Every finding on record at Yoakum Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food and nutrition services. The facility failed to ensure food items were properly dated in the refrigerator and the freezer. The facility failed to ensure dietary staff used facial hair restraints properly during meal preparation and dish washing. These failures could place residents at risk for food borne illness. The findings included: During observation and interview on 07/07/2026 at 10:50 a.m. revealed in refrigerator #1 clear gallon container of what looked like fried rice and a clear gallon container of corn both items were not dated. The Dietary Manager stated he believed they were put in the refrigerator yesterday but could not tell due to there not being a date on the containers. The Dietary Manager removed the items and threw them out. During an observation and interview of freezer #2 on 07/07/2026 at 10:55 a.m. revealed a clear gallon container with a substance that looked to possibly be refired beans with no label or date. The Dietary Manager stated the container was fortified pudding that had been placed in the freezer to chill after having been made that morning. The Dietary Manager stated the items in the refrigerator and the freezer should have been labeled and dated by the staff members who placed them in the refrigerator and freezer. During an observation on 07/09/2026 at 10:46 a.m. the Dietary Manager was observed assisting with puree preparation wearing a beard restraint pulled over his mustache and chin but did not cover the hair leading to his neck with the hair showing from under the beard restraint along the neckline open to air. The Dietary Manager was observed during the puree preparation assisting the cook by taking the blending container from the processor between food items that were pureed to the 3 compartments sink, washing, rinsing then returned to the cook. During an interview on 07/09/2026 at 3:36 p.m. the Dietary Manager stated hair restraints were to be worn at all times in the kitchen. The Dietary Manager further stated all hair should be restrained. The Dietary Manager stated his beard restraint should have covered all of his facial hair. The Dietary Manager stated they were used due to not wanting hair to fall out and get in the food. The Dietary Manager stated that by not wearing hair restraints or wearing them properly could cause the potential for contaminated food and residents could receive contaminated food. During an interview on 07/10/2026 at 11:39 a.m. the Administer stated food should have been labeled and dated when stored in the refrigerator and freezer. She further stated this was to prevent spoiling, and just numerous other reasons. The Administrator stated by labeling and dating items would avoid the risk of someone becoming sick. The Administrator stated beard restraints were to be worn if a male had facial hair/beard, and the facial hair needed to be covered all the time they were in the kitchen. The Administrator stated the hair restraints prevented hair from getting in the food and prevented residents being at risk of consuming the hair and cross contamination. Review of facility's policy, Food Storage, revised date June 1, 2019, read, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US Food Codes, and HACCP guidelines. Procedure: 2. Refrigerators: d. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.3. Freezers: e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Review of facility's policy, Employee Sanitation, dated October 1, 2018, read, Policy: The Nutrition & Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure: 3. Employee Cleanliness Requirements: b. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; for 1 of 4 hallways with 12 residents residing on the hallway reviewed for environment, in that:The facility failed to ensure a housekeeping cart on 200-hall was locked while unattended that contained potentially unsafe cleaning chemicals.This deficient practice could place residents at risk of coming in contact with potentially unsafe cleaning chemicals.The findings included: Observation on 07/07/2026 at 11:40 a.m. revealed on the 200-hall secure unit a housekeeping cart sitting near the middle of the hallway in front of the shower room, unattended, the shower room door was closed with no residents in the hallway. Observation on 07/07/2026 at 11:45 a.m. revealed the housekeeping cart remained in middle of the 200-hall outside of the shower room unlocked. The observation further revealed the domed top to be rolled back unlocked and the doors to the cart unlocked with the following items: 1. Micro Kill spray bleach 32-ounce bottle approximately half full warning to keep out of reach of children CAUTION. 2. Clorox Germicide 32-ounce spray bottle full warning to keep out of reach of children CAUTION.3. DC33 Detergent Disinfectant 2 spray bottles with one bottle approximately half full and one spray bottle full warning to keep out of reach of children DANGER. During interview and observation on 07/07/2026 at 11:55 a.m. Housekeeper D was observed coming out of the shower room. Housekeeper D stated his cart should have been locked. Housekeeper D further stated it should have been locked so residents would not be able to get into the chemicals on the cart. Housekeeper D stated it was important to lock the cart so something bad did not happen like a resident accidentally eating or drinking the chemicals. Houskeeper D stated he was supposed to lock the cart when it was not near him. Housekeeper D was then observed taking his cart with him into the shower room that had a punch key lock to the room. During an interview on 07/07/2026 at 11:57 a.m. the Administrator stated the housekeeper's cart should have been locked if they were not right by it. The Administrator stated by the cart not having been locked it could have placed residents at risk of getting to the chemicals and they could ingest them. The administrator stated the effect on the residents was dependent on what the chemical was and if they ingested them. During an interview on 07/10/2026 at 10:01 a.m. the Environmental Supervisor stated housekeepers should close the carts and then go in to clean, and the cart should be always locked. The Environmental Supervisor stated the housekeeping cart should not have been unlocked if the housekeeper was not present. The Environmental Supervisor stated the housekeeping carts should be locked so that there would not be the risk of a resident getting to the chemicals such as getting on their skins or getting in their mouths. Review of the facility's policy, General Housekeeping Policies, no date, read, The facility provides sufficient housekeeping and maintenance personnel, equipment, and supplies to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. All Bleaches, detergents, disinfectants, insecticides, and other potentially hazardous substances are labeled and kept in a safe place accessible only to employees.

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 1 nursing station reviewed for storage. The facility failed to ensure that a Trulicity auto-injector pen was stored in a locked compartment. This failure could place residents at risk of misappropriation of medications. The findings were:Observation on 07/09/2026 at 12:00 p.m. a Trulicity auto-injector pen (once-weekly subcutaneous injection used to treat type 2 diabetes) was observed sitting on the nurses' station on top of an alcohol swab, no name, with no staff present at or around the nurses' station. Observation on 07/09/2026 at 12:04 p.m. LVN C approached the nurses' station and sat at the opposite side of the station with her back to the side where the Trulicity auto-injector pen was sitting on the station and answered the phone. During an interview and observation on 07/09/2026 at 12:10 p.m. LVN C stated the medication was a Trulicity pen and was given as a weekly injection. LVN C stated it was a refrigerated medication and typically they would take them out to allow them to warm up some prior to giving it to the resident and this was possibly why it may have been sitting there. LVN C further stated the prescriptions were on the boxes the pens were kept in. LVN C stated typically they would have her watch them, but she was not aware of the medication being out and on the nurses' station. LVN C stated it should have been locked up in the cart or med room if no one was present. LVN C further stated by leaving out on the station and no one present a patient could just come and get it. LVN C stated this could possibly have an effect on a resident if they injected themselves, but it would depend on if the resident had a reaction to the medication. LVN C observed picking up the medication. During an interview on 07/09/2026 at 1:24 p.m. LVN B stated she had taken the medication out because she was going to give it to the resident after lunch. LVN B further stated she was just waiting for the resident to come out of the dining room. LVN B stated she had looked for him, and he was eating in the dining room. LVN B stated she did not believe anyone was going to grab it. LVN B stated the medication pen should have been locked in a cart so, nobody else would be able to get it. LVN B stated the reason it should have been locked in the cart was they did not want someone to take a shot that they don't need. LVN B further stated this could put a resident at risk of blood sugar dropping for someone who did not need it. During an interview on 07/09/2026 at 1:38 p.m. the DON stated the medication pen was a medication that was refrigerated and LVN B had pulled it for the resident to give when he left the dining room. The DON stated LVN B must have been pulled away but did not know what the situation was as to why the medication pen was left unattended. The DON stated the medication pen should not have been left on the station. The DON stated it should have been placed in the fridge until she was able to give it to the resident. The DON stated the medication was an injection and if a resident or staff member wasn't being honest, they could walk away with the medication. The DON further stated the medication was for diabetes and could possibly affect a resident if they injected themselves with it. During an interview on 07/10/2026 at 11:35 a.m., the Administrator stated the medication should have been stored in the medication cart. The Administrator stated any resident could have wandered up grabbed the medication, lost the medication, or have taken the medication. The Administrator further stated a negative effect would depend on the medication. The Administrator stated the charge nurse was responsible for ensuring medication was stored properly. Review of facility's policy, Medication Carts and Supplies for Administering Meds, revised date 10/01/2019, read, Policy: The facility maintains equipment and supplies necessary for the preparation of and administration of medications to residents. The mobile medication care will be used to facilitate administration of medications to residents. The purpose of system is to ensure appropriate control and surveillance of resident assigned medications.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 24 residents (Resident #18) reviewed for infection control in that: The facility failed to ensure CNA A changed soiled gloves and sanitized hands prior to applying Resident #18's clean C brief during incontinent care. The facility failed to ensure LVN B adhered to EBP recommendations and wore a gown when she administered an enteral medication for Resident #18. These facility failures affect residents who need assistance with ADL's or who require feeding tubes to receive medications and could result in cross contamination and the spread of infections.The findings include: Record review of Resident #18's electronic face sheet dated 07/08/2026 reflected a [AGE] year-old female admitted on [DATE]. Her diagnoses included: gastrostomy status (opening in stomach from the abdominal wall, made surgically for the introduction of food and medications) and Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain). Record review of Resident #18's quarterly MDS assessment dated [DATE] reflected that she usually understood and could sometimes be understood. She scored a 10 of 15 on the BIMS which signified her cognitive status was moderately impaired. She required maximal assistance with ADLs and dependent on toileting, hygiene. She was always incontinent with bowel and bladder. Record review of Resident #18's Active Orders as of: 07/08/2026 reflected she received enteral feedings as of 05/25/2026. Record review of Resident #18's comprehensive care plan dated 01/21/2026 reflected Focus, has tube placement with water flushes, receives feedings, Interventions, Enhanced barrier precautions per CDC guidelines. Further review reflected, Focus, has bowel and bladder incontinence, Interventions, Provide peri care after each incontinent episode. Observation on 07/09/2026 10:34 a.m. of CNA A performed incontinent care for Resident #18, revealed she took away the soiled brief and then proceeded to pull the clean brief through without changing gloves and sanitizing hands. During an interview on 07/09/2026 at 10:35 a.m., CNA A, stated she was trained to clean hands and change gloves between soiled and clean items. She stated not doing so could result in cross contamination and the residents getting an infection. Observation on 07/09/2026 at 10:55 am observation, LVN B administered Resident #18's potassium chloride 20meq/15ml, 15 ml via G-tube. Resident #18 was on EBP for her enteral feedings and LVN B did not wear a gown when she administered the medication. During an interview on 07/09/2026 at 11:00 a.m., LVN B stated she forgot to wear a gown, and it was on her mind, don't forget your gown. She stated she was trained for residents on EBP to put on the appropriate PPE. She stated not wearing a gown could result in a resistant infection for the residents by cross contamination. During an interview on 07/10/2026 at 11:30 a.m., the DON stated, CNA A needed to remove her soiled gloves and sanitize her hands and put on clean gloves prior to pulling Resident #18's clean incontinent brief through to be fastened. She stated that it could lead to cross contamination and cause a urinary tract infection. She stated LVN B should have worn a gown when she administered G-tube medication for Resident #18, and it could result in a multi drug resistant organism infection. During an interview on 07/10/2026 at 12:00 p.m., the ADM stated CNA A and LVN B both needed to comply with infection control practices to prevent the spread of infection. She stated she was accountable for all care in the facility. Record review of the facility's policy and procedure titled Hand Hygiene dated 10/24/2022 reflected All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors, the use of gloves does not replace hand hygiene. If the task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Record review of the facility's policy and procedure titled Enhanced Barrier Precautions dated 11/24/2025 reflected, Initiation of Enhanced Barrier Precautions, make gowns and gloves available outside of the resident's room. Further review reflected, High-contact resident care activities include device care or use, feeding tubes. Record review of the facility's policy and procedures titled Infection Prevention and Control Program dated 05/13/2023 reflected This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

Based on observation, interviews and record reviews, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 5 residents (Resident #1) observed for call light placement. The facility failed to ensure Resident #1's call light was within reach. This deficient practice could place residents at risk for decreased ability to contact staff for assistance. The findings included: Record review of Resident #1's electronic face sheet dated 05/29/26 reflected a [AGE] year-old male admitted on [DATE]. His diagnoses included: normal pressure hydrocephalus (brain disorder in which excess cerebrospinal fluid accumulates in the brain's ventricles, causing thinking and reasoning problems and difficulty walking), bipolar disorder (condition that causes extreme mood swings) and schizoaffective disorder (mental health condition, marked by a mix of symptoms such as hallucinations and delusions). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected he could understand others and be understood. He scored 9 of 15 on his BIMS which signified his cognitive status was moderately impaired. He required moderate assistance with ADLs. He used a walker for mobility. Record review of Resident #1's FRA dated 05/19/2026 reflected he was high risk for falls. Record review of Resident #1's comprehensive care plan dated 03/11/2026 reflected Focus, is at risk for falls r/t Normal Pressure Hydrocephalus, unsteady gait, use of w/c for mobility, history of falls, be sure the resident's call light is within reach. Observation on 05/29/2026 at 10:30 am accompanied by the ADON, Resident #1 was on the male secured unit. He was sitting in a chair across the room from his bed near the window, his call light was hooked on the room divider curtain approximately 6 feet away, and his walker was in front of him. During an interview on 05/29/2026 at 12:40 pm, Resident #1 stated he would have to cross the room to get his call light if he needed help. He stated he would use the call light if it were located near him. He stated he had not used a wheelchair since he was admitted and always ambulated with a walker. During an interview on 05/29/2026 at 1:13 pm, CNA A, who tended to Resident #1 stated she did not realize his call light was not within reach and missed it. She stated Resident #1 never had a wheelchair and always used a walker. During an interview on 05/29/2026 at 1:20 pm, MA B, who administered medications for Resident #1 on the male secured unit stated she saw him up in a chair but did not think about the call light not being near him. She stated he needed to reach the call light to call for help. During an interview on 05/29/2026 at 1:34 pm, the ADON stated she did not think about putting the call light within Resident #1's reach when she was there earlier. She stated he had fallen previously and it was important to have his call light within reach so he could call for assistance. During an interview on 05/29/2026 at 1:43 pm, the DON stated Resident #1's call light needed to be within his reach, so he could call for help and not fall if he transferred himself. Record review of the facility policy and procedure titled Call Lights: Accessibility and Timely Response dated 10/13/2022 reflected Staff will ensure the call light is within reach of resident and secured, as needed.

Based on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected the status of the residents for 1of 5 residents (Residents #1) reviewed for resident assessments. The Facility failed to ensure Resident #1's fall on 04/15/2026 was reflected on his quarterly MDS assessment dated [DATE]. This deficient practice could place residents at risk of missed or inaccurate care. The findings included: Record review of Resident #1's electronic face sheet dated 05/29/26 reflected a [AGE] year-old male admitted on [DATE]. His diagnoses included: normal pressure hydrocephalus (brain disorder in which excess cerebrospinal fluid accumulates in the brain's ventricles, causing thinking and reasoning problems and difficulty walking), bipolar disorder (condition that causes extreme mood swings) and schizoaffective disorder (mental health condition, marked by a mix of symptoms such as hallucinations and delusions). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected he could understand others and be understood. He scored 9 of 15 on his BIMS which signified his cognitive status was moderately impaired. He required moderate assistance with ADLs. He was not coded to have any falls since admission/entry or reentry or prior assessment, whichever was more recent. He used a walker for mobility. Record review of Resident #1's FRA dated 05/19/2026 reflected he was high risk for falls. Record review of Resident #1's comprehensive care plan dated 03/11/2026 reflected Focus, is at risk for falls r/t Normal Pressure Hydrocephalus, unsteady gait, use of w/c for mobility, history of falls, be sure the resident's call light is within reach. Observation on 05/29/2026 at 10:30 am accompanied by the ADON, Resident #1 was on the male secure unit. He was sitting in a chair across the room from his bed near the window. During an interview on 05/29/2026 at 12:40 pm, Resident #1 stated he had fallen in April. During an interview on 05/29/2026 at 12:45 pm, the MDS nurse stated she did not know how she missed reflecting Resident f#1's fall on his quarterly MDS assessment dated [DATE], but she did. She stated the MDS needed to be accurate to reflect the residents and their care requirements or care could be missed. She stated the facility did not have a separate policy that addressed MDS accuracy and she followed the RAI manual. During an interview on 05/29/2026 at 1:43 pm, the DON stated Resident #1 had fallen in April and May, but she could not provide the incident reports because they were part of their QA program. She stated the importance of MDS accuracy was that the care required based on an accurate picture of the resident, and care could be missed. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025 reflected The RAI process has multiple regulatory requirements. Federal regulation required the assessment accurately reflects the resident's status.

Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment for 1 resident of 5 residents (Resident #1) reviewed for care plans. The facility failed to implement Resident #1's intervention of keeping his call light within reach, and reflected he required a w/c on his fall care plan instead of a walker. These deficient practices could place residents at risk for missed or inaccurate care.The findings included: Record review of Resident #1's electronic face sheet dated 05/29/26 reflected a [AGE] year-old male admitted on [DATE]. His diagnoses included: normal pressure hydrocephalus (brain disorder in which excess cerebrospinal fluid accumulates in the brain's ventricles, causing thinking and reasoning problems and difficulty walking), bipolar disorder (condition that causes extreme mood swings) and schizoaffective disorder (mental health condition, marked by a mix of symptoms such as hallucinations and delusions). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected he could understand others and be understood. He scored 9 of 15 on his BIMS which signified his cognitive status was moderately impaired. He required moderate assistance with ADLs. He used a walker for mobility. Record review of Resident #1's FRA dated 05/19/2026 reflected he was high risk for falls. Record review of Resident #1's comprehensive care plan dated 03/11/2026 reflected Focus, is at risk for falls r/t Normal Pressure Hydrocephalus, unsteady gait, use of w/c for mobility, history of falls, be sure the resident's call light is within reach. Observation on 05/29/2026 at 10:30 am accompanied by the ADON, Resident #1 was on the male secured unit. He was sitting in a chair across the room from his bed near the window, his call light was hooked on the room divider curtain approximately 6 feet away, and his walker was in front of him. During an interview on 05/29/2026 at 12:40 pm, Resident #1 stated he would have to cross the room to get his call light if he needed help. He stated he would use the call light if it were located near him. He stated he had not used a wheelchair since he was admitted and always ambulated with a walker. During an interview on 05/29/2026 at 12:45 pm, the MDS nurse stated she did not know how Resident #1's care plan reflected w/c under his fall area when he used a walker. She stated the importance of the care plan was, it provided information for the aides on what the residents needed and care could be missed. During an interview on 05/29/2026 at 1:13 pm, CNA A, who tended to Resident #1 stated she did not realize his call light was not within reach and missed it. She stated Resident #1 never had a wheelchair and always used a walker. During an interview on 05/29/2026 at 1:20 pm, MA B, who administered medications for Resident #1 on the male secured unit stated she saw him up in a chair but did not think about the call light not being near him. She stated he needed to reach the call light to call for help. During an interview on 05/29/2026 at 1:34 pm, the ADON stated she did not think about putting the call light within Resident #1's reach when she was there earlier. She stated he had fallen previously and it was important to have his call light within reach so he could call for assistance. During an interview on 05/29/2026 at 1:43 pm, the DON stated Resident #1's call light needed to be within his reach, so he could call for help and not fall if he transferred himself. She stated the care plan intervention was not implemented. She stated he used a rollator and has not used a wheelchair. Record review of the facility policy and procedure titled Comprehensive Care Plans dated 10/24/2022 reflected It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on interviews and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as those which had not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay for 1 of 3 residents (Resident #1) reviewed for having their grievances heard. LVN A failed to generate a grievance report for Resident #1's Representative's grievance made on 10/20/2025 when Resident #1's representative complained that Resident #1 had blood on his linens as observed through a bedroom camera. LVN A failed to generate a grievance report for Resident #1's Representative's grievance made on 10/25/2025 at 6:05 AM when Resident #1's Representative complained that Resident #1 did not have the use of a bedside table. These failures could place residents at risk for demoralized spirits and low self-esteem. The findings included: A record review of Resident #1's admission record dated 11/4/2025 revealed an admission date of 4/11/2025 and a discharge date of 11/1/2025; with diagnoses which included dementia (a general term for a decline in cognitive function, affecting memory, thinking, and social abilities to the extent that it interferes with daily life.). review revealed Resident #1 was a [AGE] year-old male admitted for long term care with ADL needs for dementia. A record review of Resident #1's care plan dated 11/4/2025 revealed, (Resident #1) has an ADL self-care performance deficit related to dementia . Resident requires substantial / maximal assistance for personal hygiene. A record review of Resident #1's physicians orders dated 7/5/2025 revealed the physician ordered for Resident to receive care related to his indwelling urinary catheter twice a day and as needed. A record review of Resident #1's medication administration record for October 2025 revealed LVN A documented she provided urinary indwelling Catheter care on the evening of 10/20/2025. A record review of Resident #1's nursing progress notes dated 10/25/2025 at 6:05 AM, revealed LVN A documented, Note Text: resident's (representative) called upset wanting to know why did his bedside table get taken out of his room. wanted to know if we had put him off to eat on his own, I explained to her that her (resident #1) had eaten in the dining room that it was being borrowed it was not used for him.[sic] During an interview on 11/4/2025 at 11:00 AM Resident #1's Representative stated she was unsatisfied with the care provided for Resident #1. Resident #1's Representative stated she had made many grievances to the facility regarding Resident #1's care and gave 2 examples:1. On October 20th, 2025, she reviewed the evening video footage captured by the bedroom camera which revealed at 7:02 PM LVN A entered Resident #1's room and discovered Resident #1 was seated on his bedside. LVN A redirected Resident #1 back to bed and covered him with blankets. Resident #1's Representative stated she observed some blood to Resident #1's linens and blankets. Resident #1's Representative stated she called the facility sometime that evening approximately around 10:00 PM and spoke to LVN A and inquired about Resident #1's bleeding and complained about LVN A's care, specific for urinary indwelling catheter.2. Resident #1's Representative stated on 10/25/2025 at 6:00 AM she called the facility and spoke to LVN A and complained that Resident #1's bedside table was not at the bedside as observed with the in-room camera.Resident #1's Representative stated her grievances were not resolved.During an interview on 11/4/2025 at 5:50 PM LVN A stated she was a nurse for the facility and usually worked the 6:00 PM to 6:00 AM shift and had cared for Resident #1. LVN A stated Resident #1 was a [AGE] year-old male under hospice and facility care. LVN A stated Resident #1 had a need for a urinary indwelling catheter related to his enlarged prostate urinary retention. LVN A stated she was familiar with Resident #1's Representative who had a camera in the resident's' bedroom and often made complaints. LVN A stated she recalled sometime late last month, October 2025, Resident #1's representative called the facility late in the evening and complained she had reviewed the camera footage and saw some blood on the bed linens. LVN A stated she had rounded on Resident #1's several times that evening and redirected him back to bed when she would find him sitting on his bedside. LVN a stated Resident #1 had a history of tugging / pulling on his urinary indwelling catheter and had caused some bleeding. LVN A stated she had assessed Resident #1 without any bleeding to the urinary indwelling catheter and redirected him back to bed. LVN A stated Resident #1's Representative called the morning of 10/25/2025 and spoke with her to complain that Resident #1 was not in his room, and neither was his bedside table. LVN A speculated Resident #1's Representative believed Resident #1 was put aside and not cared for. LVN A stated she reported to Resident #1's Representative that Resident #1 was attending the breakfast service and his bedside table was moved temporarily. LVN A stated she had not documented Resident #1's complaints but had training to help residents and their representatives to generate a grievance report to have their grievances reviewed by the leadership and have their grievances resolved. During a joint interview on 11/05/2025 at 3:20 PM the Administrator and the DON stated the expectation for grievances was for staff who hear a grievance should assist the complainant to generate a grievance form and submit the grievance form to the Administrator and/ or the DON. The Administrator and DON stated LVN A had not generated a grievance form for Resident #1's Representative's complaints. The Administrator and the DON stated the potential negative outcomes for residents was their grievances may go unresolved. A record review of the facility's Resident and Family Grievances policy dated 10/4/2025 revealed, Policy: It is the policy of this facility to support each residents and family members right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their long term care facility stay. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form.

Based on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized for 1 of 3 residents (Resident #1) reviewed for reviewed for accurate records. LVN A and LVN B failed to document the failed attempts to instill a urinary indwelling catheter for Resident #1 and the report to the physician. These failures could place residents at risk for diminished health status. The findings included: A record review of Resident #1's admission record dated 11/4/2025 revealed an admission date of 4/11/2025 and a discharge date of 11/1/2025; with diagnoses which included dementia (a general term for a decline in cognitive function, affecting memory, thinking, and social abilities to the extent that it interferes with daily life). Further review revealed Resident #1 was a [AGE] year-old male admitted for long term care with ADL needs for dementia. A record review of Resident #1's care plan dated 11/4/2025 revealed, (Resident #1) has an ADL self-care performance deficit related to dementia . Resident requires substantial / maximal assistance for personal hygiene. A record review of Resident #1's physicians orders dated 7/5/2025 revealed the physician ordered for Resident to receive care related to his indwelling urinary catheter twice a day and as needed. A record review of Resident #1's physicians orders dated 9/11/2025, revealed, the physician ordered Resident #1 to have a urinary indwelling catheter to support his urinary retention complicated by an enlarged prostate; Foley Catheter: Change 22F with 30ml bulb q month every night shift starting on the 11th and ending on the 11th every month. A record review of Resident #1's medication administration record for October 2025 revealed LVN A documented she instilled Resident #1's urinary indwelling catheter on 11/11/2025. A record review of Resident #1's medical record for the review period of 11/10/2025 through 10/13/2025 revealed no documentation to detail Resident #1's indwelling urinary catheter, nor his change of condition or report to the physician of the change in condition. A record review of Resident #1's nursing progress notes dated 10/12/2025 revealed LVN B at 8:17 AM documented, Note Text: Resident noted with copious amounts of blood clots following having his foley catheter replace 3 hours prior. Dr. (name) on call called for Dr. (name), no answer awaiting response.[sic] During an interview on 11/4/2025 at 11:00 AM Resident #1's Representative stated she was unsatisfied with the care provided for Resident #1. Resident #1's Representative stated Resident #1 was hospitalized on [DATE] for bleeding related to his indwelling urinary catheter. Resident #1's Representative stated she learned from LVN B that attempts to change Resident #1's indwelling urinary catheter were unsuccessful, and the physician ordered for Resident #1 to be hospitalized for evaluation and treatment. During an interview on 11/4/2025 at 5:50 PM LVN A stated she was a nurse for the facility and usually worked the 6:00 PM to 6:00 AM shift and had cared for Resident #1. LVN A stated Resident #1 was a [AGE] year-old male under hospice and facility care. LVN A stated Resident #1 had a need for a urinary indwelling catheter related to his enlarged prostate urinary retention. LVN A stated Resident #1 had a history of tugging / pulling on his urinary indwelling catheter and had caused some bleeding. LVN A stated Resident #1's physician had ordered for Resident #1 to have his Indwelling urinary catheter changed once a month beginning on 10/11/2025 during the evening shift. LVN A stated she worked that evening and decided to change the catheter the morning of 10/12/2025 around 5 AM in order to have another nurse available if she had complications. LVN A stated when she attempted to instill the new catheter she met with resistance and had no urine return flow and had reported the finding to the next nurse, LVN B. LVN A stated she had not documented the details of the procedure and stated she believed signing the medication administration record was sufficient. LVN A stated she had not documented the nurse-to-nurse report either. During an interview on 11/4/2025 at 6:00 PM LVN B stated she was an LVN at the facility and usually worked 6 AM to 6 PM and recalled she received a report from LVN A on the morning of 10/12/2025 where LVN A had a difficult procedure of instilling an indwelling foley catheter for Resident #1 and had received a report from a CNA that Resident #1 had bleeding evidence in his adult brief. LVN B stated she and LVN A assessed Resident #1 with no return urine flow and LVN B re-attempted to instill a fresh indwelling urinary catheter with no success. LVN B stated she could not overcome Resident #1's enlarged prostate to reach the bladder evidenced by no urine return flow. LVN B stated she reported the findings to the physician and received new orders for Resident #1 to be transferred to the hospital for evaluation and treatment. LVN B stated she believed she had documented the details of the incident and upon record review stated she had not documented details to accurately document the chain of events. During a joint interview on 11/05/2025 at 3:20 PM the Administrator and the DON stated the expectation for accurate records was for staff who provided care would document the care provided to include enough details to effectively document the care. The Administrator and the DON stated the facility had a policy for documenting indwelling foley catheterization and followed the [NAME] guidance and procedures (a series of evidence-based, step-by-step clinical resources for healthcare professionals, primarily nurses, created by Wolters Kluwer. These online and print resources provide consistent and safe patient care guidelines at the point of care, offering detailed instructions, skills checklists, and competency assessments for a wide range of procedures and topics, as described on the Wolters Kluwer website.) The Administrator and the DON stated the potential negative outcome for residents could be inaccurate records. A record review of the [NAME] Solutions website https://procedures.lww.com/lnp/view.do?pId=4420096&hits=inserting,urinary,insertion,catheter,catheters,inserted,insert&a=true&ad=false&q=insert%20urinary%20catheterAccessed 11/4/2025, titled Procedures: Indwelling urinary catheter (Foley) insertion, assigned male at birth Revised: November 17, 2024, revealed, . Documentation associated with indwelling urinary catheter insertion includes:assessment findingsindication for catheter usedate and time of insertionsize and type of catheteramount of sterile water used to inflate the balloonintake and output (if ordered)characteristics and amount of urinecomplicationsname of the practitioner you notifieddate and time of notificationprescribed interventionspatient's response to those interventionsteaching provided to the patient and family (if applicable)understanding of that teachingfollow-up teaching needed.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 staff (FSS) reviewed for competency and skill sets. The FSS did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: During an interview on 05/27/2025 at 11:20 AM, the FSS stated she was not a certified dietary manager or certified food service manager, and he did not have an associate's or higher degree in food service management or in hospitality. He did not have 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting. He had completed a course of study in food safety management that included topics integral to managing dietary operations including foodborne illness, sanitation procedures, and food purchasing/receiving, but had not yet taken the exam to become a certified dietary manager and able to apply for certification. He consulted periodically with a registered dietitian, but the dietitian was not employed by the facility full-time. During an interview on 05/29/2025 at 3:12 PM, the HR Director stated the FSS assumed the position of FSS on 03/01/2024. During an interview on 05/29/2025 at 3:30 PM, the Administrator stated she was aware the FSS was not a certified dietary manager, certified food manager, or met the other qualifications to serve as the Director of Food and Nutrition Services for the facility. The Administrator stated the FSS would be taking the exam to become a certified dietary manager shortly. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with S2-102.12.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to discard a bag of salad mix dated 03/24/2025 containing brown and rotted leaves in the reach-in cooler. 2. The facility failed to ensure an opened bag of pinto beans in the dry storage room was properly sealed. 3. The facility failed to properly sanitize the compartments of the blender used to puree food for modified diets in accordance with manufacturer's instructions. These failures could place residents at risk for food borne illness. The findings included: 1. Observation on 05/27/2025 at 11:29 AM in the reach-in cooler revealed 5-lb. bag of salad mix with a label indicating it was received on 05/22/2025 and opened 05/23/2025. The bag was sealed and approximately 15% of the salad leaves had turned brown or were rotten. During an interview on 05/27/2025 at 11:30 AM, the FSS stated the salad mix should have been discarded. All dietary staff were responsible for properly labeling and dating food items stored in the cooler and discarding items past their use-by dates. 2. Observation on 05/27/2025 at 11:36 AM in the dry storage room revealed a 50-lb. bag of pinto beans on a rack. The bag had been opened and was rolled over. The bag was not sealed or placed in a sealed bin or container. During an interview 05/27/2025 at 11:37 AM the FSS stated the bag of pinto beans should have been placed in a sealed container, and failing to ensure food was properly sealed could result in deterioration in food quality and potential contamination from pests. 3. Observation on 05/29/2025 at 10:35 AM revealed [NAME] D used the high-speed blender to puree bread for the lunch meal for residents on a modified consistency (pureed) diet. After emptying the contents of the blender in a pan, [NAME] D took the blender to the preparation sink and rinsed the components in hot water. [NAME] D did not use hot, soapy water to wash the blender components or sanitize the components in a sink containing a sanitizing solution or use the dish machine to wash/sanitize the components. During an interview on 05/29/2025 at 10:36 AM, [NAME] D stated she was told she just needed to rinse the blender components in very hot water, almost too hot to touch, between the preparation of different foods for residents on a pureed diet. [NAME] D stated she had not used soap or sanitizing solution for the blender components after preparing pureed roast pork, pureed sweet potatoes or pureed cauliflower. During an interview on 05/29/2025 at 10:37 AM, the consultant RD stated utensils needed to be sanitized in the sink with sanitizing solution or in the dish machine. During an interview on 05/29/2025 at 10:55 AM, the FSS stated the dietary staff had been trained by his predecessor, and he would ensure the staff was retrained on proper sanitizing procedures for equipment and utensils. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, O. Retail Food Protection Program Information Manual: Recommendations to Food Establishments for Serving or Selling Cut Leafy Greens. Following 24 multi-state outbreaks between 1998 and 2008, cut leafy greens was added to the definition of time/temperature for safety food requiring time-temperature control for safety (TCS). The term used in the definition includes a variety of cut lettuces and leafy greens. Record review of facility policy 03.003 Food Storage revised 06/01/2019 reveled, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 1. Dry storage rooms. d. To ensure freshness, store opened and bulk items in tightly covered containers. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Record review of facility policy 04.005 Manual Cleaning and Sanitizing of Utensils and Portable Equipment approved 10/01/2018 revealed, Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for manual cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. 1. Use a three-compartment sink with running hot and cold water for cleaning, rinsing and sanitizing. 5. Prior to washing, pre-flush or pre-scrape all equipment and multi-use utensils. When necessary, presoak to remove gross food particles and soil. 6. In the first sink, immerse the equipment or utensils in a hot, clean detergent solution at a temperature of no less than 120 F. 7. Rinse in the second sink using clear, clean water between 120 F and 140 F to remove all traces of food, debris, and detergent. 8. Sanitize all multi-use eating and drinking utensils and the food-contact surfaces of other equipment in the third compartment by one of the following methods: a. Immerse for at least 30 seconds in clean, hot water at a temperature of 170 F or above. b. Immerse for at least 60 seconds in a clean sanitizing solution containing: i. A minimum of 50 parts per million of available chlorine at a temperature not less than 75 F. c. Be sure to cover all surfaces of the utensils and/or equipment with hot water or the sanitizing solution and keep them in contact with it for the appropriate amount of time. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 4-702.11 Before Use After Cleaning. UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning.

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 residents (Resident #52) whose assessments were reviewed, in that: Resident #52's quarterly MDS assessment incorrectly documented the resident as having received an insulin injection. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings were: Record review of Resident #52's face sheet, dated 05/28/2025, revealed an admitted [DATE] with diagnoses including: Dementia (progressive cognitive decline, affecting thinking, memory, and reasoning, impacting daily life), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (elevated level of any or all fat in the blood), and anxiety disorder (a group of mental illnesses that cause constant fear and worry). Record review of Resident #52's Physician orders and Medication administration records for March 2025 revealed an order for: Trulicity Solution Pen-injector 0.75 MG/0.5ML (Dulaglutide) Inject 0.75 mg subcutaneously one time a day every Thu related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. There was no order for insulin or record of insulin administration. Record review of Resident #52's Significant Change MDS, dated [DATE], revealed a BIMS score of 09, indicating moderate cognitive impairment. The assessment further indicated in Section N0300. Injections, A. Insulin injections, Resident #52 received one insulin injection during the previous seven days. During an interview on 05/29/2025 at 3:13 PM, the MDS LVN and the Regional Care Manager both stated they were unaware the medication Trulicity was not considered insulin since it was an injectable medication, and Resident #52's MDS dated [DATE] was incorrectly coded as the resident having received insulin. During an interview on 05/30/2025 at 12:30 PM, the Administrator stated Resident #52's Significant Change MDS dated [DATE] was incorrectly marked as the resident having received insulin when the resident received the medication Trulicity, which was not insulin. The entire nursing staff was unaware of the properties of this medication and would be subsequently trained on the difference between this medication and insulin. The facility used the RAI manual in lieu of a separate policy on coding MDS. Record review of Trulicity fact sheet, accessed on 06/05/2025, revealed, Trulicity is a non-insulin option that helps your body release the insulin it's already making. Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.11, October 2024 revealed, N0350: Insulin. 1. Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Determine if the resident received insulin injections during the look-back period. 3. Determine if the physician (or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) changed the resident's insulin orders during the look-back period. 4. Count the number of days insulin injections were received and/or insulin orders changed. Coding Instructions for N0350A o Enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received.

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 set forth at S483.10(c)(2) and S483.10(c)(3), that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #29) whose comprehensive person-centered care plans were reviewed. The facility failed to ensure that Resident #29's diagnosis of depression was a focus area in the resident's comprehensive care plan. This deficient practice could affect residents by failing to ensure residents received appropriate care for their health conditions. The findings included: Record review of Resident #29's face sheet dated 05/29/2025, revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with diagnoses including: Schizoaffective disorder (a chronic mental illness that combines symptoms of both schizophrenia and a mood disorder, such as depression or mania), major depressive disorder (a mental disorder characterized by persistent feelings of sadness, loss of interest, and difficulty functioning) and dementia (group of symptoms that affect memory, thinking, and other cognitive functions, significantly impacting daily life). Record review of Resident #29's Significant Change MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition. Further review of this MDS revealed in Section I - Active Diagnoses, I5800, Depression was checked. Record review of a note from the consultant psychiatric nurse practitioner dated 05/20/2025 revealed under Assessment/Plan the first diagnosis addressed was the resident's major depressive disorder. Record review of Resident #29's comprehensive care plan, updated 02/06/2025, revealed the diagnosis of depression was not listed as a focus area. During an interview on 05/29/2025 at 3:13 PM, MDS LVN C stated the diagnosis of depression was not listed as a focus area in Resident #29's comprehensive care plan and should be there. A possible reason for the omission might be because the resident was not taking any medication for the diagnosis, but the diagnosis should be listed regardless to ensure the resident received proper care. During an interview on 05/29/2025 at 3:15 PM, the Regional Care Manager stated the diagnosis of depression was not in Resident #29's comprehensive care plan and needed to be included in the care plan. During an interview on 05/30/2025 at 12:15 PM, the Administrator stated the diagnosis of depression should have been in Resident #29's comprehensive care plan, and there was no reason for its omission, especially since the resident had been at the facility for a long time. Record review of the facility's policy Comprehensive Care Plans implemented 10/24/2022 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 resident (Resident #63) reviewed for incontinent care, in that: While providing incontinent care for Resident #63, CNA B used a back to front motion to clean Resident #63's buttocks. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #63's face sheet, dated 05/30/2025, revealed an admitted [DATE], with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension (High blood pressure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure). Record review of Resident #'63's Significant change MDS, dated [DATE], revealed the resident had a BIMS score of 12 indicating moderate impairment. Resident #63 required limited to extensive assistance and was frequently incontinent of bladder and bowel. Review of Resident #63''s care plan, dated 05/01/2023, revealed a problem of has occasional bladder incontinence r/t not making it in time and dx of BPH. Uses a urinal at times but will not keep it in a bag. and an intervention of Clean peri-area with each incontinence episode. Observation on 05/29/2025 at 2:30 p.m. revealed while providing incontinent care for Resident #63, CNA B wiped Resident #63's buttocks in a back to front motion. During an interview on 05/29/2025 at 2:40 p.m. with CNA B, she confirmed she had wiped Resident #63's buttocks in a back to front motion She said she thought she was using the correct technique. She confirmed receiving training on incontinent care from the facility. During an interview with the DON on 05/29/2025 at 3:00 p.m., she confirmed the correct motion to clean the residents during perineal care was front to back to prevent fecal matter from contacting the urethra and possibly cause an infection. The DON revealed the staff received training on infection control and incontinent care at least annually. The staff skills were checked yearly. The DON and ADON spot check the staff while they provided care for infection control and quality of care. Review of annual skills check for CNA B revealed CNA B passed competency for Perineal care/incontinent care on 03/06/2025. Review of facility policy, titled Incontinent care skills checklist, undated, revealed Wash from front to towards rectum, front to back, using clean stroke [ .] cleanse the entire buttock area and surrounding hip area.

Based on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #1) of 8 residents reviewed, in that: The facility failed to ensure the thermometer inside Resident #1's personal refrigerator was functioning properly and the staff recorded the accurate temperatures of the refrigerator for five months. This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included: Record review of Resident #1's face sheet, dated 05/27/2025, reflected the resident was a [AGE] year-old female and was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: Alzheimer's disease (the most common type of dementia, a progressive brain disorder that damages memory, thinking, and other cognitive abilities), dementia (a decline in mental abilities severe enough to interfere with daily life, and it is caused by damage to the brain), hypertension (high blood pressure), and depression (a persistent feeling of sadness, loss of interest, and changes in thinking, sleeping, eating, and acting). Record review of Resident #1's quarterly MDS, dated [DATE], reflected the resident's BIMS score was 08 out of 15, indicating moderately impaired cognition. The resident required supervision or touching assistance with eating (helper provided verbal cues or touching/steadying assistance as resident completed activity). Observation on 05/27/2025 at 2:30 PM revealed Resident #1 was sitting in her wheelchair in her room. The resident had a personal refrigerator, and inside the refrigerator was an analogue thermometer. The interior temperature of the refrigerator according to the thermometer was 26 degrees F. Further observation inside the refrigerator revealed an open can of soda approximately half-full. Shaking the can revealed the soda was not frozen, indicating the thermometer was not accurate. Record review of the temperature log attached to the side of the refrigerator revealed temperatures taken for the months of January through May 2025. The temperatures ranged from 32 - 12 degrees F in January, 26 - 22 degrees F in February, 32 - 18 degrees F in March, 20 - 12 degrees F in April and 34 -12 degrees F in May 2025. During an interview on 05/27/2025 at 2:35 PM, LVN E stated Housekeeping was responsible for recording the temperatures of the refrigerator on the temperature log. During an interview on 05/27/2025 at 2:40 PM, the DON stated the thermometer inside Resident #1's read 26 degrees F, indicating it was not working properly, as the contents of the refrigerator were not frozen. The Housekeeping staff recorded the temperatures of this thermometer on a Temperature log placed in a document protector and posted on the left side of the refrigerator from January - May 2025 without noting the thermometer was broken and failed to bring the situation to the attention of nursing staff. She would ensure a new thermometer was placed in the refrigerator. Observation on 05/27/2025 at 3:30 PM inside Resident #1's refrigerator revealed the new analogue thermometer read 40 degrees F, indicating the previous thermometer was broken and the refrigerator was functioning properly. During an interview on 05/27/2025 at 3:20 PM, the Housekeeping Director and Administrator stated they understood the thermometer in Resident #1's facility was not functioning properly and had not been for several months. The facility's policy needed to be clearer, as it stated at the top of the temperature log form Resident Room or nourishment refrigerators should have temperatures 40 degrees F or lower. Housekeeping staff needed education on the proper range for refrigerator temperatures. Record review of https://www.kitchenaid.com/pinch-of-help/major-appliances/refrigerator-temperature.html accessed on 06/05/2025 revealed, .the ideal refrigerator temperature is around 37 F (3 C). That said, a range of 33-40 F (0-4 C) is typically considered safe for most purposes. Temperatures that fall below 33 F can freeze foods while temperatures above 40 F may contribute to food spoilage. Record review of facility policy 02.005 Potluck Meals and Foods from Home approved 10/18/2018 revealed, Policy: Residents have a right to participate in potluck events and consume foods brought into the facility from outside sources. The facility will provide the resident and family education on the basics of food safety and the use and storage of food to ensure safe consumption. 2. The facility must ensure safe food handling techniques once the food is brought into the facility including safe reheating to 165 degrees for 15 seconds, holding cold items <41 degrees .

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 and to help prevent the development and transmission of communicable diseases and infections, including a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment, and written standards, policies, and procedures for the program, which must include, but are not limited to: . (ii) When and to whom possible incidents of communicable disease or infections should be reported, for 1 of 1 facility reviewed for infection control, in that: The facility failed to have written standards that include when and to whom possible incidents of communicable disease or infection should be reported. These failures could place residents at risk of a delay in identification of infectious outbreaks and lack of timely follow-up on recommended interventions to prevent harm, or impairment. The findings included: 1. Record review of Resident #2's face sheet, dated 2/11/25 revealed a 94 -year-old female admitted [DATE] with diagnoses that included: UNSPECIFIED DEMENTIA, ENCEPHALOPATHY (enlargement of the brain), UNSPECIFIED MACULAR DEGENERATION (blindness over time), and GLAUCOMA (eye damage). Record review of Resident #2's most recent quarterly MDS assessment, dated 11/13/24 revealed, the resident's BIMS score was zero (severely cognitively impaired) and required limited assistance with mobility and transfers. Record review of Resident #2's Order Summary Report, dated 12/13/24 revealed the following: - Enhanced Barrier Precautions - PPE: Gloves/Gown during high-contact resident care activities every shift with order - Skin Scraping Test one time only to rule out scabies for one day, with order date 12/13/24. -biopsy 12/16/24 one positive for scabies - Ivermectin Oral Tablet 3 MG, give 3 mg tablet by mouth one time only for scabies for 1 day, with order date 12/24/24 and 12/31/24. -permethrin 5% cream two doses 12/20/24 and 12/27/24 Record review of Resident #2's microbiology report dated 12/16/24 revealed the resident was positive for scabies. Record review of Resident #2's comprehensive care plan dated 12/13/24 revealed the resident had a rash to the torso and was prescribed Triamcinolone Acetonide Cream 0.5 %. 2. Record review of Resident #3's face sheet, dated 2/11/25 revealed a 94 -year-old female admitted to the facility on [DATE] with diagnoses that included: UNSPECIFIED DEMENTIA, RIGHT FEMALE BREAST CANCER, and MAJOR DEPRESSION. Record review of Resident #3's most recent quarterly MDS assessment, dated 12/26/24 revealed, the resident's BIMS score was 3, which indicated she was severely cognitively impaired and required extensive assistance with mobility and transfers. Record review of Resident #3's Order Summary Report, dated 1/3/25 revealed the following: - Enhanced Barrier Precautions - PPE: Gloves/Gown during high-contact resident care activities every shift with order - Skin Scraping Test one time only to rule out scabies for one day, with order date 1/2/25 - permethrin 5% cream two doses 1/3/25 Record review of Resident #3's microbiology report dated 1/2/25 revealed the resident was positive for scabies. Record review of Resident #3's comprehensive care plan dated 1/2/25 revealed the resident had Scabies and was prescribed permethrin 5% cream two doses. During an interview on 2/11/25 at 11:46 AM, the DON (IC Preventionist) stated: the outbreak started with Resident #2 on December 16, 2024, and subsequent infection of Resident #3 was January 2, 2025 (end of scabies outbreak). The DON stated no other resident tested positive. The DON stated the treatment given for Resident #2 on 12/19/24 was permethrin 5 % cream one application neck to toe and second application one week later. DON stated the treatment for Resident #3 was permethrin 5 % cream one application neck to toe. The DON stated the spread was contained by skin assessments for all residents. The DON stated the physician orders were given for prophylactic treatment of Hall 200 and 400. The DON stated all linen in Halls 200 and 400 were removed and replaced and washed, and deep cleaning in every room was conducted by housekeeping. The DON stated that 100% training on infection control and scabies was given to the staff from the time 12/16/24-01/2/25. The DON stated that the RP/family and MD were notified for the residents that tested positive for scabies. The DON stated that scabies was not a reportable event to the local health department. The DON stated that no staff presented with positive scrapings for scabies, but staff could have received prophylactic treatment in the community during the outbreak. The DON stated that the positive residents were placed in isolation. The DON stated that no self-report to HHS was made about the scabies outbreak. The DON stated that the facility did not know the source of the scabies. During an interview on 2/11/25 at 4:11 PM, LVN A stated she worked with Resident #3 since the resident was admitted . LVN A stated that the resident had dementia with no behaviors exhibited and nursing care involved medication administration and ADL services. Also, LVN A stated nursing care involved weekly skin assessments and daily observation of skin integrity. LVN A stated scabies was a mite that got under the skin and was contagious and formed skin clusters LVN A stated that Resident #3 had scabies and treatment involved cream and an PO (by mouth) medication. The LVN stated the MD and RP were notified. LVN A stated that HHS should have been notified because scabies was a parasite, and it could spread to other residents and cause an infection. During an interview on 2/12/25 at 8:56 AM, LVN B stated: she did not know the source of the scabies in December 2024 and January 2025. LVN B stated the interventions put in place included: treatment for Resident #2 and Resident #3; handwashing, PPE (contact isolation), and in-service for all staff on scabies. LVN B stated the outbreak ended around 1/3/25. LVN B state preventative measures put in place were continued education on IC for staff and residents, and weekly skin assessments. LVN B stated at the time of the outbreak RPs, MD C, and families were notified of the outbreak; but did not know whether HHS was notified. LVN B stated that Resident #2 had a rash, and MD C was making rounds and assessed the rash and ordered the skin scraping which was negative. The resident had a second appointment with MD C and a procedure (biopsy) which revealed one site (middle back) positive for scabies and the other site was negative (upper middle). Regarding Resident #3, LVN B stated that her family was changing the resident and noticed a few spots on the resident's abdomen area and informed the charge nurse. LVN B stated that Resident #3 was sent out for a medical appointment the same day with MD D and skin scraping was done which revealed a positive result for scabies. LVN B was not sure about reporting requirements to HHS. During an interview on 2/12/25 at 10:08 AM, the Housekeeping Supervisor stated: housekeeping did deep cleaning of halls 200 and 400 in the months of December 2024 and January 2025 because there were cases of scabies. The Housekeeping Supervisor stated that deep cleaning involved: clothing out of closets was washed, curtains and bed linen were washed, and surface cleaning with DC-33 (disinfectant) done in the residents' rooms. During a telephone interview on 2/12/25 at 10:20 AM, MD E stated: there was an outbreak of scabies in the facility that started December 2024 and ended in January 2025. MD E stated the source of the scabies was likely a visitor or a staff member that brought the scabies into the facility. MD E stated that he treated the infected residents (Resident #2 and #3) with permethrin 5% cream and/or Ivermectin Oral Tablet. MD E stated that the facility put in place preventative measures which included: contact precautions, monitoring, and skin assessments. During an interview on 2/12/25 at 11:20 AM, the Administrator stated: the timeline of confirmed cases of scabies was 12/19/24 to 1/2/25. The Administrator stated there had been no other confirmed cases based on scrapings after 1/3/25. The Administrator stated that preventative measures included: education, employees to fill out incident reports if they had scabies, IC training, Plan of Correction to capture rash and skin issues, proper IC measures and rooms were cleaned. The Administrator stated that she could not determine the source of the scabies. The Administrator stated that another preventative measure for residents was prophylactic treatment for residents in hall 200 and 400; and the halls were deep cleaned. In December 2024 and January 2025. The Administrator stated that the outbreak was reported to the MD (C), RP, and residents and families. The Administrator stated the outbreak was not reported to the local health department because it was not a reportable event. The Administrator stated the outbreak was not reported to HHS because it was not a self-report, and the source was not known. Observation and interview on 2/11/25 at 4:30 PM, Resident #3 was sitting in a wheelchair in the dining room alert and not oriented. There were no signs of skin tears, bruises, or injury. The resident revealed no signs of itching or a rash. The resident stated that she did not want an interview with the surveyor. Observation and interview on 2/11/25 at 4:40 PM, Resident #2 was in the secured unit. The resident was ambulatory with visual impairment. The Resident had no skin tears, bruises, or injuries present. The resident was not itching or scratching and did not have a rash. The resident stated that she received the care needed and had no complaints about care. The resident stated she could not remember having scabies. The resident stated she was not itching. Record review of the facility's policy and procedure titled, Infection Prevention program dated 5/13/23, revealed in part, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines . [Policy did not address reporting communicable diseases to HHSC.]

Based on observation, interview and record review the facility failed to ensure residents had the right to be free from misappropriation of resident property for 2 of 3 Residents (Resident #4 and Resident #5) whose records were reviewed for misappropriation of medications. 1. Nursing staff did not follow procedures when re-ordering Ativan for Resident #4; two Ativan tabs were unaccounted for after an exchange of a 30 day blister pack between MA G and LVN A . 2. MA G failed to sign off after administering Resident #5's scheduled Ativan 0.5 MG tab. These deficient practices could affect residents prescribed controlled medications and could result in the misappropriation of resident's medications. The findings were: 1. Review of Resident #4's face sheet, dated 2/14/25, revealed he was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Bipolar Disorder and Anxiety Disorder, Unspecified. Review of Resident #4's quarterly MDS assessment, dated 12/0/24, revealed his BIMS score was 6 of 15 reflective of severe cognitive impairment and he had diagnoses of Anxiety, Depression and Bipolar and he received anti-anxiety and anti-depression medications. Review of Resident #4's Care Plan, revised 10/18/24, revealed he was receiving anti-anxiety medications related to Anxiety. One of the interventions read: Administer ANTI-ANXIETY Ativan medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Review of Resident #4's consolidated physician orders for April 2024 revealed he an order for Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth one time a day related to OTHER SPECIFIED ANXIETY DISORDERS. Review of Resident #4's MAR for April 2024 revealed he received Ativan daily per physician orders. Review of Provider Investigation Report, dated 4/30/24, read in part: Incident: On April 23, 2024, at approximately 7:45 p.m. Administrator [name] was notified by Director of Nursing [name] that a blister pack of Ativan was not accurately accounted for in medication cart and when located at nurses' station two pills were missing from blister pack. Further review of the investigation revealed MA G and LVN A were both interviewed. MA G's interview read: Administrator and Treatment Nurse interviewed Certified Medication Aide G [name]. [name] MA G states that at approximately 9:30 a.m. on April 23, 2024, she gave her Charge Nurse, LVN A [name] a blister pack of Ativan for Resident #4 [name] with two pills in the blister pack. She states that she informed Charge Nurse that the resident had two pills left and needed to be re ordered. MA G [name] states that at 7:15 p.m. she began to count her cart with Charge Nurse, LVN H [name]. At this time LVN H [name] would not take over the cart because the blister pack of Ativan was missing from the cart. MA G [name] recalled giving the blister pack to LVN A [name] and it not being returned. Charge Nurse, LVN H, [name] began looking for it at the nurses station and it was located between a stack of papers. The blister pack was missing two pills and was empty. Charge Nurse, LVN H [name] immediately notified Director of Nursing [name]. LVN A interview read: Administrator and Treatment Nurse interviewed LVN A [name]. LVN A [name] states that at approximately 10 a.m.-12 p.m. MA G [name] brought her a blister pack of Ativan for Resident #4 [name]. LVN A [name] states that she reviewed the blister pack and it stated no refills. At that time she wrote a note to Dr. [name] to be faxed requesting refills. LVN A [name] states that when she looked at the blister pack there were no pills in the blister pack. LVN A [name] states that she put the blister pack with her fax and set it at nurses station. Interview on 2/14/25 at 12:59 PM with MA G revealed she remembered the incident with the missing Ativan for Resident #4. She stated she pulled the card, blister pack, because she noticed there were only 2 tabs left. She took LVN A the card and let the nurse know there were only 2 tabs left. MA G stated LVN A took the card without question. MA G stated she knew she was not supposed to pull a narcotic card out of the cart under any circumstances unless another nurse verified the count with her prior to pulling it. She stated she wanted to show LVN A that she needed to re-order the Ativan for Resident #4. She stated she could have called her on the phone but did not. MA G stated she understood 2 tablets went missing and again stated she saw 2 tablets left in the Ativan card. MA G stated she did not take the 2 tablets. Interview on 2/12/25 at 4:50 PM with the DON revealed she vaguely remembered the incident because it was after hours and the ADM took the lead with the investigation. She stated she understood 2 Ativan tabs were not accounted for Resident #4. She reiterated MA G pulled the card and gave it to LVN A. When the relieving nurse, LVN H, reported for shift, she noted the card was not in the cart and asked MA G about it. MA G reported she gave it to LVN A with 2 tabs left. The DON stated she called LVN A who reported it was at the nurses station with paperwork but stated the card had 2 remaining Ativan tabs. LVN A stated she called the PCP who reordered Resident #4's medications. Resident #4 did not miss any scheduled doses of Ativan. The DON stated the relieving LVN H found the card and it did not have the 2 tabs in question. The DON stated MA G should have never removed the card from the cart. She stated MA G should have let the nurse know Resident #4 needed a re-order for the Ativan. The DON stated checks and balances included: MA G and LVN H would sign off when all narcotics were administered from a blister pack. They would then remove the empty blister pack and they would give her the narcotic count sheet. The DON stated she would waste the card (empty blister pack) and count sheets were added to the Resident's hard chart and a copy was scanned and uploaded into the Resident's electronic Health Record. The DON stated ultimately, they were not able to determine what happened to the 2 missing Ativan tabs. She stated Resident #4 did not miss any Ativan doses. Left VM for LVN A on 2/12/25 at 5:10 PM requesting she return the call. She did not return the call before the investigation was completed. Left VM for LVN A on 2/13/25 at 2:13 PM requesting she return the call. She did not return the call before the investigation was completed. Observation and interview on 2/14/25 at 9:17 AM revealed Resident #4 was lying in bed watching TV (volume very loud), eating chips. Resident #4 stated he had lived in the facility for about 2 years. He stated he received his medications regularly and had not missed any medications. Interview on 2/14/25 at 4:34 PM with the ADM revealed she remembered the incident with the two missing Ativan tabs for Resident #4. The ADM stated she interviewed staff involved. She stated MA G pulled the Ativan card blister pack from the cart and took it to LVN A. MA G reported there were 2 tabs left in the card. During interview, LVN A stated when MA G handed her the card, she noted there were no tablets left in it. LVN A reported she noted there were no refills left so she called the doctor for a re-order. LVN A reported she left the empty card at the nurse's station. LVN H, who was scheduled for duty found the card at the nurse's station and it was empty. The ADM stated during interviews all the staff was upset and claimed they did not know what happened to the two tablets. The ADM stated they were not able to determine what happened to the two missing Ativan tablets. The ADM stated nursing staff should not have pulled the Ativan card before administering all the tablets. She stated there were processes in place for this reason, to avoid discrepancies, medication errors or diversion of medications. 2. Review of Resident #5's face sheet, dated 2/14/25, revealed he was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia and Anxiety Disorder. Review of Resident #5's quarterly MDS, dated [DATE], revealed staff was not able to interview him to determine BIMS score; he had a diagnoses of Bipolar and Anxiety and was receiving anti-anxiety medication. Review of Resident #5's Care Plan, revised on 12/16/24 read: he was receiving anti-anxiety medications related to Anxiety. One of the interventions read: Administer ANTI-ANXIETY Ativan medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Review of Resident #5's consolidated physician orders revealed an order: Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth two times a day for ANXIETY. Review of Resident #5's MAR for February 2025 revealed he received Ativan per physician orders. Observation and interview of MA G counting controlled medications on 2/14/25 at 1:10 PM revealed MA G pulled Resident #5's Ativan card. She compared it to the narcotic count sheet and the count was correct. However, there was no signature of the person who administered the medication. MA G stated she administered the Ativan to Resident #5 but she did not sign off when she administered it on 2/14/25 during the 9:00 AM medication pass. MA G stated it was important that she follow processes to prevent discrepancies which could lead to medication errors or diversion of medications. She stated she meant to sign off on it but was distracted and forgot. Interview on 2/14/25 at 1:16 PM with the DON revealed anytime nursing staff did not follow processes when administering medications it could cause a medication error, discrepancy and or diversion of medications. If given incorrectly it could cause a resident to have a decline in condition. The DON stated it was important to pay attention and for staff to follow the processes per facility policy. Review of facility policy, Medication Administration, dated 10/24/22, read in relevant part: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 14. Administer medication as ordered in accordance with manufacturer specifications. 17. Sign MAR after administered. 18. If medication is a controlled substance, sign narcotic book.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency for 1 of 11 Residents (Resident #6) who were reviewed for abuse, in that: The facility did not report an allegation of abuse per facility policy to the State Survey Agency (HHSC) when Resident #6 alleged Resident #7 that provided unwanted sexual favors. This deficient practice could affect any resident and could contribute to further abuse. The findings were: Record review of the facility policy and procedure titled, Abuse, Neglect and Exploitation dated 8/15/22, revealed in part, .Reporting of all alleged violations to the .state agency .within specified timeframe's . 1. Review of Resident #6's face sheet, dated 2/11/25, revealed he was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Recurrent, Moderate and Schizoaffective Disorder, Depressive type. Review of Resident #6's annual MDS assessment, dated 12/6/24, revealed his BIMS score was 3 of 15 reflective of severe cognitive impairment. 2. Review of Resident #7's face sheet, dated 2/11/25, revealed he was admitted to the facility on [DATE] with a diagnosis unspecified Dementia. Review of Resident #7's admission MDS assessment, dated 2/5/25, revealed his BIMS score was 10 of 15 reflective of moderate cognitive impairment. Review of a Provider Investigation Report, dated 2/12/25, revealed an allegation of verbal and physical aggression was investigated. Allegedly, Resident #6 slapped Resident #7 on the leg. Further review revealed Resident #6 stated he did it because Resident #7 crawls over to him in the night and provides sexual favors. Record review of Texas Unified Licensure Information Portal (TULIP) revealed that no self-reported incident regarding allegations of sexual abuse Interview on 2/13/25 at 11:30 AM with the DON related to the incident between Resident #6 and Resident #7 revealed both made an allegation. Resident #7 alleged that Resident #6 slapped him on the leg. Resident #6 alleged that Resident #7 would suck his [penis] at night which was not solicited or wanted. The DON stated she did not know if the allegation Resident #6 was reported because the ADM was responsible for reporting allegations of abuse to HHSC; however, she stated to her understanding both were reportable allegations of abuse. Interview on 2/13/25 at 4:34 PM with the ADM revealed she identified during the investigation involving Resident #6 and Resident #7 there were 2 allegations that should have been reported; physical abuse which she reported and sexual abuse which she did not report. The ADM stated she incorporated both allegations into the investigation for physical aggression but should have reported and investigated each allegation separately.

Based on observation, interview and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 4 residents (Resident #1) reviewed for notification of changes, in that: Resident #1 developed new wounds on 08/01/24 and the resident representative (RP) was not informed until 08/02/24 by facility staff. This failure could lead to the facility making decisions without the resident's right to designate a surrogate or representative to make treatment or transfer decisions for the resident; and could deny the resident through the resident representative their wishes and preferences. The findings included: Record review of Resident #1's face sheet, dated 8/13/24, male age 72, reflected, the resident was admitted on [DATE] and discharge 8/2/24 to home with diagnoses that included: POSTCHOLECYSTECTOMY SYNDROME (removal of the gall bladder at admissions); CALCULUS OF KIDNEY WITH CALCULUS OF URETER (kidney stone), TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING LEFT NON-DOMINANT SIDE [from history of stroke], PERIPHERAL VASCULAR DISEASE, UNSPECIFIED [poor blood circulation], COLOSTOMY STATUS, UNSPECIFIED OSTEOARTHRITIS [weak bones]. RP (responsible party) was listed as: a family member. Record review of Resident #1's Significant Change (weight loss) MDS (minimum data set), dated 7/30/24, reflected: A BIMS (brief interview of mental status) Score was 8 meaning (moderate impairment); and the ADLs (activities of daily living) reflected : B/B (bowel and bladder)- and Resident #1 had a colostomy and was incontinent for urine. Transfer was mechanical lift for Resident #1. Bed Mobility was total assist and the ROM (range of motion) was total; to upper and lower. Record review of Resident #1's CP (care plan), undated, reflected: Resident#1 had the potential for pressure ulcer development related to immobility and history of CVA (cerebrovascular accident) Hemiplegia, and Hemiparesis (stroke). Resident #1 has the potential for pressure ulcer development related to Immobility: and a history of CVA Hemiplegia, and Hemiparesis (stroke). Record review of Resident #1's Wound Physician Assessments, dated below, reflected: 7/8/24: Right Second Toe: measurements: 7 (L) X 7 (W) X 0.1 (D). 7/25/24: Right Second Toe: measurements: .6X 6X.1. Left lateral leg 4X4X no depth (dead tissue). 8/1/24: Right second Toe: measurements .6X.6X Depth (not measurable) (dead tissue and narcosis) Left lateral measurements:4X4X (Depth) not measurable Buttocks 4.5X2.5X0.1 Right heel 3.5X3.0XDepth (not measurable) (necrosis). During an interview on 8/13/24 at 10:29 AM, LVN A stated: on 8/1/24 the Wound Care Specialist identified left buttocks (8/1/24) wound, left lateral leg (7/25/24) wound and right second toe (7/18/24). LVN A stated the resident was not admitted with any wounds. LVN A stated that the wounds developed because of Resident's diabetes, stroke, and poor blood circulation. Resident could not move his left lateral leg (side of stroke). LVN A stated the wounds were All arterial wounds. LVN A stated the wounds were unavoidable because of the resident's comorbidities and declining health. LVN A stated the resident did not want to be in the nursing home and refused to eat. LVN A stated that PT (physical therapy), SP (speech therapy) and OT (occupational therapy) were all working with the resident to encourage eating, strength building, and mobility. LVN A stated that she had no information as to whether the RP was notified on 08/01/24 when Resident #1 was found to have developed new wounds. During an interview on 6/13/24 at 1:19 PM, LVN B stated: the resident (Resident #1) was developing wounds due to not eating, poor vascular circulation, diabetes, dementia, and refused care (not wanting to leave his bed) LVN B stated she kept the RP verbally informed but may not have documented the 8/1/24 communications with the RP. LVN B stated that RP was informed on 7/25/24 about the new arterial left lateral leg wound. LVN B stated she did not know the reason the RP wanted to discharge the resident home. During an interview on 8/13/24 at 1:41 PM, NA C stated: she provided bed baths to the resident (Resident #1) in the month of July 2024. NA C stated that part of giving a bed bath was documenting any wounds in the POC (point of care used by nurse aides to document activities of daily living)). NA C stated that she saw a wound on the Resident #1's buttocks and on his leg in July 2024. NA C stated, I did not know I had to tell the nurse about the wounds I saw except to document in POC. NA C stated that she often saw the RP present in the resident's room. NA C stated that as part of HIPAA she did not communicate to the RP about the wounds she saw. During an interview on 8/13/24 at 1:55 PM, LVN D stated: she provided nursing care to Resident #1 which included: medication administration, monitoring, vital signs and assessments every day, and coordination of care. LVN D stated that the RP was present almost every day. LVN D stated she kept the RP informed about the resident's refusal not to eat and the loss of weight and the interventions attempted by the physician. LVN D stated that the verbal communications about the Resident's wounds were not documented. LVN stated that it (new wounds) needed to be documented otherwise it didn't happen. During an interview on 8/13/24 at 2:19 PM, the DON stated: Resident #1 refused to eat, and interventions included: referral to SP, weekly weights, getting the RP involved, orders for ensure (supplement) and milkshakes. The DON stated that Resident #1 developed wounds after 30 days not eating and not wanting to get out of bed. The DON stated that the RP had been informed about the resident's decline on 7/25/24 and that the resident would accrue more wounds. The DON stated that the new wounds assessed by the Wound Care Specialist on 8/1/24, she stated she needed to check to determine whether the RP was informed on 8/1/14. During a telephone interview on 8/13/24 at 2:57 PM, the RP stated that the facility never told her about the new wounds identified by the wound physician on 8/1/24. The RP stated the wounds were totally new and the staff never told me. The RP stated that during a mechanical lift on 7/30/24 she noticed the buttock wound. During a telephone interview on 8/13/24 at 3:05 PM, the Wound Care Specialist stated: the resident (Resident #1) loss weight because he did not want to eat. Interventions were attempted to include IV fluids. The Wound Care Specialist. The Wound Care Specialist The Wound Care Specialist. The Wound Care Specialist, The Wound Care Specialist stated: the resident developed wounds because or arterial vascular issues, co-morbidities, and did not want to leave his bed. The Wound Care Specialist. The Wound Care Specialist stated: that his belief was that the RP was kept informed about the resident's refusal to eat and worsening condition. During observation and interview on 8/14/24 at 8:30 AM, reflected Resident #1 was in bed in a community rehabilitation hospital. Observation revealed the resident was alert and oriented to person, place and time. The resident received by IV an antibiotic (daptomycin 500 mg); and right toe was bandaged, and there was a pressure release boot on the left leg. Resident #1 stated that the care at the nursing home was not good [but provided no specifics]. The resident stated he lost weight at the nursing home because he did not like the food and stopped eating for 30 days. The resident stated the facility offered him milkshakes and appetite stimulants and alternate diets; but he did not want to eat. The resident stated he developed wounds in the nursing home but did not know the cause of the wounds. The resident stated that he preferred to stay in bed and had a wound to his buttocks which caused him to want to be in bed. The Resident stated the facility made efforts to move him out of bed; and he did not remember about staff re-positioning him. The resident stated his right toe was amputated and he had a history of diabetes. Resident #1 stated his plan was to return home after the current hospital and rehab stays. When asked about the RP being kept informed about changes in his medical condition, Resident #1 stated: I do not think so . they were not notifying my (RP) as my condition was worsening. Record review of facility's Resident Rights policy dated 10/24/22 reflected: .The facility will periodically assess the resident for decision making abilities and approach the health care proxy or legal representative if the resident is determined not to make decision making capacities. After exit on 8/14/24, the facility provided by email Resident #1's Weekly Wound Progress Note authored by LVN B which reflected resident developed new wounds on 08/01/2024 and the RP was notified on 08/02/2024 00:00 (midnight).

Based on interview and record review the facility failed to ensure that the comprehensive person-centered care plan described services that are to be furnished to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans, in that: Resident #1's care plan, undated, did not indicate that Resident #1 was on a regular diet consisting of mechanical soft texture and regular liquids as of 6/18/2024. Resident #1's care plan inaccurately indicated Resident #1 was NPO status, onset date 05/29/2024. This deficient practice could affect residents who had a diet order change by serving a resident the wrong diet. The findings included: Record review of Resident #1's face sheet, undated, reflected Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of traumatic subdural hemorrhage (type of bleeding in which a collection of blood gathers between parts of the brain usually caused by a severe head injury) and dysphagia (difficulty speaking). Record review of Resident #1's admission MDS assessment, dated 06/03/2024, reflected Resident #1 had a BIMS score of 8, indicating moderate cognitive impairment. Record review of Resident #1's June 2024 administration record, reflected Resident #1 had an enteral feed order: six times a day for provide 2130kcal, 91g pro, 2280ml total water [brand name] 1.5 bolus feeding x 6 cans/day + 100ml flush before and after q feed, start date 06/03/2024 and discontinued date, 06/19/2024. Resident #1 had an enteral feed order: three times a day bolus 2 cans of [brand name] 1.5 after meals if PO intake is < 50%, start date 06/19/2024. Record review of Resident #1's physician order summary for June 2024, reflected Resident #1 had an order for regular diet: mechanical soft texture and regular liquids, start date 06/18/2024. Record review of Resident #1's nutrition/dietary note, dated 06/19/2024, reflected, Diet: regular diet, mech soft texture, regular liquids. Noted diet started 06/18/2024 per ST recommendations. PO intake 75%-100% no supplements ordered. Record review of Resident #1's care plan, undated, reflected Resident #1 has a care plan [Resident #1 first name] has a swallowing problem r/t dysphagia. He is NPO and received g-tube feedings, dated initiated 06/12/2024. The goal of the care plan stated, the resident will maintain weight and nutritional balance through the review date, dated initiated, 06/12/2024 and target date, 09/10/2024. Record review of Resident #1's weights revealed Resident weighed 157.4 on 05/29/2024 and 159.0 on 08/05/2024 indicating Resident #1 had not lost weight. During an interview with Resident #1, 08/07/2024 at 10:00 a.m., Resident #1 revealed he had been receiving food and medication orally since sometime in June. During an interview with LVN A, 08/07/2024 at 12:29 p.m., LVN A stated she was the Charge Nurse for Resident #1 and Resident #1 ate meals by mouth and was administered medications by mouth. LVN A stated Resident #1 had an order for bolus feeding if Resident #1 ate less than 50% but he has not needed that in months. LVN A stated the accuracy of a resident's care plan was important because It is what we go by to provide proper care for each resident. During an interview with MDS LVN B, 08/07/2024 at 1:51 p.m., MDS LVN B stated resident care plans should be updated whenever something happens like a fall, bruise, medication change, behavior or anything that is a change. MDS LVN B said the accuracy of resident care plans was important so staff can see what the plan of care is for the resident and so staff know how to care for the resident. MDS LVN B said a resident's care plan that was inaccurate could cause harm by injury or death. During an interview with MDS LVN A, 08/07/2024 at 2:03 p.m., MDS LVN A revealed Resident #1 was not NPO and stated Resident #1 was eating and drinking orally. MDS LVN A revealed she and another MDS Nurse were responsible for initiating a resident care plan upon admission and the nurse managers assist with updating the care plans during the start-up morning meeting. MDS LVN A stated care plans should be updated daily, if there are any changes and MDS LVN A stated the accuracy of the resident care plan was important because it is for everyone to see how to care for a resident and what to do. MDS LVN A stated Resident #1's NPO care plan could have potentially caused Resident #1 to not get his meals, nutrition and fluids. During an interview with the DON, 08/07/2024 at 2:45 p.m., the DON stated the nursing team checked resident orders every morning and resident care plans should have been updated by the MDS nurses or ADONs. The DON stated the accuracy of the care plans was important because it is our plan of care for the patient and if anyone needs to know how to care for the patient, they can check the care plan. The DON stated the MDS nurses had received training on care plans annually and stated, we just had an all-day training on care plans last week in a regional training. Record review of facility policy titled Comprehensive Care Plans, date implemented 10/24/2022, reflected it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation, interview and record review, the facility failed to ensure the residents' right to be free from abuse for one (Resident #1) of 7 residents reviewed for abuse. The facility failed to prevent Resident #1 from being abused when a rubber band was discovered wrapped 4-5 times around the shaft of his penis on 6/07/2024 at approximately 2:00 AM. The non-compliance was identified as past non-compliance (PNC). The PNC IJ began on 06/07/24 and ended on 06/08/24. The facility had corrected the non-compliance before the state's investigation began on 6/08/2024 8:00 AM. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. The findings included: Record review of the Admission Record, dated 6/09/2024, reflected Resident #1 was a [AGE] year-old male originally admitted on [DATE]. Record review of the quarterly MDS assessment, dated 3/27/2024, reflected Resident #1 had a BIMS summary score of 3, indicative of severe cognitive impairment. Under section E - Behavior, Resident #1 was documented with a lack of behavioral symptoms: did not exhibit the behavior of rejection of care; did not exhibit physical behavioral symptoms directed toward others. Under section GG - Functional Abilities and Goals, Resident #1 was documented as impairment on one side of both upper and lower extremities; Resident #1 routinely used a wheelchair for mobility; Resident #1 was coded as dependent for eating, oral hygiene, toileting hygiene, shower/bathe self. Resident #1 was coded as dependent in the following activities: lower body dressing, putting on/taking off footwear, personal hygiene, sit to lying transition, lying to sitting on one side transition, chair/bed-to-chair transfer. Resident #1 was coded as dependent in the following activities: wheel 50 feet with two turns, wheel 150 feet. Under section H - Bladder and Bowel, Resident #1 was coded as always incontinent of bowel and bladder and was not utilizing a toileting program to manage continence. Resident #1's primary medical condition category that best described the primary reason for admission was coded as medically complex conditions related to unspecified dementia without behavioral disturbance. Other active diagnoses included diabetes mellitus, hemiplegia or hemiparesis [weakness to one side of the body], seizure disorder or epilepsy, contractures [permanent tightening of the muscles, tendons, skin and surrounding tissues that causes the joints to shorten and stiffen] : right hand, left and right knee, left and right hip, and right elbow. Resident #1 was coded as unable to answer, Have you had pain or hurting at any time in the last 5 days? Under section M - skin conditions, Resident #1 had a clinical assessment that determined he was a risk of developing pressure ulcers/injuries. Record review of the Care Plan reflected Resident #1 had a focus area of [Resident #1] was subjected to allegations of abuse as evidenced by a rubber band found wrapped around penis with a date initiated of 6/07/2024, and a revision on 6/08/2024. Interventions included the following: administer clobetasol [potent corticosteroid topical treatment for inflammation and pain] and solumedrol [intramuscular corticosteroid that reduces inflammation, pain, swelling, redness, heat]; apply ice packs; monitor and provide patient with as needed pain medication; monitor for swelling and follow orders; monitor penis for change in condition; monitor for urinary output; notify the medical doctor of any further complications/new developments of adverse effects. Further focus areas included: [Resident #1] was passive and receives one-on-one visits . with a revision on 1/25/2022; [Resident #1] had an ADL self-care performance deficit related to .confusion, hemiplegia . with a revision date of 4/20/2021. Interventions included the following: totally dependent on staff to provide shower and or bed bath; totally dependent on staff for repositioning and turning in bed; totally dependent on staff for dressing; extensive to total assistance by staff to eat; totally dependent on staff for personal hygiene and oral care; incontinent of bowel and bladder causing Resident #1 to be totally dependent on staff for toilet use; required mechanical Hoyer lift with 2 staff for transfers. Additional focus areas, [Resident #1] had limited physical mobility related to contractures and stroke, with a revision date of 3/29/2024. [Resident #1] had a history of stroke affecting cognition, communication ability and right sided hemiplegia with a revision date of 11/07/2018. [Resident #1] had bowel/bladder incontinence related to cognitive impairment diagnosis of dementia with a revision date of 4/20/2021. Interventions included the following: use disposable briefs, change every 2 hours, and as needed; check every 2 hours and as required for incontinence. Record review of the Nurses Note, authored by RN D dated 6/07/2024 at 3:21 AM reflected, called to Residents Room by [CNA B]; found resident with rubber band wrapped around shaft of penis 4 to 5 times. Thick rubber band constricting resident from urinating .unable to remove rubber band by hand; had to use scissors to cut [rubber band] off; upon release resident started urinating large amount of urine . Resident #1's responsible party was left a message regarding the incident. NP I was notified as she was on-call for MD H. Resident #1 was administered 1000 milligrams of Tylenol [a medication used to treat fever, pain and inflammation]. Record review of Nurses Note, authored by RN C late entry for 6/7/2024 at 2:00 AM reflected, initiation of incident report and notification of the abuse coordinator. RN C reassessed Resident #1 an hour after initial incident and noted no signs or symptoms of discomfort and penis noted to not be as swollen. RN C documented urination and bowel movement between discovery of the incident and the reassessment at 3:00 AM. In an observation on 6/08/2024 at 9:40 AM, revealed Resident #1 was lying supine in bed, with the head of bed elevated 30-45 degrees, with the linens pulled up to axillae [arm pit]. Resident #1 had his eyes open but did not respond to verbal stimuli. Resident #1 did not maintain eye contact or tract movement with his eyes. Resident #1 appeared awake but was not responsive to the surveyor. He exhibited slow deep breaths, and a relaxed body and facial expression with no overt signs of distress. In an interview on 6/08/2024 at 11:00 AM, NA A stated she was the staff member responsible for providing care to Resident #1 on the 6A-6P shift on Thursday 6/06/2024. NA A stated she had been working at the facility for almost 6 months so far. NA A stated she had no other interventions she knew of to make caring for Resident #1 easier. NA A stated that Resident #1 was easy to care for; he was incontinent of bowel and bladder; and could not really converse, he would just repeat back what he heard [echolalia]. NA A stated she was new and had not yet learned how to document in the electronic health record, so that other staff would enter her tasks as completed for her. NA A stated she had provided him a shower after lunch but was unsure of the time. NA A stated that during the shower Resident #1 was incontinent of bowel and bladder. NA A stated at that time there was no rubber band around his penis. NA A stated she did not know how the rubber band got around Resident #1's penis. NA A stated she did not believe that Resident #1 would be able to do that himself. NA A stated that after showering Resident #1, she had an in-service that took approximately half an hour and then she had her 30-minute lunch break at 2:40 PM. Upon returning from lunch [approximately 3:15 PM], it was then time to assist Resident #1 to the dining room for dinner. [Subsequent interviews with more tenured staff indicate that seating for the evening meal starts no earlier than 4:30 PM.] NA A stated she was not the person that assisted Resident #1 to return to his room after dinner, or assist him from his wheelchair to bed, which was his known preference. NA A stated she was assisting Resident #2 after dining and noted that Resident #1 was in bed at the end of her shift. NA A stated she did not know who put Resident #1 to bed the evening of 6/06/2024. NA A stated she assumed that whoever had assisted Resident #1 to bed had also provided incontinence checks to Resident #1 as that task was supposed to be done before the end of the shift as per facility practice. NA A stated she left the floor at approximately 6:10-6:15 PM the evening of 6/06/2024. NA A stated the last time she provided any care to Resident #1 was when she showered him, and during that shower Resident #1 had a bowel movement and was incontinent of urine in the shower. In an interview on 6/08/2024 at 11:20 AM, the DON stated as she was walking by, she saw Resident #1 was sliding down his wheelchair in his room after dinner on 6/06/2024. The DON stated she called out to CNA F to assist her with getting Resident #1 repositioned from his wheelchair on to his bed. The DON stated she and CNA F used a mechanical lift to place Resident #1 on the bed, on top of the fitted sheet without providing an incontinence check. The DON stated she expected the person assigned to provide care for Resident #1 to check for incontinence and assist Resident #1 into his night clothes before the end of the shift. The DON stated that would have been NA A on the 6A-6P shift on 6/06/2024. The DON stated, It was pushing close to the end of shift, maybe 5:50 to 6 o'clock [in the evening] when we [the DON and CNA F] assisted [Resident #1] to the bed . In a joint interview on 6/08/2023 at 12:30 PM, the ADM stated she was the abuse coordinator for the facility. The ADM stated she was notified just after 2:00 or 2:30 AM on 6/07/2024 that Resident #1 had been discovered with a rubber band around his penis. The DON stated she was notified around 2:30 AM on 6/07/2024. The ADM stated that she initiated an investigation immediately by interviewing staff on site and then by telephone. The ADM stated that there were inconsistencies in the explanation NA A provided detailing when she provided care to Resident #1. Additionally, the DON stated it was unusual that NA A did not document any provision of care to any resident on 6/06/2024. The ADM stated that NA A indicated that CNA F was present during all provision of care to Resident #1 on 6/06/2024. This prompted the ADM to re-interview CNA F. The ADM stated that CNA F denied being asked to help NA A by NA A or any other staff on 6/06/2024. The ADM stated at this point she suspended NA A pending the outcome of the investigation. The DON stated in-service trainings were initiated with all nursing staff working the 6A-6P shift on Friday 6/07/2024 before they were allowed to work with residents. The DON stated she included non-nursing but direct care, such as habilitation therapy staff and non-direct care staff, such as laundry personnel, with that training. The DON stated she trained each on coming shift there after before they were allowed to work with residents. The DON stated she did not believe Resident #1 had the cognitive acuity or the physical dexterity to put a rubber band around his penis. The DON stated she inspected carts and nurses' station for access to rubber bands, but could not find any that would be accessible to Resident #1. In an interview on 6/08/2024 at 2:42 PM, RN J stated she was the nurse assigned to Resident #1 on 6/06/2024 6A-6P shift. RN J stated Resident #1 can sometimes answer very simple and immediate yes/no type questions. RN J stated Resident #1 had a stroke and had cognitive deficits and only had use of one arm. RN J stated she did not believe that Resident #1 would be able to figure out how to put a rubber band around his penis and did not think he had the manual dexterity to do so. RN J stated that Resident #1 was always incontinent of bowel and bladder and needed frequent incontinent care. RN J stated she rounded on Resident #1 several times on 6/06/2024 and did not observe any overt signs of distress, abuse or neglect. RN J stated she did not perform any incontinent care or skin checks on Resident #1 that day. RN J stated Resident #1 had not displayed any subsequent signs of discomfort or distress since the rubber band was discovered. In an interview on 6/08/2024 at 5:36 PM, RN D stated she was not the nurse assigned to Resident #1 but had been called over by CNA B at approximately 2:00 AM. RN D stated she entered the room with CNA B and RN C and observed that a rubber band had been tightly wound around Resident #1 penis. RN D stated she attempted to unwind the rubber band, but had to use scissors to release the rubber band. RN D stated Resident #1 did not appear in pain or in any distress, and that he immediately urinated. In an interview on 06/08/2024 at 5:47 PM, RN C stated she was the nurse assigned to Resident #1. RN C stated she followed RN D and CNA B into Resident #1's room when she heard CNA B ask for assistance. RN C stated she observed a rubber band around Resident #1's penis. RN C stated it was wrapped so tightly that they were unable to remove it by hand, and it required two snips of scissors to release the rubber band. RN C stated she stayed with and assessed the resident while RN D left the room to start an incident report and make the required notifications. RN C stated once that was complete, RN C and RN D both made rounds on all residents, starting on the 300 hallway and continuing throughout the building, to assess for any other concerns of abuse or neglect on any resident. In an interview on 6/08/2024 at 6:10 PM, CNA E stated she was assigned the area of the hallway for Resident #1 on Thursday 6/06/2024 from 6 PM to 10 PM. CNA E stated she did not see the off going aide [NA A] and no shift change report was done. CNA E stated that was not unusual, as not all CNAs talked at shift change, and even then, would only do a mini report if something significant was going on with a particular resident. CNA E stated she had assisted Resident #1's roommate, Resident #5 to bed at around 6:30 PM on Thursday 6/06/2024, when she noticed that Resident #1 was already in bed, with his night gown on, but Resident #1 still had his pants from earlier in the day on but they were pulled down lower on his hips. CNA E stated she was thankful for that because it made it easier to remove his pants and do a check of the brief to get Resident #1 ready for bed. CNA E stated she could see from the outside of the brief there was no urine, and from the back she could tell there was no feces in the brief. CNA E stated she did not open the brief to look inside. CNA E stated she did another check on Resident #1 around 8:30 PM on 6/06/2024 and again there was no bowel movement or urine visible from the outside of his brief, and she did not open the brief to look inside . CNA E stated she was not aware of the rubber band around Resident #1's penis. CNA E stated she had received in-servicing after the incident that included abuse and neglect, the correct way to perform an incontinence check and reporting change in condition requirements. In an interview on 6/08/2024 at 6:40 PM, CNA B stated she had started her shift at 10:00 PM on Thursday 6/06/2024. CNA B checked on Resident #1 at about 11:00 PM but did not see any urine or feces in the brief from the outside. CNA B stated she did not open the brief to inspect inside it at that time. CNA B stated she next checked on Resident #1 at about 1:45 AM on 6/07/2024. CNA B stated that when she checked from the outside, Resident #1 still appeared to have no bowel movement or urine in the brief, and that prompted her to investigate further. CNA B stated she had worked at the facility long enough to know that Resident #1 was frequently incontinent of bowel and bladder, and almost always required incontinence care every 2 hours. CNA B stated one dry brief was a favor, but 2 dry briefs in a row felt like something was wrong with Resident #1. CNA B stated that when she opened the brief to check Resident #1, she found a rubber band wrapped tightly around the shaft of Resident #1's penis. CNA B stated she immediately went to get the first nurse she could find. CNA B stated Resident #1 was sleeping lightly and had not seemed distressed at any point during her shift. CNA B stated the nurses (RN D and RN C) were able to quickly get the rubber band off Resident #1 with scissors, and Resident #1 immediately started urinating a strong stream. CNA B stated as soon as Resident #1 was situated, she immediately began checking on all the residents on her workload. CNA B stated the nurses were doing full body checks and looking to see if the residents seemed bothered by anything. CNA B stated she had not worked at the facility since the incident, but had been told that she would have to complete in-service training before starting her next shift. In an interview on 6/09/2024 at 12:35 PM, MD H stated that the on-call NP had been notified first, since he was on vacation, but he had been apprised of the situation upon his return. MD H stated that the swelling Resident #1 was still experiencing was not unexpected. MD H stated that over the next 7 to 10 days, barring any complications, the swelling and discoloration should resolve with the current conservative course of treatment. MD H stated it was good that urine was able to flow immediately, and the swelling and discomfort seemed only moderate. MD H stated if the rubber band had not been found when it was and immediately removed, the consequences could have been dire, including total loss of the penis. In an interview on 6/9/2024 at 1:15 PM, the DON stated in-service training was initiated on 6/7/2024 at the start of the 6 AM shift with every worker on site since the incident was discovered. The DON stated the in-servicing curriculum was explicit in that nothing should be wrapped around genitalia with out a direct order from the provider. The DON stated the in-service training would change how the facility would approach incontinence checks. The DON stated that briefs would now need to be opened for the interior of the brief and skin of the perineum to be visualized. The DON stated that abuse prohibition policies were included in in-service training that was initiated in response to the incident with Resident #1. The DON stated that no staff would be allowed to work with residents until they had had the in-servicing. The DON stated any new, agency or staff pulled from a sister facility would be trained before being allowed to work with residents. The DON stated the investigation was started immediately upon discovery of the rubber band around Resident #1's penis. All residents were assessed for emotional or physical signs and symptoms of distress, abuse or mistreatment. Record review of Abuse Prevention Program policy, updated September 2018, reflected policy statement, committed to protecting our residents from abuse by anyone including but not necessarily limited to: employees, other residents, consultants, volunteers, agents or power of attorney, and or staff from other agencies providing services to our residents. Policies and procedures that govern .identification of occurrences, and patterns of potential mistreatment/abuse, protection of residents. Reporting of Alleged Abuse, updated September 2018, included definition of abuse as: willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Record review of Skin Assessments revealed all 29 residents on 300 hallway received assessments 6/07/2024; followed by the remaining 57 residents of the other hallways, totaling 86 residents assessed. Record review of In-Service Sign In sheet started 6/07/2024, reflected the following topics: Abuse and Neglect prohibition and policy; Proper Incontinent Care; Changes in Condition (notify charge nurse immediately). 22 of 22 nursing staff scheduled to work on Friday 6/07/2024 were trained on 6/07/2024 prior to working with residents included: 3 of 3 day shift nurses, the Treatment Nurse, 2 of 2 MAs, 11 of 11 day shift CNAs, 2 of 2 night shift nurses, 4 of 4 night shift CNAs. 6 of 6 nursing staff not previously scheduled to work on Friday 6/07/2024, who worked on Saturday 6/08/2024 were trained on 6/08/2024 prior to working with residents included: 2 of 2 MAs, 3 of 3 day shift CNAs, and 1 of 1 night shift CNAs. 5 of 5 nursing staff not previously scheduled to work on Friday 6/07/2024 or Saturday 6/08/2024, who worked on Sunday 6/09/2024 were trained on 6/09/2024 prior to working with residents included: 3 of 3 dayshift CNAs, and 2 night shift CNAs. A total of 51 staff that included direct and non-direct care/non-Nursing Staff were trained starting on 6/07/2023 prior to the start of their shift, included the following departments: accounting, dietary, habilitation therapy, social services, business office, human resources, receptionist, housekeeping, and laundry. In interviews starting on 6/08/2024 8:00 am through 6/09/2024 5:45 PM, 20 staff interviews indicated, if they had worked since the incident with Resident #1, they had received training prior to working with any resident. If they had not been scheduled to work yet, they had been informed they must be in-serviced prior to working with any resident. In-servicing topics included: included: abuse and neglect: definitions, signs and symptoms, reporting requirements; change in conditions; and new protocols for incontinence checks to open brief to visualize interior and residents' perineum. Record review of Provider Investigation Report addendum received 6/7/2024 at 12:45 PM revealed ADM was notified at 2:08 AM of incident with Resident #1. ADM arrived at the facility within 15 minutes to initiate investigation. Ad-Hoc QAPI meeting held to discuss the incident. Additionally, local police department was notified, and provided a police report number 24-3584. Facility suspended the suspected Alleged Perpetrator, NA A, prior to entrance on 6/08/2024.

Based on observations, interviews, and record reviews, 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 including COVID-19 for 1 of 29 (Resident #1) by 3 of 7 staff (LVN F and CNAs B and E) reviewed for infection control, in that: A. The facility did not move COVID-19 negative status Resident #1 out of the Men's Secured Unit when Residents #2-#18 (residing on the Men's Secured Unit) tested positive for COVID-19 and the unit was converted to a COVID-19 unit. B. LVN F and CNAs B and E failed to correctly donn/doff PPE when going from COVID-19 positive (Residents #2-#18) to COVID-19 negative (Resident #1) rooms. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/02/2020. While the IJ was removed on 12/05/2020, the facility remained out of compliance at a severity of potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern until interventions were put in place to ensure negative residents were being monitored and assessed for signs and symptoms of COVID-19. These deficient practices placed residents at risk of exposure to COVID-19/Infectious Disease, a decline in health and/or death. The findings were: Record review, provided by the facility, of resident list by hallway, dated 12/01/2020, revealed a list of 29 resident names, located on COVID-19 Unit, with 17 (Residents #2-18) highlighted resident names which indicated COVID-19 positive residents. Further review revealed there were 12 non-highlighted resident names which indicated either COVID-19 negative (Resident #1) or COVID-19 recovered residents. Record review of Residents #1-#18 clinical records revealed: 1. Record review of Resident #1's face sheet, dated 12/02/2020, revealed the resident was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's MDS, dated [DATE], revealed the resident had a BIMS score of 12, which indicated moderate cognitive impairment. 2. Record review of Resident #2's face sheet, dated 12/04/2020, revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's MDS, dated [DATE], revealed the resident had a BIMS score of 11, which indicated moderate cognitive impairment. 3. Record review of Resident #3's face sheet, dated 12/04/2020, revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's MDS, dated [DATE], revealed the resident had a BIMS score of 14, which indicated intact/borderline cognitive impairment. 4. Record review of Resident #4's face sheet, dated 12/04/2020, revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's MDS, dated [DATE], revealed the resident had a BIMS score of 7, which indicated severe cognitive impairment. 5. Record review of Resident #5's face sheet, dated 12/04/2020, revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's MDS, dated [DATE], revealed the resident had a BIMS score of 11, which indicated moderate cognitive impairment. 6. Record review of Resident #6's order summary, dated 12/04/2020, revealed order entered on 07/02/2020 which read, Admit to (Facility Name). Order Summary further revealed [DIAGNOSES REDACTED]. Record Review of Administrator's email, dated 12/01/2020 at 9:38 p.m., revealed Resident #6 tested COVID positive on 11/25/2020. 7. Record review of Resident #7's face sheet, dated 12/04/2020, revealed the resident was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #7's MDS, dated [DATE], revealed the resident had a BIMS score of 13, which indicated intact/borderline cognitive impairment. Record Review of Administrator's email, dated 12/01/2020 at 9:38 p.m., revealed Resident #7 tested COVID positive on 11/23/2020. 8. Record review of Resident #8's face sheet, dated 12/04/2020, revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #8's MDS, dated [DATE], revealed the resident had a BIMS score of 00, which indicated severe cognitive impairment. Record Review of Administrator's email, dated 12/01/2020 at 9:38 p.m., revealed Resident #8 tested COVID positive on 11/23/2020. 9. Record review of Resident #9's face sheet, dated 12/05/2020, revealed the resident was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #9's MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated intact/borderline cognitive impairment. Record Review of Administrator's email, dated 12/01/2020 at 9:38 p.m., revealed Resident #9 tested COVID positive on 11/25/2020. 10. Record review of Resident #10's face sheet, dated 12/05/2020, revealed the resident was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #10's MDS, dated [DATE], revealed the resident had a BIMS score of 12, which indicated moderate cognitive impairment. Record Review of Administrator's email, dated 12/01/2020 at 9:38 p.m., revealed Resident #10 tested COVID positive on 11/23/2020. 11. Record review of Resident #11's face sheet, dated 12/05/2020, revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's MDS, dated [DATE], revealed the resident had a BIMS score of 13, which indicated borderline cognitive impairment. Record Review of Administrator's email, dated 12/01/2020 at 9:38 p.m., revealed Resident #11 tested COVID positive on 11/23/2020. 12. Record review of Resident #12's face sheet, dated 12/05/2020, revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #12's MDS, dated [DATE], revealed the resident had a BIMS score of 4, which indicated severe cognitive impairment. Record Review of Administrator's email, dated 12/01/2020 at 9:38 p.m., revealed Resident #12 tested COVID positive on 12/01/2020 13. Record review of Resident #13's face sheet, dated 12/05/2020, revealed the resident was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #13's MDS, dated [DATE], revealed the resident had a BIMS score of 7, which indicated severe cognitive impairment. Record Review of Administrator's email, dated 12/01/2020 at 9:38 p.m., revealed Resident #13 tested COVID positive on 12/01/2020. 14. Record review of Resident #14's face sheet, dated 12/05/2020, revealed the resident was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #14's MDS, dated [DATE], revealed the resident had a BIMS score of 4, which indicated severe cognitive impairment. Record Review of Administrator's email, dated 12/01/2020 at 9:38 p.m., revealed Resident #14 tested COVID positive on 11/23/2020. 15. Record review of Resident #15's face sheet, dated 12/05/2020, revealed the resident was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #15's MDS, dated [DATE], revealed the resident had a BIMS score of 5, which indicated severe cognitive impairment. Record Review of Administrator's email, dated 12/01/2020 at 9:38 p.m., revealed Resident #15 tested COVID positive on 12/01/2020. 16. Record review of Resident #16's face sheet, dated 12/05/2020, revealed the resident was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #16's MDS, dated [DATE], revealed the resident had a BIMS score of 8, which indicated moderate cognitive impairment. 17. Record review of Resident #17's face sheet, dated 12/05/2020, revealed the resident was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #17's MDS, dated [DATE], revealed the resident had a BIMS score of 4, which indicated severe cognitive impairment. 18. Record review of Resident #18's face sheet, dated 12/05/2020, revealed the resident was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #18's MDS, dated [DATE], revealed the resident had a BIMS score of 3, which indicated severe cognitive impairment. Observation on 12/01/2020 at 6:00 p.m., revealed COVID-19 Unit treated as a communal area with DONNING/DOFFING only located at the entrance to the hallway. Further observation revealed DONNING area located in an ADON's office and DOFFING area across the hallway located in the beauty salon (located on the COVID-19 unit). Further observation revealed no other DONNING/DOFFING areas anywhere on COVID-19/Men's unit to include outside any of the resident's rooms. A. Record review of Administrator's email, dated 12/01/2020 at 9:38 p.m., revealed Residents #10, #11, #8, #14, #17, #18, #7 tested COVID-19 positive on 11/23/2020, Residents #6, #5, #4, #9 tested COVID-19 positive on 11/25/2020, and Residents #15, #3, #2, #13, #12, #16 tested COVID-19 positive on 12/01/2020. During an interview with Administrator on 12/01/2020 at 7:01 p.m., the Administrator confirmed non-highlighted residents, residing on the COVID-19 Unit, on resident list indicated recovered and/or negative residents. Record review of Administrator's email, dated 12/01/2020 at 9:27 p.m., which read Good evening, This is the basic guidance leading us to the decision to maintain our residents on secured unit in our facility. This is information does not specifically address the use of PPE but does state due to the challenges in memory care unit implement eye protection and face masks for HCW protection . The email continued to reveal pasted information from CDC's website titled Considerations for Memory Care Units in Long-term Care Facilities. Record review of Administrator's email, dated 12/02/2020 at 11:02 p.m., revealed surveyor asked the Administrator, who were the resident(s) who have remained negative on 100 hall? and the Administrator's reply read, Resident Name (Resident #19) and Resident Name (Resident #1). Mr. (Resident #19) did previously have COVID in another facility prior to admitting to our building. During an interview with LVN F on 12/02/2020 at 5:51 p.m., LVN F confirmed Resident #1 was originally admitted to the facility 02/08/2020 and had not been COVID-19 positive during entire stay. LVN F further stated Resident #1 received [MEDICAL CONDITION] treatments Monday-Friday due to a [DIAGNOSES REDACTED]. B. During an interview with MA A on 12/01/2020 at 6:20 p.m., MA A stated she was only trained to DONN/DOFF when entering/exiting the COVID-19 Unit. MA A further stated she was only trained to use hand sanitizer and switch out gloves between resident rooms located on this hallway (COVID-19 Unit). MA A stated her PPE training was about 1-2 months ago. During an interview with CNA B on 12/01/2020 at 6:28 p.m., CNA B stated she was only trained to DONN/DOFF when entering/exiting the COVID-19 Unit. CNA B further stated she was only trained to use hand sanitizer and switch out gloves between resident rooms located on this hallway (COVID-19 Unit). CNA B stated her PPE training was about 1-2 months ago. During an interview with LVN C on 12/01/2020 at 6:29 p.m., LVN C confirmed he was not changing out PPE in between resident rooms on the COVID-19 Unit. LVN C stated when there was only a few COVID-19 positive residents on this hallway (COVID-19 Unit), the PPE was stationed outside the residents' doors. LVN C confirmed, 12/02/2020 at 6:07 p.m., when returning to work on 11/26/2020, the COVID-19 Unit was set up as a hot zone with DONNING/DOFFING upon entering the hallway. During an observation on 12/02/2020 at 12:02 p.m. and at 12:05 p.m., CNA B entered/exited Resident #14 and Resident #15 room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 12:15 p.m., CNA B entered/exited Resident #10 and Resident #11 room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 12:18 p.m. and at 12:19 p.m., CNA B entered/exited Resident #13 room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 12:21 p.m. and at 12:38 p.m., CNA B entered/exited Resident #12 room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 12:34 p.m., CNA B entered/exited Resident #17 and Resident #18 room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 12:21 p.m., at 12:38 p.m., and at 12:47 p.m., CNA E entered/exited Resident #13 room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 12:23 p.m., CNA E entered/exited Resident #10 and Resident #11 room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 1:15 p.m., CNA E entered/exited Resident #1 (COVID-19 negative) room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 1:19 p.m. and at 1:23 p.m., CNA E entered/exited Resident #6 and Resident #7 room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 1:20 p.m., CNA E entered/exited Resident #8 and Resident #9 room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an interview with CNA E on 12/02/2020 at 1:34 p.m., CNA E stated she was only trained to DONN/DOFF when entering/exiting COVID-19 Unit. CNA E further stated she was only trained to use hand sanitizer and switch out gloves between resident rooms located on this hallway. CNA E recalled her PPE training was about 1-2 months ago. CNA E confirmed wearing the same PPE throughout her entire shift while on COVID-19 Unit. During an observation on 12/02/2020 at 4:47 p.m., CNA E entered/exited Resident #4 and Resident #5 room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 4:50 p.m., CNA E entered/exited Resident #2 and Resident #3 room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 4:57 p.m., CNA E entered/exited Resident #16 room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 5:00 p.m., CNA B and CNA E entered/exited Resident #1 (COVID-19 negative) room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 1:13 p.m. and at 1:16 p.m., LVN F entered/exited Resident #4 and Resident #5 room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 1:17 p.m., LVN F entered/exited Resident #6 and Resident #7 room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 1:24 p.m., LVN F entered/exited Resident #16 room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 1:27 p.m. and 1:42 p.m., LVN F entered/exited Resident #8 and Resident #9 room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an observation on 12/02/2020 at 1:53 p.m., LVN F entered/exited Resident #1 (COVID-19 negative) room without DONNING/DOFFING PPE except changing out gloves and using hand sanitizer. During an interview with LVN F on 12/02/2020 at 2:41 p.m., LVN F stated she was only trained to DONN/DOFF when entering/exiting COVID-19 Unit. LVN F further stated she was only trained to use hand sanitizer and switch out gloves between resident rooms located on this hallway. LVN F confirmed wearing the same PPE throughout her entire shift while on COVID-19 Unit. During an interview with HK D on 12/02/2020 at 2:33 p.m., HK D stated he was only trained to DONN/DOFF when entering/exiting COVID-19 Unit. HK D further stated he was only trained to use hand sanitizer and switch out gloves between resident rooms located on this hallway. HK D confirmed wearing the same PPE throughout his entire shift while on COVID-19 Unit. Record review of Administrator's email, dated 12/01/2020 at 9:27 p.m., which read Good evening, This is the basic guidance leading us to the decision to maintain our residents on secured unit in our facility. This is information does not specifically address the use of PPE but does state due to the challenges in memory care unit implement eye protection and face masks for HCW protection . The email continued to reveal pasted information from CDC's website titled Considerations for Memory Care Units in Long-term Care Facilities. Record review of CDC's handout titled, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, revealed, Before caring for patients with confirmed or suspected COVID-19, healthcare personnel (HCP) must: Receive comprehensive training on when and what PPE is necessary, how to don (put on) and doff (take off) PPE, limitations of PPE, and proper care, maintenance, and disposal of PPE. Remember: PPE must be donned correctly before entering the patient area. Record review of facility's, Preventing the Spread of COVID-19: Infection Prevention & Control Policy, undated, revealed, It is the policy of our company to comply with Center for Disease Control (CDC), Local and State Department of Health (DOH) guidelines regarding awareness and prevention of the spread of Coronavirus 2019 (COVID-19). Record review of HHSC's, COVID-19 Response for Nursing Facilities, dated 10/08/2020, revealed on page 26, Attachment 1: Immediate Response Guidelines - Create an isolation wing/unit. Identify a separate, well-ventilated area to use as an isolation area. This NF area should be an isolated wing, unit, or floor that provides meaningful separation between COVID-19 positive residents and the space where the facility cares for residents who are COVID-19 negative or untested and asymptomatic. A curtain or a moveable screen does not provide meaningful separation. Further review revealed, when possible, use an area with an entrance separated from the rest of the building. The isolation space should be separated so the essential NF personnel maintaining the building or providing services to residents in the isolation space are not required to go through areas where negative or asymptomatic residents are receiving care. Further review revealed, Attachment 3: Interim Guidance for Prevention, Management, and Reporting of COVID-19 Outbreaks in LTC Facilities under Isolation - once a case of COVID-19 is identified in the facility, immediate action must be taken to isolate the resident who is positive for COVID-19 away from other residents. Further review revealed, Attachment 14: Isolation Unit (Diagram) - Prior to COVID-19 [DIAGNOSES REDACTED]. Create isolation unit. Identify dedicated staff to work in isolation unit, train staff on proper use/maintenance of PPE. Move residents without COVID-19 out of isolation unit. Record review [MEDICAL CONDITION].org, dated 12/12/2020, revealed under title Which people are at higher risk for serious illness if they get COVID-19 which read, According to the CDC, the risk for severe illness from COVID-19 ( .) People with certain medical conditions are also at increased risk: Cancer ( .) Many other medical conditions might also increase the risk of severe illness from COVID-19, including having a weakened immune system after a stem cell (bone marrow) transplant, or after getting other drugs that weaken the immune system (such [MEDICAL CONDITIONS] drugs). The Administrator was notified on 12/02/2020 at 7:22 p.m., by phone that an Immediate Jeopardy situation was identified, and surveyor emailed the IJ template to the Administrator on 12/02/2020 at 7:28 p.m., and a Plan of Removal was requested. The facility's Plan of Removal was accepted on 12/04/2020 at 1:10 p.m. and included (quoted as received from facility, clarification provided in brackets): The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: -- Effective 12/02/2020, the identified negative male resident was relocated from the male secure unit. He was placed in a private room in the warm zone on 400 hall. His family was notified of room move. Medical Director gave orders to transfer resident to the warm zone. He will remain in the warm zone for monitoring x 14 days. -- Effective 12/02/2020 and 12/03/2020, the nine COVID-19 positive residents were transferred to a neighboring sister facility with a dedicated COVID-19 Hot Zone. The facility notified the residents' families and were (facility was) given permission to move the residents. The Medical Director gave orders to transfer the residents and admit them to (Sister Facility Name)'s COVID-19 positive unit. -- Effective 12/03/2020, the male secure unit was deep cleaned by the Housekeeping Staff -- Effective 12/03/2020, the male secure unit became a negative/cold zone and contained only recovered COVID-19 male residents. Interventions and Monitoring Plan: -- Effective 12/02/2020, the DON and the Administrator reviewed the facility's infection control policy and procedure. A decision was made to transfer COVID-19 positive residents to a separate COVID-19 positive facility. Residents with unknown status due to possible exposure were transferred to a designated warm zone for monitoring x 14 days. COVID-19 recovered residents will be cohorted together in a designated negative or cold zone. -- On 12/03/2020, the DON began re-educating all employees on donning and doffing requirements for each designated zone: cold, warm and hot. -- On 12/03/2020, the DON began re-educating all employees that the Male Secure Unit is now a designated cold zone and contains only recovered residents. -- On 12/03/2020, the DON had re-educated Licensed Nurses to continue to assess residents three times daily for signs and symptoms of COVID-19. Residents with signs and symptoms of COVID-19 will be transferred to the designated warm zone and tested for COVID-19. COVID positive residents will be transferred to a sister facility with a dedicated COVID-19 hot zone. Recovered residents will be relocated to a negative/cold zone. -- Licensed Nurses have an assessment in electronic medical record that lists all the signs and symptom of COVID-19 (fever, cough, SOB, fatigue, muscle and/or body aches, headache, new loss of taste or smell, sore throat, congestion, nausea, diarrhea). It automatically fires off (triggers staff to complete) every 8 hours. Nursing Management reviews the record daily during clinical morning meeting. -- DON will begin re-educating licensed nurses on performing the assessment, notifying the physician if signs and symptoms present, notifying the DON and/or Administrator and moving the resident to the warm zone. -- All re-education will be completed by end of working day (5:00 pm) on 12/03/2020. The employees that are currently at home on quarantine will be re-educated by phone by end of day on 12/03/2020. Those employees will be required to sign the re-education upon return to work. -- Adhoc QAPI meeting was held on 12/03/2020 with Inter Disciplinary Team (IDT) to review and discuss items identified by surveyor regarding Immediate Jeopardy. A Plan of Removal was developed, implemented, and completed as designee in this document. The investigator confirmed, by surveyor on 12/04/2020, the plan of removal had been implemented sufficiently to remove the IJ by: -- Confirmed via observation, interview, and record review the identified COVID-19 negative resident (Resident #1) was relocated from the male secure unit and placed in a private room in the warm zone on 400 hall with physician orders [REDACTED]. -- Confirmed via observation and record review the nine COVID-19 positive residents were transferred to a neighboring sister facility with a dedicated COVID-19 Hot Zone and no COVID-19 positive residents remained in facility. -- Confirmed via interview with housekeeping staff that male secure unit was deep cleaned. -- Confirmed via interview and record review the male secure unit had become a negative/cold zone. -- Confirmed via interview with the DON and Administrator that the DON and Administrator had reviewed the facility's infection control policy and procedure. -- Confirmed via interview and record review residents with unknown COVID-19 status due to possible exposure were transferred to a designated warm zone for monitoring x 14 days. COVID-19 recovered residents will be cohorted together in a designated negative or cold zone. -- Confirmed via interview and record review the DON had re-educated all employees on PPE donning and doffing requirements for each designated zone: cold, warm and hot, and that the Male Secure Unit is a now a designated cold zone and contains only recovered residents. -- Record review of training revealed an in-service performed in person or via telephone by the DON for 100% of facility staff informing them of: change from warm to cold zone in the 100 hall (male secure unit), PPE requirements for cold, warm, and hot zones with infographics depicting proper donning and doffing procedure for masks, gloves, gowns, face shields, and booties, and defining each item of PPE, and transfer of residents with unknown COVID-19 status due to possible exposure a designated warm zone for monitoring x 14 days. -- Confirmed via interviews with twenty staff members that training had been conducted and understood. Staff members were able to verbalize understanding of training materials, correctly identify facility's cold and warm zones, the proper PPE to be utilized in each, and to correctly demonstrate proper PPE donning and doffing techniques. Investigator interviewed one dietary staff member, two housekeeping staff members, four administrative staff members, six licensed nurses, one medication aide/nurses' aide, and six nurses' aides. -- Confirmed via interview with two nurse managers (DON and ADON) and Administrator that residents' daily symptom record will be reviewed during daily clinical meeting. -- Record review of training revealed an in-service performed in person or via telephone by DON for 100% of licensed nursing staff regarding: assessment 3 x per day of all facility residents for signs and symptoms of COVID-19 infection including fever, cough, SOB, fatigue, muscle and/or body aches, headache, new loss of taste or smell, sore throat, congestion, nausea, and/or diarrhea. If symptoms are present, immediate notification of DON and/or Administrator and physician and transfer of resident to warm zone for monitoring for 14 days. -- Confirmed via interviews with six licensed nurses that training had been conducted and understood. Staff members were able to verbalize understanding of training materials including: correctly identifying signs and symptoms of COVID-19, demonstrate where and how to document presence of lack of symptoms, and when and whom to notify if symptoms occur. -- Review and comparison of staff list and training log revealed all licensed and unlicensed staff received training on 12/03/2020. On 12/05/2020 at 10:32 a.m. the Administrator and DON were informed the IJ was lifted, but the facility remained out of compliance at a severity of potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern until interventions were put in place to ensure negative residents were being monitored and assessed for signs and symptoms of COVID-19.