implemented in accordance with CMS regulations regarding PIPs. PIPs are developed when there is a problem identified and needs a solution to the problem. The PIP implemented is reviewed during the QAPI meetings with the medical director.

Based on interview and record review, the facility failed to send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Office of the State Long-Term Care Ombudsman for one (Resident #1) of two residents reviewed for transfer and discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #1 was discharged home on 7/14/23. This failure could affect residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. Findings included: Record review of Resident #1's electronic face sheet, dated 10/31/23 revealed she was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include fracture of unspecified part of neck, Depressive Disorder, and type 2 diabetes mellitus. Review of Resident #1's progress notes dated 7/14/23 indicated Resident #1 discharged home with her prescriptions and personal items. Resident #1's family member was at the facility to assist with the discharge and transport he resident home. The resident was in stable condition at time of discharge. Electronic communication via email dated 11/1/23 Ombudsman wrote: The Ombudsman Program has not received any 30-day discharge notices since 3.21.2022 and has not received transfer/discharge reports since 6.7.2023, from the facility. During an interview on 11/1/23 at 3:15 PM the ADMIN stated the social worker should be the one that handles all discharges and documentation even with the Ombudsman. She stated a spreadsheet of all residents who were transferred out of the facility should be kept and emailed to the Ombudsman monthly. During an interview on 10/26/2022 at 2:25 the SW stated that for long term care discharges there was 30-day notice but if they were only in the facility for skilled care then it could be up to 48 hours. He stated that he did not know he needed to contact the Ombudsman of all transfers and discharges. Record review of facility policy on 11/1/23 titled: Criteria for Transfer and Discharge revealed: It is the policy of this facility that each resident will remain in the facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When the facility transfers or discharges a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.

Based on observation, interview, and record review, the facility failed to immediately notify resident's family/representative(s) when a significant change in condition that required hospitalization occurred for 1 or 3 (Resident #1) residents reviewed for change of condition. The facility failed to notify Resident #1's family/POA when he was admitted to the hospital for serious medical complications for more than 24 hours after he was admitted . This failure could place all residents at risk for not having their family or legal representative notified when having a change in condition. Findings included: Record review of Resident #1's Face Sheet, dated [DATE], revealed a [AGE] year-old-male who was admitted to the facility on [DATE]. Diagnoses were noted as Non-ST Elevation (NSTEMI) Myocardial Infarction (type of heart attack involving a partly blocked coronary artery [surround the heart] that causes reduced blood flow), Thromboangiitis Obliterans or Buerger's Disease (disease that affects blood vessels in the body, most commonly in the arms and legs, causing vessels to swell which can prevent blood flow), Type II Diabetes Mellitus (Chronic disease in which your blood glucose or blood sugar, levels are too high) with Hyperglycemia (high blood glucose), End Stage Renal Disease (medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), Chronic (long-term) Pulmonary Edema (condition caused by too much fluid in the lungs), Kidney Transplant Status (has received a kidney transplant), Chronic (long-term) Obstructive Pulmonary Disease (diseases that cause airflow blockage and breathing-related problems), Acquired Absence of Left Leg Below Knee (surgically amputated), and Dependence on Renal Dialysis (treatment to clean your blood when your kidneys are not able to). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 05 which indicated a severe cognitive impairment. Functional status in Section G of the MDS indicated Resident #1 required extensive assistive and total dependence with daily living activities of personal care. Resident #1 required extensive assistance with the assistance of at least two staff to move to and from a lying position in bed or turn from side to side. Resident #1 required total staff assist to transfer from his bed to a wheelchair or bed . Record review of Resident #1's Care Plan, dated [DATE], revealed Resident #1 had renal failure due to end stage kidney disease and had the need for hemodialysis every Monday, Wednesday, and Friday. The care plan revealed Resident #1 had impaired circulation due to diabetes, infections, Buerger's Disease, PVD, and CAD. During an interview on [DATE] at 3:15 p.m., the DON said she was aware Resident #1's family had not been notified when Resident #1 had been sent out to the hospital on the morning of Monday, [DATE] . The DON said on [DATE] at approximately 1:30 p.m., the Infection Control RN had informed her she had not contacted the family immediately after Resident #1 had been transported to the hospital. The DON said Resident #1 had been transported to the ER due to edema and shortness of breath at approximately 9:10 a.m. on [DATE]. During an interview on [DATE] at 4:10 p.m., the Infection Control RN said she had been at the facility for approximately two (2) years. The Infection Control RN said she was on duty and the nurse who made the decision to send Resident #1 out to theER on [DATE]. The Infection Control RN said she entered Resident #1's room and observed his face and arms to be swollen and made the determination to call the paramedics to transport Resident #1 to the hospital. The Infection Control RN said she contacted his physician, the DON, the Dialysis Provider, and the Administrator. The Infection Control RN said she did not contact the family of Resident #1 immediately because she became busy checking the vital signs of another resident, received a personal phone call, and became distracted and overlooked calling the family. During an interview on [DATE] at 4:32 p.m., Resident #1's Family Member A said Resident #1 was sent to the hospital on the morning of [DATE], which was Monday, at approximately 9:30 a.m. and he was not notified until Tuesday morning ([DATE]). Resident #1's Family Member A said a member of his family was first notified by the hospital that Resident #1 had been admitted to the hospital. Resident #1's Family Member A said the nursing facility contacted his family member several hours after the hospital had call to notify the family Resident #1 had been sent out to the hospital the morning of [DATE]. Resident #1's Family Member A said he was upset because Resident #1 could have died and he would have not known until 24 hours later. During an observation on [DATE] at 9:05 a.m., Resident #1 was observed in the ICU unit of the local hospital. Resident #1 was lying in a hospital bed on his back and wearing a lightweight oxygen tube in his nose. Observed an intravenous (into or within the vein) pole by his bed with an intravenous bag attached. Resident #1 was observed with his eyes closed, grimacing, and moaning. During an interview on [DATE] at 9:15 a.m., ICU RN said Resident #1 was moved to ICU from the third floor of hospital on [DATE] due to unstable blood pressure and unsteady cardiac rhythm. During an interview on [DATE] at 9:45 a.m., Resident #1's Family Member/POA said she was Resident #1's responsible party and Power of Attorney for his medical care. Resident #1's Family Member/POA said she had received a call on Tuesday, [DATE] at approximately 10:00 a.m. from the local hospital requesting permission to complete a medical procedure on Resident #1. Resident #1's Family Member/POA said she was not aware Resident #1 was in the hospital at the time of the call. Resident #1's Family Member/POA said she was not contacted by the nursing facility until approximately 2:00 p.m. on Tuesday, [DATE]. Resident #1's Family Member/POA said the Infection Control RN called her and explained that Resident #1's blood pressure had dropped the morning of Monday, [DATE] and he was sent to the hospital by ambulance at approximately 9:30 a.m. Resident #1's Family Member/POA said the Infection Control RN told her she was the nurse who made the decision to send Resident #1 to the hospital by ambulance. Resident #1's Family Member/POA said the Infection Control RN said she had prepared Resident #1 to go to the hospital and then the Infection Control RN said she assisted another resident and forgot to call Resident #1's family. During an interview on [DATE] at 1:15 p.m., the DON said the fact that the Infection Control RN did not contact Resident #1's family immediately after Resident #1 was transported to the hospital on [DATE] did not meet her expectation. The DON said with Resident #1's fragile medical condition, Resident #1 could have expired. The DON said she immediately took action and started an in-service to inform all staff that family/Responsible Party/POAs must be notified immediately when a resident was sent to the emergency room or hospital and she took disciplinary action against the Infection Control RN for her oversight. Record review of the form, Counseling/Disciplinary Notice, dated [DATE] and signed by the Infection Control RN on [DATE] revealed the Infection Control RN was given a written warning for not notifying family when a resident was sent out to the hospital by ambulance. Record review of an In-service Attendance Record, dated [DATE], revealed the DON and ADON initiated an all-staff in-service training that informed staff, When a resident is sent out of facility family must be notified. No matter what the time of send out, a call is to be made to the emergency contact until they are reached and or the second contact is reached. Once family is contacted it is to be documented. Documentation should include the name of who you spoke with and what information was given. Record review of the facility policy, Resident Rights, not dated, revealed it was the policy of the facility to notify the family/responsible party of changes in the resident's condition and/or status. The charge nurse would notify the resident's family/responsible party when: (E). It was necessary to transfer the resident to a hospital.

Based on observation, interview and record review, the facility failed to ensure the menu was followed, for 1 of 1 observed lunch meal on 04/10/2023. The facility failed to ensure residents received a fresh baked role or an approved alternative during the lunch meal. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss. The findings include: Observation and review of posted daily facility menu for Monday 04/10/06/2023 revealed: Lunch: Sweet/Sour Meatballs, Steamed Rice, Seas Green Beans, Roll/Marg, Iced Brownie, Beverage and Whole Milk. Observation of the meal on 04/10/2023 at 11:30 AM revealed residents were served Sweet/Sour Meatballs, Steamed Rice, Green Beans, and an Iced Brownie. Resident trays were served without a roll or an approved alternative. During an interview on 4/10/2023 at 11:45 AM the DM stated resident trays were served without a roll. The DM stated the cook should have substituted a slice of bread, if there were no rolls. The DM stated she did not know why there was no rolls served. During an interview on 04/11/2023 at 10:15 AM the DM stated her expectation was that staff were to follow the menu and if an item was not available for some reason it would need to be substituted. The DM did not know why the roll was missing from food tray yesterday. The DM stated the cooks and herself were responsible for monitoring the menu being followed. During an interview on 04/12/23 at 3:36 PM the ADMN stated her expectation was that staff follow menus and needed to notify staff and residents of substitution. The ADMN stated the roll should have been substituted with adequate substitution. The ADMN stated the DM was responsible to monitor to ensure menus were being followed. The ADMN stated what led to failure was inconsistent training structures. The ADMN stated the effect on residents when menus were not followed was resident did not get proper nutrition. Review of facility's policy titled, Nutrition and Menu Planning undated revealed: Menu and Nutritional Adequacy: Understands and follows prescribed diet orders, menu spreadsheets and corresponding recipes, Understands menu substitutions and use of nutritionally equivalent foods. Prepares appropriate quantity of food based on menu spreadsheets.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed . The facility failed to ensure foods were sealed and/or labeled properly in refrigerator. The facility failed to ensure all food was not past expiration date. The facility failed to ensure that staff utilized proper personal hygiene practices. These failures could place residents that eat from the kitchen at risk for food borne illnesses. Findings included: Observation of the kitchen on 04/10/23 between 10:15 AM to 11:15 AM revealed the following: Refrigerator 1. A container of Pimento Cheese with a use by 4/7/23. 2. A bag of broccoli with a use by date of 3/17/23. 3. A package of bologna not sealed open to air. 4. A plastic bag with a seal not sealed contained grated cheese. 5. A plastic bag with a seal not sealed contained lettuce. 6. A plastic bag with a seal not sealed contained sliced white cheese. 7. Two bags of lettuce with a use by date of 4/7/23. 8. A container containing BBQ pork without a prep or use by date. 9. A plastic bag with seal not sealed containing ham. 10. A container of refried beans with a use by date of 4/7/23. 11. A container of pasta with a use by dated of 4/9/23. Observation on 04/10/2023 at 11:30 PM revealed DS C entered the kitchen without washing hands, walked thru kitchen carrying personal food and drink itmes, entered into the office with items, then returned to kitchen without personall items, went to warmer and removed food containers before washing hands. While DS C washed her hands, she turned off water with bare clean hands and then grabbed a paper towel to dry hands; and went to get food containers out of warmer. During observation on 04/11/23 at 10:40 AM revealed DS B failed to perform hand hygiene while pureeing food, DS B touched mask, pulled down mask, adjusted glasses picked up food containers numerous times without performing hand hygiene. During an interview on 04/11/2023 at 10:15 AM the DM stated her expectation was the food needed to be sealed and labeled with item description, date prepared and date needed to be discarded. The DM stated items needed to be discarded when dated. The DM stated the effect on residents would be that residents could have received food poisoning. The DM stated staff should perform hand hygiene every time they enter kitchen, touch something on their person or change tasks. The DM stated what led to failures were staff were rushing and trying to do too much at one time. The DM stated all dietary staff should have been monitoring but ultimately fell on cooks and DM to monitor. The DM stated staff are trained on proper hand hygiene and food storage and labeling at hire thru the facility's online training system and when complete food handler's certificate. During an interview on 04/12/23 at 3:36 PM the ADMN stated her expectation was that staff follow policy for hand hygiene and food storage and labeling. The ADMN stated staff should have washed hands anytime they changed tasks. The ADMN stated the DM was responsible to ensure staff followed policy. The ADMN stated the effect on residents was food could have lost nutrient content or have been spoiled. The ADMN stated what led to failure of items not being stored properly was inconsistent training structure. The ADMN stated what led to failure of staff not performing hand hygiene was lack of accountability. Review of Facility policy titled, Infection Control Policy/Procedure dated 05/2007 revealed: Wash hands carefully with soap and water whenever they become soiled, immediately before work in the morning, after using the bathroom, after coughing, sneezing, or blowing the nose, after touching the hair, mouth, or cigarettes, after handling raw unwashed food and dirty dishes; Before touching food, clean dishes and silverware. Review of FDA Food Code 2022 accessed https://www.fda.gov/media/164194/download revealed on page 20: (C) TO avoid recontaminating their hands or surrogate prosthetic devices, FOOD EMPLOYEES may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a HANDWASHING SINK or the handle of a restroom door . FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms . Before donning gloves to initiate a task that involves working with FOOD; (I) After engaging in other activities that contaminate the hands.

Based on observation, interviews and record reviews the facility failed to maintain an environment that remained free of accident hazards. The facility failed to keep cleaning agents out of the reach of residents. This failure placed residents at risk of accidental ingestion of chemicals. Findings included: In an observation on 4/10/23 at 12:29 PM, residents were being served and eating their noon meal in the facility dining room. On a countertop in the dining room there was a bottle of Comet cleaner with bleach sitting on top of counter with a white washcloth on top of the bottle. There were three dining tables near the counter with residents at each table. In an interview on 4/10/23 at 12:42 PM with ICP, she said the cleaner should not have been out on the countertop within reach of the residents. She said the residents could suffer an adverse reaction from the chemicals. In an interview on 4/10/23 at 12:50 PM with the ADM, she said the Comic cleaner with bleach should not have been out on the countertop within reach of the residents. She said residents should not have easy access to the cleaner. She said anyone knows what could potentially happen. ADM did not wish to elaborate further on a potential safety hazard. Record review of MSDS for Comic cleaner with bleach undated revealed: eye damage irritation. Corrosive 2 metals. Handling and storage use personal protective equipment as required. Keep container closed when not in use . Keep out of reach of children. Keep containers tightly closed in a dry, cool and well-ventilated place. Store in corrosive resistant container. First aid measures. Eye contact rinse with plenty of water. Get medical attention immediately if irritation persists. Skin contact. Rinse with plenty of water. Get medical attention if irritation develops and persists. Ingestion. Drink one or two glasses of water. Do not induce vomiting. Get medical attention immediately if symptoms occur. Inhalation. Made fresh air. If symptoms persist call a physician. Accidental release measures. Personal precautions. Use personal protective equipment. Do not get in eyes, on skin, or on clothing.

Based observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments for 1 of 2 medication carts, and unsecured respiratory medications at resident bedside, reviewed for label and storage of drugs and biologicals. The facility failed to ensure medication cart #1 was locked when unattended by RN-A. The facility failed to ensure Resident #25srespiratory treatments were not left at bedside and used unsupervised . This failure could place residents at risk of having access to unauthorized medications, leading to possible harm or drug diversions. Findings include: 1.During observation on 04/10/2023 at 10:20 PM, Station 3 Nurses Station, med cart #1 was unlocked with a pill cup that included one pill on top of the med cart accessible to residents. Observation also at that time revealed a resident who walked up to Station 3 Nurses Station. During an interview on 04/10/2023 at 10:25 PM, the RN-A stated, a resident had refused a medication and placed the pill cup with one pill on top of the cart, leaving the cart unlocked and walked away. He stated the negative impact to residents, if accessed, would have been a possible overdose and/or an adverse reaction. His failure, he stated, was not locking the med cart, and having not disposed the refused medication properly. During an interview on 04/12/2023 at 3:45 PM, the DON stated, the negative impact to residents were, they could get into the open med cart or the pill sitting on top of cart possibly causing an allergic reaction. She stated the charge nurse should have ensured the carts were locked and herself and ADON should have been monitoring all shifts. The failures she felt was an isolated incident and did not comment further. Her expectations were for the med cart to have been locked immediately before walking away. The discarding of refused meds should have been discarded immediately upon refusal. 2.Record review of Resident #25 face sheet dated for 12/2023 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis list that included: Acute combined CHF (primary), pulmonary hypertension due to left heart disease, COPD, Alzheimer's disease (late onset), cognitive communication deficit. Record review of Resident #25's Quarterly MDS dated [DATE] revealed a BIMS of 4 meaning severe cognitive deficit. Resident did not utilize oxygen while a resident of the facility. Resident did not have shortness of breath. Resident had no functional range of motion impairment of upper extremities. There was no answer for functional cognition for remembering to take medication as resident was not on an admission skilled stay at that time. Record review of Resident #25's Care Plan dated 4/12/2023 revealed: Focus: has altered respiratory status/dyspnea r/t pulmonary HTN, A-FIB, pulmonary edema, COPD. Goal: Will have no complications related to SOB though the review date. Will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. Will not have a rehospitalization within 30 days. Interventions: . Inhalers albuterol and Spiriva per MD orders . Provide oxygen as ordered. Care plan does not address that resident may keep albuterol inhaler at bedside. Record review of Resident #25's Physician Order dated 4/12/2023 revealed: Albuterol Sulfate Aerosol Powder Breath Activated 108 (90 Base) MCG/ACT 2 puff inhale orally four times a day for COPD. Start date 11/3/2022. Order does not state that resident may keep inhaler at bedside. During observation on 4/10/2023 at 10:25 AM with Resident #25. She had an albuterol inhaler laying on her bedside table. The label on the albuterol inhaler stated the medication and directions to use four times a day. The resident and roommate both stated, it was always on the bedside table. She stated, the nurse would then come by to ensure she took the inhaler when she was supposed to. Resident #25 stated, the nurse did not assist with the inhaler only to come back to check it she had taken it. Resident #25 stated, she knew how to use the inhaler and then she took it four times a day not only when she needed. Resident was wearing oxygen via nasal cannula with the oxygen setting at 2 liters per minute. Resident said she wears oxygen continuously and she has had issues in the past with her lungs. During observation on 4/12/2023 at 4:20 PM, Resident #25 was not in her room, her roommate stated, she went out with family and had left her albuterol inhaler on the bedside table. The Roommate stated that no nurse had taken the inhaler from her bedside table within the last 3 days (4/10/2023 through 4/12/2023). During an interview on 4/12/2023 at 4:28PM, the LVN-D stated, if a resident had an order a specific medication could be kept at bedside, it would be acceptable. The nurse would still have needed to do a respiratory assessment each time per say, if it were a respiratory medication such as an inhaler and ask the resident if they had taken it. LVN-D stated if a resident had a medication that could be kept at the bedside, it would been addressed in the care plan as well. She also stated, if a resident did not have an order, to be kept at bedside, the medication was to be kept locked in the medication cart. During an interview on 4/12/2023 at 4:3 3PM, the DON stated, regarding a resident with a medication at bedside, first would be the residents desire to keep a medication at bedside, then a SMA Assessment would be conducted. The DON then stated, if the assessment revealed the resident was safe and competent, a discussion would be made with the resident's physician. It would have been then, if the physician agreed, the resident could safely keep the medication at bedside, then that specific medication's order would include could be kept at bedside. If the physician had written an order resident were allowed to keep med at bedside, the care plan needed to be updated to state as such. If there were no order for it to be kept at bedside, the care plan would not be included that it could be kept at bedside. The DON stated cognition would have been a factor with the SMA assessment with having had a BIMS of 4, Resident #25 would not have been able to keep a medication at bedside. She stated, the physician's orders would not be a general May keep at bedside order but would be with the specific medication could be kept at bedside. Without that specification in the medication order, the medication should have been stored in the medication cart. Record Review of undated facility Policy and Procedure-Nursing Clinical revealed: Section: Care and Treatment Subject: Medication Access and Storage Policy: It is the policy of this facility to store all drugs and biological in locked compartments Procedures: 2. Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 3. Except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area.

Based on observations interviews and record reviews, the facility failed to maintain an infection prevention and control program for 2 (RN-A, RN-E) of 8 staff and 1(Resident #21) of 5 residents reviewed for infection control. Facility staff failed to wear facemask properly. Facility staff failed to perform hand hygiene prior to donning surgical gloves for a sterile dressing change of Resident #21's PICC line. These failures placed residents at risk of infection. Findings included: During an observation on 04/10/23 at 9:45AM, entrance of facility had a whiteboard that had information regarding Covid-19. It stated, On 11/28/22 Texas Health & Human Services released the following guidance . 5. Due to HIGH county transmission rate Masks ARE REQUIRED. A poster that included Facemask Do's and Don'ts The poster included that the proper way to wear a mask was on the face and covering the nose and mouth. Many ways not to wear it included not at all and/or not covering the nose and mouth. During an observation on 04/10/2023 at 10:20 PM, RN-A (charge nurse) was sitting at Station 3 Nurses Station with no mask on. Residents were present in hallway at this time walking towards nurses station and walking in hallways. During an interview on 04/10/2023 at 10:25 PM, RN-A stated, it was only mandatory to wear his surgical mask when performing resident care, and not in the hallways or Nurses Station. During an interview on 04/11/2023 at 4:20 PM, the ADM stated, the county positivity rate was considered high, therefore wearing surgical masks should be worn in all areas of the facility with the exceptions of Offices, or mask break areas. She stated, the charge nurse should have been monitoring actions of staff keeping them accountable when ADM was not in the facility such as the night shift. The leadership team, (Charge nurse, ADM, and DON), were ultimately responsible for monitoring the wearing of masks throughout facility at all times. The ADM stated the negative impact to residents would have been exposure to outside factors. The failure she stated, it was harder for the leadership team to monitor the night shift, and the charge nurse not following the proper protocols of such. The expectations were for the charge nurse to wear his mask and to show ownership and responsibilities of a nurse. Record review of Resident #21 Facesheet dated 4/12/23 revealed: a [AGE] year old male admitted to the facility on [DATE] with a diagnosis list that included: Other acute osteomyelitis, right tibia and fibula (primary), Other bacterial infections of unspecified sites, Other specified bacterial agents as the cause of diseases classified elsewhere, Resistance to multiple antibiotics, Metabolic encephalopathy, gangrene not elsewhere classified, acquired absence of left finger, Buergers disease(disease of blood vessels of arms and legs), NSTEMI (heart attack), Pleural effusion, Type one diabetes mellitus with hypoglycemia without coma, Peripheral vascular disease, End stage renal disease, Altered mental status, Cognitive communication deficit, Unspecified dementia, moderate, with other behavioral disturbance, Acquired absence of left leg below knee, Dependence on renal dialysis Unspecified protein calorie malnutrition. Record review of Resident #21 Quarterly MDS dated [DATE] revealed: A BIMS of 5 meaning severe cognitive impairment. IV medication while a resident of the facility. Record review of Resident #21 Care plan dated 4/12/23 revealed: Focus: on IV medications related to osteomyelitis to right tibia and fibula, resistance to multiple antibiotics. initiated 2/22/23. Goal: Will not have any complications related to IV therapy through the review date. Intervention: . change PICC line dressing every 7 days per order. Record review of Resident #21 Medication Administration Record dated 4/11/23 revealed: PICC line dressing change weekly and PRN one time a day every Tuesday for infection control. May change if dressing is falling off, notify if site won't stop bleeding, if arms circumference changes or if external catheter length changes. Order date 3/21/23. During an observation on 4/11/23 at 2:16 PM, RN-E performed a dressing change of Resident #21's PICC line. He washed his hands and donned clean gloves. RN-E opened all supplies for PICC line dressing change. He then placed a mask on resident and preceded to use an alcohol swab to assist in removal of old PICC line dressing. RN-E doffed gloves then donned sterile gloves without performing any hand hygiene. He then cleaned skin around Resident #21's PICC line port access. RN-E then utilized a skin prep wipe to protect the skin and placed a clear window dressing cover over Resident #21's PICC line. He placed a label on the dressing that included the date and RN-E's initials. RN-E then flushed the PICC line with an immediate blood return and 10CC's of normal saline. During an interview on 4/11/23 at 2:40 PM, RN-E said hand hygiene should be performed before starting the procedure and then after the procedure. He said staff should also wash hands with soap and water after doffing gloves and before donning sterile gloves. RN-E said the PICC line went directly into a resident's brachial artery that leads to the heart and allowed for IV fluids to circulate the body faster. RN-E said there was potential for greater infection with the PICC line. During an interview on 4/12/23 at 4:15PM, DON said hand hygiene should be performed between glove changes. She said it was preferred that soap and water hand washing would be performed before donning surgical gloves for a sterile procedure. Record review of facility Infection Control Covid-19 information labeled Nursing Home Visitation revised 9/23/22 revealed: Face covering or mask (covering mouth and nose) in accordance with CDC .If the nursing home's county Covid-19 transmission is high, everyone in a healthcare setting should wear face coverings or masks. Record review of Covid-19 CDC guidance accessed on 4/18/23 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revealed: Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing . When SARS-CoV-2 Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients . HCP could choose not to wear source control when they are in well-defined areas that are restricted from patient access. Record review of facility policy labeled Handwashing dated 9/20 revealed: It is the policy of this community to cleanse hands to prevent transmission of possible infectious material and to provide a clean, healthy environment for residents and staff. Handwashing is considered the most important single procedure for preventing the spread of infections. Record review of the National Institute of Health last updated 9/5/22 accessed at https://www.ncbi.nlm.nih.gov/books/NBK459338/ on 4/13/23 revealed: By definition, a central catheter is a venous access device that ultimately terminates in the superior vena cava (SVC) or right atrium (RA). They can be inserted centrally (centrally inserted venous catheter; CICC) or peripherally (PICC). PICCs are placed through the basilic, brachial, cephalic, or medial cubital vein of the arm. The right basilic vein is the vein of choice due to its larger size and superficial location. Additionally, it has the straightest route to its destination, as it courses through the axillary vein, then through the subclavian, and finally, settles in the SVC. Other factors that have been thought to make the basilic vein the superior choice for PICC lines are that it has the least number of valves, better hemodilution capabilities and has a shallower angle of insertion compared to other veins.

Based on interview and record review the facility failed to care for the residents in a manner and in an environment that promoted maintenance of or enhancement of each resident's quality of life for 1 of 5 (Resident #1). The facility failed to implement plans of care when she was calling for help for over two hours when her surgical dressing was soaked with drainage. She needed to evacuate her bladder and bowels when she was non-weight bearing. This failure could affect five residents who required assistance for ADL's and were unable to bear weight on their lower extremities. Findings included: Review of Resident #1's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #1's medical record documented a physician order [REDACTED]." Review of Resident #1's medical record docmented "Admission Care Plan" dated 7/27/12 revealed "......Assess for pain .....bathing/hygiene assist X1 ......dressing/grooming assist of one .....toileting amount of assist of one person .....ambulation/transfer assist of one person ....medications given as ordered ... ...keep call light in reach when in room ...encourage use of call light .....toileting - as requested uses bedpan ....incontinent care every two hours .....call for assistance as needed ... ....administer pain medication as ordered .....monitor effectiveness of pain medication .....monitor for pain ....follow orders for positioning/weight bearing ....." Telephone interview on 8/10/12 with Resident #1's daughter revealed that her mother was admitted to the facility 7/27/12 approximately 2:30 p.m. She stated that her mother requested side rails for her bed and was told that the facility does not allow side rails, which the facility would get her mother a bed that was low to the ground and place a mat beside her bed. She stated that did not happen that afternoon, that is was approximately a week later. She stated the evening of 7/28/12 at 12:30 a.m. she received a call from her mother, in which her mother was crying and told her that she had been calling for help over two hours and no one had answered her call light and that her mother was scared that she was the only person in the facility. Resident #1's daughter stated she arrived at the facility at 12:40 a.m., walked into the rear entrance where the door was open and was unable to find any facility staff for a few minutes. She stated that her mother's bed was soaked in drainage from her surgical incision and needed assistance for elimination of her bladder and bowels. She stated that staff did finally come to assist her mother, they threw dirty, soiled linens on the floor, and did not wipe down the mattress that was still moist from the drainage. She spoke with LVN #A that told her "It's not right about what goes on here ....that one CNA (certified nurse's aide) went home at 9:00 p.m. and they were short-handed ...." Resident #1's daughter stated that she insisted that the Administrator be called; he arrived just before 1:00 a.m. and called another staff member in to assist on that hall where Resident #1 resided. Interview on 8/10/12 at 4:20 p.m. with Resident #1, who is alert and oriented, revealed that she was crying and was scared on 7/27/12, the night when she was admitted to the facility. She stated that the last time she saw facility staff was between 7:30 p.m. and 8:00 p.m., she was watching the news, which comes on at 10:00 p.m. and put on her call light because she needed to use the restroom and her wound drainage was soaking the bandage. She stated that at 11:30 p.m. she started yelling for help. She stated that she called her daughter to come help her at 12:30 a.m. her daughter arrived at 12:40 a.m. She stated that she was very scared, she thought that the facility staff had left her alone and since she was unable to bear weight and has a below knee amputation on her other leg, she can't get up out of bed herself. Resident #1 was very tearful during this interview, she was repeating "I thought that everyone had left and I was the only one here. I thought they had forgotten about me. " Resident #1 stated that on 7/31/12, her wound bandage was changed on 7/31/12 and was not changed again until 8/2/12, she stated she knows this because she writes everything down and she looks for the date and initials that the nurses put on the bandage. Resident #1 stated that on 8/8/12, Wednesday, she gets her baths on Monday, Wednesday and Friday, she did not receive her bath and she had called her husband to come give her a bath. She stated that a CNA came to her room after shift change after 6:00 p.m. and she requested her bath, a CNA stated "How about I come in early in the morning and give you a bath then, I don't have time now." She stated her husband gave her a bath then. Review of Resident #1's medical record revealed "Pain Risk Assessment" dated 7/27/12 documented a total score of "13" which represented as "High Risk" for pain. Review of Resident #1's " Nursing & Rehabilitation Care Plan - ADL's extensive assist" dated 8/5/12 documented "I require extensive assist of one or two for ADL's due to [MEDICAL CONDITION] and I have had a BKA (below knee amputation) of my other leg and I can't do much ......" Review of Resident #1's "Nursing & Rehabilitation Care Plan - Pain Management - acute/chronic" dated 8/5/12 documented "I have [MEDICAL CONDITION] Arthritis and experience chronic pain. I also recently had a fall with a [MEDICAL CONDITION] and have acute pain also and receive [MEDICATION NAME] (a controlled medication prescribed to relieve pain) as needed for pain ........" Review of Resident #1's "Nursing & Rehabilitation Care Plan - Treatments" dated 8/5/12 documented "......I am currently receiving treatment to my left hip, cleanse with normal saline, apply gauze and apply [MEDICATION NAME] (a clear adhesive used to cover wounds) daily .....I am also non-weight bearing on my left lower extremity ...." Review of Resident #1's "Nursing & Rehabilitation Care Plan - Incontinent Care" dated 8/5/12 documented "I am occasionally incontinent of urine and require extensive assist to toilet - I may use adult briefs ... ....Answer my call light promptly .....check me every two hours for incontinent care and assist me with changing ....." Review of Resident #1's "Nursing & Rehabilitation Care Plan - Falls " dated 8/5/12 documented " I am at risk for falls due to my recent fall that resulted in a [MEDICAL CONDITION] and my BKA (below knee amputation) need for assist with all ADL's ......" Review of Resident #1's "Nursing & Rehabilitation Care Plan - Fractures" dated 8/5/12 documented ...I have had an injury resulting in a fracture with the potential for further injuries due to falls. I fell and fractured my hip ... ....Administer pain medication as ordered per physician .....Assist me with ADL's ......" Interview on 8/10/12 at 2:55 p.m. with the facility Administrator revealed that he was called 7/28/12 and arrived at the facility at 1:00 a.m. He stated that the facility had been shorthanded on CNA's and he called staff and staff came into work. The Administrator stated that the usual staffing pattern for Hall 3 was one nurse and two CNA's at night. However, that night there was one CNA, because another CNA had left, which left one CNA on Hall 3. Requested clock in and out time sheets for the 7/27/12 time sheets and had not received them prior to exit. The Administrator had made a "graph" of staffing for the evening of 7/27/12, and did not provide the night shift time sheets as requested prior to exit. Review of CMS 672, Resident Census and Condition of Residents, dated 8/10/12, revealed a census of 88.