Alameda Oaks Nursing Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one (Resident #1) of four residents reviewed for call light placement. The facility failed to ensure Resident #1's call light was within reach. This failure could place residents at risk of needs and accommodation being unmet.Record review of a face sheet dated 3/12/2026 indicated Resident #1 was a [AGE] year-old female, re-admitted [DATE] (initial admission date 11/13/2025), with diagnoses of Acute and Chronic Respiratory failure with Hypoxia (occurs when the lungs cannot adequately oxygenate the blood), Encounter for attention Tracheostomy (routine maintenance needed for a tracheostomy), Dependence on supplemental oxygen, Hemiplegia and Hemiparesis following cerebral infarction (partial paralysis or weakness after a stroke), and Persistent Vegetative State (a disorder or consciousness following severe brain injury where a patient may be awake but have no awareness of themselves or their surroundings). Review of a quarterly MDS assessment, dated 2/24/2026, indicated Resident #1 should not be interviewed for a BIMS due to the resident was rarely/never understood. The MDS indicated Resident #1 was unable to answer questions for cognitive review. The MDS also indicated Resident #1 needed maximum assistance with all activities of daily living, all functional abilities regarding mobility were not assessed due to Resident #1's active diagnosis of Persistent Vegetative state. Record review of Resident #1's care plan, undated, revealed, Resident #1 had a focus goal of being unable to communicate with others related to persistent vegetative state with an intervention of the resident being provided a specialized call device that is easier to operate. During an observation on 3/11/2026 at 2:15 p.m., Resident #1 was in her room with no call light within reach. Resident #1's call light was clipped to itself behind the resident on the wall. (Resident #1 was not interviewed due to current diagnosis). During an interview on 3/12/2026 at 10:45 a.m., Resident #1's family member stated the facility was responsive to his requests for his family member. The family member stated the facility was good about repositioning Resident #1, she was kept clean and the facility staff ensured her vent and feeding tube are well maintained. During an interview on 3/11/2026 at 2:15 p.m., LVN B stated she was unaware Resident #1's call light was not within her reach, but that it should be within her reach. LVN B stated CNA A may have repositioned the resident and did not place it back within reach of Resident #1. LVN B stated this resident unable to respond to any stimuli and cannot use the call light. During an interview on 3/11/2026 at 2:25 p.m., CNA A stated she did care for Resident #1 today and did reposition Resident #1 in bed with LVN B. CNA A stated she was unsure why the call light was not placed within reach of the resident. CNA A stated it was expected for the call lights to always be within reach of all residents, including Resident #1. CNA A stated since Resident #1 was without her call light and does not move or respond to stimuli she does not think anything would have changed with this resident. CNA A stated she ensured Resident #1 was checked on and repositioned during her rounds which are every 2 hours. During an interview on 3/11/2026 at 2:45 p.m., the DON stated it expected that all residents should have a call light pinned on the bed, blanket, or within reach of the resident, including Resident #1. The DON stated even though Resident #1 was not aware of her surroundings the resident could go into respiratory distress. The DON stated she provided re-education to staff about call lights being in reach of all residents to include Resident #1. Record review of facility policy titled, Resident Call System reviewed 12/23/2025 and revised 01/04/2023, reflected, 1. Facility associates should always be aware of call lights and 5. The call light should be positioned within reach of the resident. Return demonstration may be used when educating the resident about call light use. If the resident is unable to demonstrate appropriate call light use, the nurse must be notified to determine an adequate alternative. A. The call system must be accessible to residents while in their bed or other sleeping accommodation within the residents' room. B. The call system must be accessible to the resident at each toileting and bath or shower facility and would be accessible to a resident lying on the floor in this area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a baseline care plan that included the instructions needed to provide effective and person-centered care of the residents, for one (Resident #1) of five residents reviewed for base line care plans for newly admitted residents. 1) The facility did not develop a baseline care plan that addressed Resident #1's diabetes mellitus when he was admitted on [DATE]. This failure could place residents at risk of not having their needs met and increase the risk of adverse events regarding diabetes mellitus exacerbation or complications. The findings included: Record review of Resident #1's admission record dated 12/19/2025 revealed Resident #1 was initially admitted on [DATE] and readmitted [DATE]. Resident #1 discharged home with home health services on 09/22/2025. Resident #1 was admitted to the facility with multiple diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease, and heart disease. Record review of Resident #1's discharge MDS dated [DATE] revealed Resident #1 had a BIMS score of 12-Moderate cognition impairment and needed partial/moderate assistance with ADLs and was coded for type 2 diabetes with diabetic peripheral angiopathy without gangrene (narrowing of arteries in the legs due to diabetes but without tissue death). Record review of Resident #1's NURSING: Baseline Care Plan assessment admission date 09/18/2025 revealed #18 was not check marked for Resident has Diabetes Mellitus. Record review of Resident #1's Care Plan Report date initiated 09/18/2025 revealed it did not include a care plan for diabetes mellitus. During an interview on 12/19/2025 at 3:37PM the MDS Coordinator stated while she reviewed the baseline care plan assessment, box number 18 was not checked marked. The MDS Coordinator stated number 18 was entitled resident has diabetes mellitus. The MDS Coordinator stated if Resident #1 had diabetes mellitus the baseline care plan would be reflective of the admitting diagnosis. The MDS Coordinator stated Resident #1 was admitted to the facility on [DATE] for respite care and discharged on 09/22/2025. The MDS Coordinator stated LVN A failed to check mark number 18 by mistake. The MDS Coordinator stated there was no negative outcome due to Resident #1's baseline care plan lacking his admitting diagnosis of diabetes mellitus. The MDS Coordinator stated while she reviewed Resident #1's baseline care line, Resident #1's diagnosis of diabetes mellitus should have been within his baseline care plan. The MDS Coordinator stated baseline care plans are important because they outline the individualized plan of care, but reiterated there was no negative outcome from the missed baseline care assessment of diabetes mellitus for Resident #1. The MDS Coordinator stated the usual procedure for admission/readmissions begins when the admitting nurse facilitates the admission baseline care plan assessment, which will then be reviewed by the RN which used to be the previous DON. The MDS Coordinator stated that going forward she will be more diligent while reviewing baseline care plans as well as comprehensive care plans. During an interview on 12/20/2025 at 10:32AM LVN A stated Resident #1 was admitted on [DATE] for a 5-day respite stay. LVN A stated she was Resident #1's admitting nurse and recalled Resident #1 had diabetes mellitus. LVN A stated while reviewing Resident #1's baseline care plan assessment, dated 09/18/2025, she had forgotten to click the resident has diabetes mellitus box, and since she did not check mark the box on the admission assessment, the baseline care plan did not populate interventions/care plan for diabetes mellitus. LVN A stated Resident #1 never suffered any negative outcomes due to the missed diabetes mellitus diagnosis on the baseline care plan. LVN A stated she recalled Resident #1 received oral antidiabetic medication. LVN A stated she followed Resident #1's physician orders, and completed glucose monitoring, and oral antidiabetic medication administration. LVN A stated the procedure for facilitating a baseline care plan commences when the admission nurse populates a care plan assessment. Once the care plan assessment was completed, an RN would review the assessment and sign off that the assessment was accurate and addresses the admitting diagnoses. Once the RN signed off, a baseline care plan would then be populated within Resident #1's electronic health record. LVN A stated lastly, the MDS Coordinator would review the baseline care plan as a third review. LVN A stated she accidentally missed clicking the resident has diabetes mellitus box. LVN A stated she should have clicked that specific box, but did not, and therefore affected the accuracy of Resident #1's baseline care plan. However, LVN A stated there were no negative outcomes for the missed check mark. LVN A stated baseline care plans are important as they reflect the individualized plan of care for Resident #1. LVN A stated going forward she will be more diligent in clicking the admission assessment boxes to ensure the baseline care plans are accurate. During an interview on 12/20/2025 at 11:34AM the Interim DON stated she became the interim DON in November 2025 and could not speak to the actions of the previous DON. The interim DON stated that going forward all admissions/readmissions would thoroughly be reviewed during the daily morning meetings, as well as being reviewed by not only herself but also the MDS Coordinator to ensure accuracy. Additionally, the facility would facilitate an impromptu in-service regarding care plan assessments, and baseline care plans. The interim DON stated while she reviewed Resident #1's electronic health care record as well as through her staff interviews, Resident #1 had no negative outcome due to the mistake of LVN A. The interim DON stated a diagnosis of diabetes mellitus would be within a baseline care plan. The interim DON stated baseline care plans were important, as they were individualized plans of care of what the facility was doing to mitigate any potential exacerbation of disease processes. Attempted to phone interview with the previous DON on 12/19/2025 at 4:58PM, 12/20/20/2025 at 10:30AM, 11:46AM but they did not return call by the exit conference. Record review of the facility's Area of focus: Care Planning-Baseline, Comprehensive , and routine updates Baseline care plan issued: 01/04/2022 and reviewed: 12/04/2025 revealed, Baseline care plan: Completion and implementation of the baseline care plan within 48 hours of the resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard again adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 5 residents (Resident #1) reviewed for accuracy and completeness of clinical records.The facility failed to accurately document oxygen use by Resident #1 nine times during the month of August 2025 in the MAR. This failure could result in residents' records not accurately reflecting the residents' status or condition.The findings included:Record review of Resident #1's face sheet dated 10/01/25 revealed a [AGE] year-old female with an admission date of 08/31/23 and a discharge date of 08/18/25. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (COPD) (ongoing inflammation and narrowing of the airways, making it difficult to breathe) and Alzheimer's Disease (progressive brain disorder that causes memory loss, cognitive decline, and behavioral changes). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 (severe impairment). Record review of Resident #1's comprehensive care plan dated 08/18/25 revealed the focus [Resident #1] has occasional episodes of SOB [related to] COPD initiated on 03/09/25 and revised on 07/04/25. Interventions listed for the focus included .oxygen at 2 liters via nasal cannula when necessary initiated on 4/25/25 and revised on 05/09/25. Record review of Resident #1's order summary revealed Resident #1 had an order for Oxygen at 2 liters/minute via nasal cannula as needed for shortness of breath initiated on 05/09/25 and discontinued on 08/20/25. Record review of Resident #1's MAR revealed Resident #1 was never administered 2 liters/minute of oxygen via nasal cannula in the month of August 2025. Record review of Resident #1's oxygen saturation log revealed Resident #1 received oxygen via nasal cannula when her oxygen saturation was measured on 08/07/25, 08/08/25, 08/12/25, 08/13/25, 08/14/25, 08/15/25, 08/16/25, 08/17/25, and 08/18/25. In an interview with the ADON at 10:21 AM on 10/01/25, the ADON stated Resident #1 would occasionally use oxygen, but Resident #1 had a habit of removing it herself. The ADON stated she was not sure about specific days that Resident #1 used oxygen, except for 08/14/25, in which she was certain Resident #1 received oxygen via nasal cannula on that day because she helped the floor nurse treat Resident #1 with oxygen. The ADON stated it was important to sign the MAR anytime medication was administered to a resident to track and trend medication usage and possibly adjust therapies. In an interview with the DON at 10:40 AM on 10/01/25, the DON stated Resident #1 would mostly use oxygen in the evenings. The DON stated she knew Resident #1 used her oxygen more after a shortness of breath incident on 08/14/25. The DON stated it was her and the ADON's responsibility to train staff on proper documentation. The DON stated it was important to sign the MAR after medication was administered to ensure medication was not given twice and to have an accurate record to look back on and make medication changes. Record review of the facility policy General Dose Preparation and Medication Administration written on 12/01/07 and revised on 11/15/24 revealed the following policy: .6. After medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following:6.1 Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application site) on appropriate forms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for change in condition. The facility failed to ensure Resident #1's RP was notified immediately when her oxygen saturation fell to 82% on 08/14/2025. This failure could place residents at risk of their representative being unaware of their change in condition.The findings included:Record review of Resident #1's face sheet dated 10/01/25 revealed a [AGE] year-old female with an admission date of 08/31/23 and a discharge date of 08/18/25. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (COPD) (ongoing inflammation and narrowing of the airways, making it difficult to breathe) and Alzheimer's Disease (progressive brain disorder that causes memory loss, cognitive decline, and behavioral changes). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 (severe impairment). Record review of Resident #1's comprehensive care plan dated 08/18/25 revealed the focus [Resident #1] has occasional episodes of SOB [related to] COPD initiated on 03/09/25 and revised on 07/04/25. Interventions listed for the focus included .oxygen at 2 liters via nasal cannula when necessary initiated on 4/25/25 and revised on 05/09/25. Record review of Resident #1's order summary revealed Resident #1 had an order for Oxygen at 2 liters/minute via nasal cannula as needed for shortness of breath initiated on 05/09/25 and discontinued on 08/20/25.Record review of Resident #1's oxygen saturation log revealed Resident #1 received oxygen via nasal cannula when her oxygen saturation was measured at 82% on 08/14/25. Record review of the change in condition evaluation completed by ADON dated 08/14/25 revealed Resident #1 experienced abnormal vital signs, decreased food and/or fluid intake, and functional decline on the morning of 08/14/25. Further review revealed Resident #1 experienced a sudden decreased level of consciousness along with a low-grade fever of 99.1 degrees Fahrenheit. Further review revealed Resident #1 had SOB, non-productive cough, abnormal lung sounds, and common cold symptoms. Further review revealed the ADON documented the physician was notified on 08/14/25 and the RP was notified on 08/21/25. In an interview with the RP at 2:18 PM on 09/30/25, the RP stated she was not notified of the change in condition for Resident #1 on 08/14/25. The RP stated she found about the change of condition when she requested Resident #1's medical records after she was discharged on 08/18/25. In an interview with the ADON at 4:04 PM on 09/30/25, the ADON stated she filled out the change in condition evaluation for Resident #1 on 08/14/25. The ADON stated she noticed Resident #1 had coughing, SOB, had not gotten out of bed, and generally did not look well. The ADON stated she was pretty sure she called the RP but could not specifically remember doing it. The ADON stated she thought she might have accidentally checked the wrong date on the evaluation for when she notified the RP. The ADON stated after a change in condition the RP should be notified right afterwards because it was important to keep them updated on the residents' status in case they had any relevant information. In an interview with the DON at 5:03 PM on 09/30/25, the DON stated she did not know why the change of condition form for Resident #1 stated the RP was notified a week after the change in condition occurred. The DON stated the date and time the RP was notified should be entered after the RP was contacted. The DON stated the RP should have been notified right away once the resident was stabilized after a change of condition so they may ask questions, come visit, or request medical treatments. Record review of the facility policy Changes in Resident's Condition or Status dated 11/26/18 and reviewed 08/29/25 revealed the following policy:.(i) A facility must 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 - .(B) 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);(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment);

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents participated in the care planning process with the resident and the resident's representative for 1 of 5 residents (Resident #1) reviewed for comprehensive care plans in that: The facility failed to ensure care plan meetings were held with Resident #1 and/or the resident's representative. This failure could place residents at risk of not being involved in developing the plan for the care they will receive.The findings included:Record review of Resident #1's face sheet dated 10/01/25 revealed a [AGE] year-old female with an admission date of 08/31/23 and a discharge date of 08/18/25. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (COPD) (ongoing inflammation and narrowing of the airways, making it difficult to breathe) and Alzheimer's Disease (progressive brain disorder that causes memory loss, cognitive decline, and behavioral changes). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 (severe impairment). Record review of Resident #1's comprehensive care plan dated 08/18/25 revealed it had been developed with interventions made in the care plan throughout her stay at the facility. The care plan did not address how often a care plan meeting should be held. Record review of the most recent care plan meeting attendance sheet dated 03/06/25 revealed Resident #1's representative was in attendance via phone call. In an interview with the RP for Resident #1 at 2:18 PM on 09/30/25, the RP stated the last time she was involved in a care plan meeting with the facility was in March of 2025. The RP stated she had not been notified about any other care plan meetings after the meeting in March of 2025. In an interview with the SW at 11:22 AM on 10/01/25, the SW stated he started working at the facility on 07/16/25. The SW stated he had not had a care plan meeting with Resident #1 or her representative since he had worked at the facility. The SW stated care plan meetings should be held at least quarterly, and possibly more often depending on the needs of the residents. The SW stated he tried to sync up their quarterly care plan meetings with comprehensive assessments. The SW stated he scheduled the care plan meetings. The SW stated it was important to invite the resident and resident representative to the care plan meetings to ensure everyone was on the same page regarding the resident's care. In an interview with the ADM at 11:43 AM on 10/01/25, the ADM stated the last care plan meeting for Resident #1 the facility had evidence for was held was on 03/06/25. The ADM stated there had not been any major changes in the care of Resident #1 since the last care plan meeting. The ADM stated the SW was responsible for scheduling care plan meetings. The ADM stated it was important to involve the resident and resident representative in the care planning process so everyone could share their opinion and be on the same page regarding care. Record review of the facility policy Comprehensive Care Plans and Conferences written on 01/26/23 and revised on 08/29/25 revealed the following policy: .2. The IDT must, at a minimum, consist of the resident's attending physician, a registered nurse and nurse aide with responsibility for the resident, a member of the food and nutrition services staff, and to the extent possible, the resident and resident representative, if applicable.4. The facility should provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation.7. The resident's care plan must be reviewed after each assessment, as required by 483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 3 residents (Residents #1, #2, and #3), reviewed for pharmaceutical services, in that: 1. LVN A failed to administer Resident #1's Morphine at his scheduled time on 10/09/25.2. LVN A failed to administer Resident #3's Tramadol at her scheduled time on 10/09/25.3. LVN B administered Resident #2's Tramadol without an order in place.The findings included: 1. Record review of Resident #1's face sheet, dated 10/10/25, revealed the resident was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses that included: other chronic pain (pain that last more than 3 months), peripheral vascular disease (circulation disorder caused by narrowing, blockage or spasms in blood vessels), secondary osteoarthritis (joint degeneration caused by another medical condition), right ankle and foot, hemiplegia (paralysis of one side of body) and hemiparesis (one side weakness) following cerebral infarction (a stroke - death of brain tissue due to lack of blood flow) affecting left dominant side. Record review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 indicating no cognitive impairment. Record review of Resident #1's care plan, with an initiation date of 06/17/24 had a focus that stated Resident #1 was on pain medication therapy related to chronic pain with an initiation date of 03/08/25 with interventions that included to administer analgesic medication as ordered by physician with an initiation date of 03/08/25. Record review of Resident #1's active physician's orders, retrieved on 10/10/25, revealed an order for Morphine Sulfate ER Tablet Extended Release 15mg with a start date of 10/02/25 and an indefinite end date stated it was to be administered two times a day, at 9:00 am and 5:00 pm. Record review of Resident #1's narcotic sheet revealed LVN A had signed that she administered Resident #1's morphine at 7:57 pm on 10/09/25. During an interview with Resident #1 on 10/09/25 at around 8:05 pm, he stated he had just gotten his morphine not too long ago. He stated he did not have any pain between 5:00 pm and the time of interview. Resident #1 stated he had a meeting after dinner, but stated he had not asked to hold his medication. During an interview with LVN A on 10/09/25 at 8:28 pm, she stated Resident #1 had morphine scheduled at 5:00 pm, and stated she administered it at 7:57 pm. LVN A stated she did not know Resident #1 had morphine scheduled at 5:00 pm and stated it was not given on time because she was busy and stated it was her first time doing med pass and she did not know there were so many scheduled narcotics. LVN A also stated Resident #1 had a lot of family in his room and they were having a meeting and she did not want to interrupt. LVN A stated Resident #1 never complained of pain from the time his morphine was scheduled at 5:00 pm to the time it was administered at 7:57 pm. LVN A stated it was important to provide medication at the time it was scheduled so that residents' pain would not get out of control. LVN A stated she had been trained over medication administration and following physician orders when she was hired in September of 2025. LVN A stated the facility policy for medication administration stated medications were due at the time they were ordered. LVN A stated she did not follow the facility policy. LVN A stated not administering medication such as morphine on time could negatively impact residents because they could have pain. During an interview with the DON on 10/10/25 at 6:48 pm, she stated Resident #1 had orders for Morphine 2 times a day, once at 9:00am and 5:00pm. The DON stated Resident #1 received his morphine late on 10/09/25 at 7:57pm. The DON stated LVN A was responsible for administering the medication to Resident #1 at the time it was late and stated it was late because Resident #1 had stuff going on with a family member trying to get power of attorney. The DON stated Resident #1 did not have any negative outcome due to receiving his medication late and did not verbalize any pain to her. The DON stated it was important that residents got their medications for the continuity of care and stated that residents with chronic pain were used to having medication at a certain time, and it was their duty to make sure they were free of pain and their pain was at a certain level to where they were comfortable. The DON stated LVN A had been trained upon hire by the SDC over medication administration and following the scheduled times. The DON stated as per their facility policy medication had to be given in a timely manner, and stated they had a 1-hour window to administer. The DON stated LVN A did her best to follow the policy in this situation, and did not state if she did or did not follow the policy. The DON stated not providing medication at the scheduled time could negatively impact residents because they could start to withdraw or start having behaviors and yelling out, or they could get anxiety. 2. Record review of Resident #3's face sheet, dated 10/10/25, revealed the resident was a [AGE] year old female who initially admitted to the facility on [DATE] with diagnoses that included: pain in left shoulder, type 2 diabetes (high blood sugar) without complications, hemiplegia (paralysis of one side of body) and hemiparesis (one side weakness) following cerebral infarction (a stroke - death of brain tissue due to lack of blood flow) affecting left non-dominant side, vascular dementia (changes in memory, thinking and behavior caused by impaired supply of blood to the brain), severe with agitation and psychotic disturbance. Record review of Resident #3's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #3 had a BIMS score of 04 indicating severe cognitive impairment. Record review of Resident #3's care plan, with an initiation date of 03/25/25 had a focus that stated Resident #3 was on as needed pain medication therapy related to limited mobility, terminal prognosis, and occasional complaint of pain with a created date of 04/02/25 with interventions that included to administer analgesic medication as ordered by physician with an initiation date of 04/02/25. Record review of Resident #3's active physician's orders, retrieved on 10/10/25, revealed an order started on 06/23/25 for tramadol 50mg to be administered 2 times a day at 9:00 am and 5:00 pm. Record review of Resident #3's narcotic sheet revealed LVN A had signed that she administered Resident #3's tramadol at 8:00 pm on 10/09/25. LVN A was attempted to be reached for interview via telephone on 10/10/25 at 4:56 pm, 4:57 pm, 5:16 pm, 5:19 pm and 5:53 pm with no calls successfully answered or returned. During an interview with Resident #3 on 10/10/25 at 5:45 pm, she required re-direction to questions and stated she had no pain yesterday and she was good. Resident #3 was unable to answer any other questions coherently. During an interview with the DON on 10/10/25 at 6:48 pm, she stated she did not know Resident #3's scheduled time to receive her tramadol, but knew it was 2 times a day. The DON stated Resident #3 received her tramadol on 10/09/25 at 8:00 pm. The DON stated she was not in front of Resident #3 from their scheduled time of 5:00 pm until she received her medication at 8:00 pm, and could not tell me if she was in any pain. The DON stated LVN A was responsible for administering the medication to Resident #3 on 10/09/25. The DON stated it was late because they did not have a med aide and LVN A was the one passing the medication. The DON stated Resident #3 did not have any negative outcome due to receiving her medication late. The DON stated it was important that residents got their medications for the continuity of care. She stated that residents with chronic pain were used to having medication at a certain time, and it was their duty to make sure they were free of pain and their pain was at a certain level to where they are comfortable. The DON stated LVN A had been trained upon hire by the SDC over medication administration and following the scheduled times. The DON stated, as per their facility policy, medication had to be given in a timely manner, and they had a 1-hour window to administer. The DON stated LVN A did her best to follow the policy in this situation, but did not state if she did or did not follow the policy. The DON stated not providing medication at the scheduled time could negatively impact residents because they could start to withdraw, start having behaviors and yelling out, or they could get anxiety. 3. Record review of Resident #2's face sheet, dated 10/10/25, revealed the resident was a [AGE] year old female who initially admitted to the facility on [DATE] with diagnoses that included: heart failure (when the heart muscle does not pump blood as well as it should), chronic kidney disease, stage 5 (when kidneys have almost completely stopped filter waste from the blood), orthostatic hypotension (sudden drop in blood pressure when going to a standing position from sitting or lying), type 1 diabetes with neuropathic arthropathy (nerve and joint damage from long term diabetes) Record review of Resident #2's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #2 had a BIMS score of 15 indicating no cognitive impairment. Record review of Resident #2's care plan, with an initiation date of 07/18/24 had a focus that stated Resident #2 was on pain medication therapy with a created date of 04/27/25 with interventions that included to administer analgesic medication as ordered by physician with an initiation date of 04/27/25. Record review of Resident #2's active physician's orders, retrieved on 10/10/25, revealed Resident #2 did not have an order for tramadol on 09/20/25. Resident #2's tramadol order was started on 09/22/25.Record review of Resident #2's narcotic sheet revealed LVN B had signed that he administered Resident #2 with tramadol on 09/20/25 at 2:00 pm. During an interview with LVN B on 10/10/25 at 3:06 pm, LVN B confirmed that he provided Resident #2 with tramadol on 09/20/25. LVN B stated Resident #2 had an order for tramadol for a long time, and she had gone to the hospital, and when she came back, the order was not put back in. LVN B stated Resident #2 asked for a tramadol and he administered it because he thought she still had the order, and after he administered it, he saw she did not have an order for tramadol. LVN B stated before administering medication, he should review the residents' charts to ensure they had orders for the medication. LVN B stated he did not review Resident #2's orders prior to providing her with tramadol. LVN B stated he should have reached out to the physician to request an order, but , he did not get a chance to. LVN B stated he should not have provided Resident #2 with the tramadol if she did not have an order. LVN B stated he had been trained over mediation administration and ensuring residents had orders in place prior to providing medication. LVN B stated he was trained about a month prior by the DON. LVN B stated the facility policy stated they could not administer a medication without an order. LVN B stated he did not follow the facility policy. LVN B stated administering medications without orders in place could cause an accidental overdose. LVN B stated Resident#2 had no negative impacts due to being administered tramadol. During an interview with Resident #2 on 10/10/25 at 4:00 pm, she stated she recalled getting tramadol on 09/20/25 after she requested it from LVN B. Resident #2 stated she did not have any negative side effects by receiving tramadol. During an interview with the DON on 10/10/25 at 5:45 pm, she stated she did not have any directly related in-services or trainings prior to the identified failures. During an interview with the DON on 10/10/25 at 6:48 pm, she stated staff should review residents charts to ensure they had orders for medication and stated the order should match the blister pack and the narcotic sheet. The DON confirmed that LVN B administered tramadol to Resident #2 on 09/20/25 at 2:00pm. The DON stated Resident #2 had gone to the hospital and when she came back the medication list they provided did not include the tramadol. The DON stated Resident #2 got orders for tramadol on 09/22/25. The DON stated she did not know if LVN B was aware the Resident #2 did not have orders for tramadol on 09/20/25 and did not know if he reviewed her orders before administering tramadol. The DON stated she was not aware of LVN B reaching out the physician to request an order for tramadol before providing it but stated LVN B should have done that. The DON stated LVN B should not have administered tramadol without an order. The DON stated when LVN B had orientation in July of 2025 he was trained over medication administration and ensuring residents had orders prior to administering medication. The DON stated, per their facility policy, medication could not be administered without an order. The DON stated LVN B did not follow this policy. The DON stated administrating medication without an order could negatively impact residents because it could be contraindicated. The DON stated Resident #3 did not have any negative outcome due to being administered tramadol on 09/20/25. Record review of an in-service completed 10/09/25 covering Administering of Medications revealed that LVN A had received the training. Record review of the facility's policy titled, Administration of Medications with a reviewed date of 09/09/25 revealed, 1. Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medication in a skilled nursing facility. 2. Staff who are responsible for medication administration will adhere to the 10 rights of Medication administration.e. Right Time and Frequency. Check the order for when it would be given and when was the last time it was given.3. A physician order that includes dosage, route, frequency, duration, and other required consideration including the purpose, diagnoses or indication for use is required for administration of medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 3 residents (Resident #1, #2 and #3) reviewed for medical records accuracy, in that: 1. Facility staff failed to document Resident #1's administered tramadol on his medication administration record in September 2025 and October 2025. 2. Facility staff failed to document Resident #2's administered tramadol on her medication administration record in September 2025 and her administered morphine in October 2025. 3. Facility staff failed to document Resident #3's administered Morphine on her medication administration record in October 2025. This failure could affect residents whose records were maintained by the facility and could place them at risk for errors in care, treatment and medication administration.The findings included: 1.Record review of Resident #1's face sheet, dated 10/10/25, revealed the resident was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses that included: other chronic pain (pain that last more than 3 months), peripheral vascular disease (circulation disorder caused by narrowing, blockage or spasms in blood vessels), secondary osteoarthritis (joint degeneration caused by another medical condition), right ankle and foot, hemiplegia (paralysis of one side of body) and hemiparesis (one side weakness) following cerebral infarction (a stroke - death of brain tissue due to lack of blood flow) affecting left dominant side. Record review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 indicating no cognitive impairment. Record review of Resident #1's care plan, with an initiation date of 06/17/24 had a focus that stated Resident #1 was on pain medication therapy related to chronic pain with an initiation date of 03/08/25 with interventions that included to administer analgesic medication as ordered by physician with an initiation date of 03/08/25. Record review of Resident #1's order summary report revealed an order for tramadol oral tablet 50 MG every 12 hours as needed for pain with a start date of 06/18/25 and discontinue date of 10/01/25. Record review of Resident #1's order summary report revealed an order for tramadol oral tablet 50 MG every 6 hours as needed for pain with a start date of 10/01/25 and a current order status of active as of 10/10/25. Record review of Resident #1's narcotic sheet revealed LVN C had signed that she administered Resident #1 with his ordered tramadol on 09/24/25 at 10:10am. Record review of Resident #1's narcotic sheet revealed LVN B had signed that he administered Resident #1 with his ordered tramadol on 09/24/25 at 9:00pm and on 10/05/25 at 8:00am and 8:00pm. Record review of Resident #1's order for tramadol on his September 2025 and October 2025 MAR revealed staff did not sign off that his medication was administered on 09/24/25 at 10:10am and 9:00pm and 10/05/25 at 8:00am and 8:00pm. During an interview with LVN C on 10/10/25 at 2:10 pm, she confirmed that she provided Resident #1 with his tramadol on 09/24/25 at 10:10 am. LVN C reviewed Residents #1's September MAR and stated it was blank, and it meant it was not signed as administered. LVN C stated she was responsible for documenting the administration of the medication. LVN C stated she did not recall why she did not document the medication was administered on Resident #1's MAR. LVN C stated the administration of Resident #1's medication should have been documented on his MAR and stated it was important to do for resident safety and because some physicians will look at the MAR and not the narcotic sheet and may discontinue a medication if they see It was not being given. LVN C stated she had been trained over medication administration and documentation and stated she was last trained on 10/09/25. LVN C stated the facility policy stated they were to document medication provided on both the narcotic sheet and the MAR. LVN C stated she had not followed the facility policy. LVN C stated not documenting the administration of medication on the MAR could impact residents safety. During an interview with LVN B on 10/10/25 at 3:06pm, he confirmed that he provided Resident #1 with his tramadol on 09/24/25 at 9:00pm and on 10/05/25 at 8:00am and 8:00pm. LVN B reviewed Residents #1's September and October MAR and stated he had not documented on the MAR. LVN B stated he was responsible for documenting the administration of the medication. LVN B stated he was planning to go back and document but he forgot. LVN B stated the administration of Resident #1's medication should have been documented on his MAR, and it was important to do so to ensure someone was not over medicated and make sure it was being monitored correctly. LVN B stated he had been trained over medication administration and documentation, and he was last trained by the DON a week or 2 prior. LVN B stated the facility policy stated they were to document medication provided on both the narcotic sheet and the MAR. LVN B stated he had not followed the facility policy. LVN B stated not documenting the administration of medication on the MAR could negatively impact residents by medication accidently being given again or the physician may not know what's being administered and if something were to occur with the residents they may not respond appropriately. During an interview with the DON on 10/10/25 at 6:48pm, she stated LVN C administered Resident #1 with tramadol on 09/24/25 at 10:10am and LVN B provided it on 09/24/25 at 9:00pm and on 10/05/25 at 8:00am and 8:00pm. The DON stated both staff members were responsible for documenting the administration of those medications. The DON stated she had already reviewed the MAR and confirmed those dates were not documented for in the MAR. The DON stated she thought the staff would sign the narcotic sheet and then get distracted and would forget to sign the MAR. The DON stated staff should document on the MAR and stated it was important to ensure they were not double dosing or giving an inaccurate dose and for the continuity of care. The DON stated staff had been trained over medication administration and documentation during their orientation and annually. The DON stated the facility policy stated when administering narcotics, they had to be documented in 2 places, the narcotic sheet and the MAR. The DON stated staff had not followed the facility policy in this situation. The DON stated not documenting medication administration in the MAR could negatively impact residents by not controlling their pain or side effects. 1. 2.Record review of Resident #2's face sheet, dated 10/10/25, revealed the resident was a [AGE] year old female who initially admitted to the facility on [DATE] with diagnoses that included: heart failure (when the heart muscle does not pump blood as well as it should), chronic kidney disease, stage 5 (when kidneys have almost completely stopped filter waste from the blood), orthostatic hypotension (sudden drop in blood pressure when going to a standing position from sitting or lying), type 1 diabetes with neuropathic arthropathy (nerve and joint damage from long term diabetes) Record review of Resident #2's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #2 had a BIMS score of 15 indicating no cognitive impairment. Record review of Resident #2's care plan, with an initiation date of 07/18/24 had a focus that stated Resident #2 was on pain medication therapy with a created date of 04/27/25 with interventions that included to administer analgesic medication as ordered by physician with an initiation date of 04/27/25. Record review of Resident #2's physician's orders, retrieved on 10/10/25, revealed Resident #2 had an order for tramadol oral tablet 50MG to be administered every 8 hours as needed for pain with a start dated of 09/22/25 and an indefinite end date.Record review of Resident #2's physician's orders, retrieved on 10/10/25, revealed Resident #2 had an order for morphine sulfate extended release tablet 15MG wit directions to administer .5 tablet every 8 hours as needed for pain with a start dated of 09/23/25 and an indefinite end date.Record review of Resident #2's narcotic sheet revealed LVN D had signed that he administered Resident #2 with tramadol on 09/22/25 at 11:15AM. Record review of Resident #2's narcotic sheet revealed LVN C had signed that she administered Resident #2 with morphine on 10/06/25 at 12:00pm. Record review of Resident #2's narcotic sheet revealed LVN D had signed that he administered Resident #2 with morphine on 10/07/25 at 11:15am. Record review of Resident #2's order for tramadol on her September 2025 MAR revealed staff did not sign off that her medication was administered on 09/22/25 at 11:15am.Record review of Resident #2's order for morphine on her October 2025 MAR revealed staff did not sign off that her medication was administered on 10/06/25 at 12:00PM and 10/07/25 at 11:15am. During an interview with LVN C on 10/10/25 at 2:10pm, she confirmed that she provided Resident #2 with her morphine on 10/06/25 at 12:00pm. LVN C reviewed Residents #2's October 2025 MAR, and stated it was blank and stated it meant it was not signed as administered. LVN C stated she was responsible for documenting the administration of the medication. LVN C stated she recalled having Resident #2's MAR open, clicking it, signing the narcotic book, and then administering the medication. LVN C stated she thought she got busy assisting Resident #2 with getting up and when she returned to click save on the MAR, it was already gone and she did not remember to sign it. LVN C stated the administration of Resident #2's medication should have been documented on her MAR, and it was important to that do for resident safety and because some physicians would look at the MAR and not the narcotic sheet and may discontinue a medication if they see it was not being given. LVN C stated she had been trained over medication administration and documentation. LVN C stated she was last trained on 10/09/25. LVN C stated the facility policy stated they were to document medication provided on both the narcotic sheet and the MAR. LVN C stated she had not followed the facility policy. LVN C stated not documenting the administration of medication on the MAR could impact residents safety. During an interview with LVN D on 10/10/25 at 1:45pm he confirmed that he provided Resident #2 with her tramadol on 09/22/25 at 11:15am and her morphing on 10/07/25 at 11:15am. LVN D reviewed Residents #2's September and October 2025 MAR and stated they were both blank and stated it meant he had not signed the MAR that the medications were administered. LVN D stated he was responsible for documenting the administration of the medication. LVN D stated he did not document on the MAR because he was just busy but did state the administration of Resident #2's medication should have been documented on her MAR and stated it was important to do so they could be accountable for the narcotics and to see how residents were doing and to do an evaluation. LVN D stated he had been trained over medication administration and documentation and stated he knew better. LVN D stated the facility policy stated they had to sign off on the MAR. LVN D stated he thought he had followed his facility policy. LVN D stated not documenting administered medication on the MAR could negatively impact residents because you couldn't prove that a resident got it and there would be no documentation when the physician reviewed the MAR and if they saw that someone's not taking the medication and they may discontinue it. During an interview with the DON on 10/10/25 at 6:48pm she stated LVN C administered Resident #1 with tramadol on 09/24/25 at 10:10am and LVN B provided it on 09/24/25 at 9:00pm and on 10/05/25 at 8:00am and 8:00pm. The DON stated both staff members was responsible for documenting the administration of those medications. The DON stated she had already reviewed the MAR and confirmed those dates were not documented for in the MAR. The DON stated she thought the staff would sign the narcotic sheet and then get distracted and would forget to sign the MAR. The DON stated the MAR should be documented on and stated it was important to ensure they were double dosing or giving an inaccurate dose and for the continuity of care. The DON stated staff had been trained over medication administration and documentation during their orientation and annually. The DON stated the facility policy stated when administering narcotics they had to be documented for in 2 places, the narcotic sheet and the MAR. The DON stated staff had not followed the facility policy in this situation. The DON stated not documenting medication administration in the MAR could negatively impact residents by not controlling their pain or side effects. 3.Record review of Resident #3's face sheet, dated 10/10/25, revealed the resident was a [AGE] year old female who initially admitted to the facility on [DATE] with diagnoses that included: pain in left shoulder, type 2 diabetes (high blood sugar) without complications, hemiplegia (paralysis of one side of body) and hemiparesis (one side weakness) following cerebral infarction (a stroke - death of brain tissue due to lack of blood flow) affecting left non-dominant side, vascular dementia (changes in memory, thinking and behavior caused by impaired supply of blood to the brain), severe with agitation and psychotic disturbance. Record review of Resident #3's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #3 had a BIMS score of 04 indicating severe cognitive impairment. Record review of Resident #3's care plan, with an initiation date of 03/25/25 had a focus that stated Resident #3 was on as needed pain medication therapy related to limited mobility, terminal prognosis, and occasional complaint of pain with a created date of 04/02/25 with interventions that included to administer analgesic medication as ordered by physician with an initiation date of 04/02/25. Record review of Resident #3's physician's orders, retrieved on 10/10/25, revealed an order started on 04/15/25 for morphine sulfate oral solution 10MG/5ML for 1ML to be provide every hours for her pain and with no end date. Record review of Resident #3's narcotic sheet revealed SDC had signed that she administered Resident #3 her morphine on `10/03/25t at 8:00AM. During an interview with the SDC on 10/10/25 at 2:38pm she confirmed she provided Resident #3 with her morphine on 10/03/25 at 8:00am. SDC stated she had already reviewed Resident #3's October MAR and stated it was blank and was not signed as administered and stated it looked as if Resident #3 had not received the medication but SDC stated she did. The SDC stated she probably did not document it on the MAR because she was probably busy. The SDC stated she was responsible for documenting medication administration on the MAR and stated she should have documented on the MAR and stated it was important to document on the MAR because the physician might not see a medication being administered and could discontinue it and because the following nurse would not know the last time something was given and might end up giving it again too soon. The SDC stated she had been trained over medication administration and documentation about 2 months prior by LVN C. The SDC stated the facility policy stated the narcotic sheet needed to match their MAR and stated they had to document their medication administration on both the narcotic sheet and resident's MAR. The SDC stated she did not follow the facility policy. The SDC stated not documenting medication administration on the MAR could negatively impact residents by giving them too much medication or the physician may see that it was not being given and discontinue the medication. During an interview with the DON on 10/10/25 at 5:45pm, she stated she did not have any directly related in services or trainings prior to identified failures. During an interview with the DON on 10/10/25 at 6:48pm, she stated the SDC administered Resident #3 with morphine on 10/03/25 at 8:00am. The DON stated the SDC was responsible for documenting the administration of medication. The DON stated she had already reviewed the MAR and confirmed that date was not documented for in the MAR. The DON stated she thought the staff would sign the narcotic sheet, and then get distracted and would forget to sign the MAR. The DON stated the MAR should be documented on, and it was important to ensure they were not double dosing or giving an inaccurate dose and for the continuity of care. The DON stated staff had been trained over medication administration and documentation during their orientation and annually. The DON stated the facility policy stated when administering narcotics, they had to be documented for in 2 places, the narcotic sheet and the MAR. The DON stated staff had not followed the facility policy in this situation. The DON stated not documenting medication administration in the MAR could negatively impact residents by not controlling their pain or side effects. Record review of Inservice completed 10/09/25 covering Administering of Medications revealed that LVN C had received the training. Record review of the facility's policy titled, Administration of Medications with a reviewed date of 09/09/25 stated, 1. Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medication in a skilled nursing facility. 2. Staff who are responsible for medication administration will adhere to the 10 rights of Medication administration.F. Right documentation. Make sure to write the time and any remarks on the chart correctly. Medication administration should be documented timely following the administration to the resident. Controlled substances should be signed out from the descending count sheet and documented on the MAR for each routine and PRN dose of medication administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident. Consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in comprehensive assessment for 1 (Resident #70) of 6 residents reviewed for care plans. The facility failed to ensure Resident #70's care plan was implemented by not having the resident's call light within reach on 08/04/25 at 2:10 PM. This failure could place residents at an increased risk of needs going unmet or harm.The findings included:Record review of Resident #70's face sheet dated 08/04/25 revealed a [AGE] year-old male with an admission date of 02/10/21. Resident #70's Pertinent diagnoses included hemiplegia and hemiparesis affecting the right dominant side (complete paralysis to right side of body), aphasia (unable to speak), and dementia (decline in mental ability that interferes with daily life). Record review of Resident #70's quarterly MDS assessment dated [DATE] revealed a BIMS score could not be obtained because the resident was rarely or never understood. Record review of Resident #70's comprehensive care plan revealed the focus [Resident #70] is at risk for falls r/t right-sided hemiplegia and hemiparesis, impaired condition initiated on 02/10/21 and revised on 07/15/25. An Intervention for this focus included Call light within reach initiated on 02/10/21. During an observation on 08/04/25 at 2:10 PM, Resident #70's call light cord and button were coiled up on the floor approximately 3 feet away from the head of the bed on Resident #70's right side. In an interview with Resident #70 on 08/04/25 at 2:10 PM, Resident #70 was unable to answer questions due to his inability to speak. Resident #70 was able to nod his head up and down or side to side to indicate yes or no answers. Resident #70 was asked if he knew how long his call light had been on the floor out of reach and he shrugged his shoulders. Resident #70 was asked if his call light was on the floor out of reach very often and he shook his head side to side. Resident #70 was asked if he was able to communicate with nursing staff in the halls with any means other than the call light and he shook his head side to side. In an interview with CNA B on 08/04/25 at 2:15 PM, CNA B stated residents' call lights were supposed to be clipped to the side of the bed within reach of the resident. CNA B stated he did not know how Resident #70's call light fell on the floor out of reach. CNA B stated it was important for residents to be able to access their call lights so they could notify the nursing staff if they had any problems. In an interview with LVN A on 08/04/25 at 2:20 PM, LVN A stated residents' call lights were supposed to be clipped to the side of the bed within reach of the resident. LVN A stated he was in Resident #70's room sometime after lunch and thought the call light was on Resident #70's bed. LVN A stated it was important for any resident to be able to access their call light so they could contact the nursing staff if they had any problems. LVN A stated it was especially important for Resident #70 to have his call light because he was unable to speak or yell to get attention. LVN A stated if a resident could not access their call light, they could accidentally injure themselves and not be able to get the nurses attention for help. In an interview with the DON on 08/06/25 at 2:50 PM, the DON stated it was important for all residents to have access to their call lights so all their needs could be met by the nursing staff. The DON stated if residents could not reach their call light, then they could have trouble informing the CNA's and nurses on the floor of any problems they had. The DON stated this issue could lead to a resident experiencing harm and then receiving a delayed response by the staff. Record review of the facility's policy Person Centered Care Planning last reviewed 09/05/2024 revealed the following: . The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the 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 comprehensive assessment. The comprehensive care plan must describe the following -i. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of their personal and/or medical records for 7 of 10 residents reviewed for residents' rights. The facility failed to ensure LVN-D locked and/or closed the medication cart computer screen and left multiple residents' information exposed. The facility also failed to ensure LVN-D turned over or put away paperwork or report sheets with multiple residents' information on it. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons. The findings include: In an observation on 08/06/25 at 8:10 AM revealed LVN-D's medication cart laptop screen was left opened with multiple residents' information exposed. While examining the laptop and information on the screen, LVN-D walked out of a resident's room, reached past this surveyor and closed the screen. In an observation on 08/06/25 at 9:31 AM revealed a report sheet with multiple residents' information left face up on LVN-D's medication cart. While examining the paperwork and getting a photo of it, LVN-D walked out of a resident's room and grabbed the paper. In an interview on 08/06/25 at 9:32 AM, LVN-D stated she should have locked and closed her laptop screen as well as placed the paper facedown or away because they had residents' information on them, and anyone could have walked by and seen it. She stated she knew it was considered a HIPAA violation to leave resident information exposed. She stated she was really busy and had forgotten to lock the screen or turn the paper over when she walked away. In an interview on 08/06/25 at 9:33 AM, the DON stated it was considered a HIPAA violation to leave residents' information exposed where anyone could have seen it or stolen it. She stated she had just in-serviced LVN-D over this topic this morning. In an interview on 08/06/25 at 9:35 AM, the ADON stated leaving residents' information out in the open for anyone to read or take was considered a HIPAA violation, and the nurses knew they were not supposed to do this to keep the information private and accessible to only those authorized to access it. Record review of the facility document titled Nursing Facility Residents' Rights, dated November 2021, revealed in part, Dignity and Respect: You have the right to: Access personal and clinical records, which will be maintained as confidential and may not be released without your consent. Record review of the facility's policy titled Resident Rights, revealed in part The facility will ensure its associates are educated to the importance of resident's rights. Any violation or potential violation should be reported immediately to their supervisor, the Director of Nursing, Social Services, or Executive Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 5 residents (Resident #54) reviewed for infection control practices. 1.The facility failed to ensure the ADON (who was also the ICP) knew the proper technique for cleansing the wound and keeping it clean during wound care. 2. The facility failed to ensure CNA-C performed hand hygiene between providing Resident #54 incontinent care and applying a clean brief. These fails could place residents at risk for cross contamination and infection. The findings include: Record review of Resident #54's face sheet, dated 08/05/25 revealed an [AGE] year-old-female with an admission date of 07/24/25. Resident #54's Pertinent diagnoses included Displaced Intertrochanteric Fracture of Right Femur with Subsequent Encounter for Closed Fracture with Routine Healing (a common type of hip fracture which typically required surgical intervention for proper healing) and Type 2 Diabetes (a chronic condition which affects the way your body metabolizes sugar). Record review of Resident #54's admission MDS assessment dated [DATE] revealed a BIMS score of 03, which indicated severely impaired cognition. The MDS also revealed Resident #54 had a surgical incision or wound. Record review of Resident #54's physician orders with a start date of 07/28/25, revealed an order for wound care to the right hip surgical incision, cleanse with normal saline, pat dry with gauze, and cover with a dry dressing daily (the order was not clear and did not specify to perform wound care to all four surgical incision areas). The Physician orders did not reveal an order for EBP. Record review of Resident #54's care plan, initiated 07/24/25 and revised 07/28/25 revealed Resident #54 had a break in skin integrity related to right hip surgical incision with interventions to include treatment as ordered and weekly skin checks. In an observation on 08/04/25 at 11:33 AM revealed Resident #54's room had no EBP sign and no PPE supplies. In an observation on 08/05/25 at 9:40 AM of Resident #54's incontinent care and wound care revealed CNA-C provided incontinent care without cleaning or sanitizing her hands in between cleaning Resident #54 and removing the old brief and applying the new, clean brief, then assisting with positioning Resident #54 for wound care. CNA-C was observed placing her dirty, gloved hand over the uncovered 4th surgical wound on Resident #54. CNA-C kept her dirty gloved hand over the surgical site with sutures throughout the entire wound care process. The ADON was observed cleansing and covering 3 of the 4 open surgical wounds. The 4th surgical wound to the lateral aspect of Resident #54's right leg was observed to have gone without wound care. In an interview on 08/04/25 at 10:52 AM, the ADON stated she was also the ICP, and she was the one who typically obtained the order for EBP and placed the EBP signs outside of the residents' doors. She stated the floor nurses did it sometimes upon admission, but if it was not ordered upon admission, she typically obtained the order, hung the signs and placed the PPE outside the residents' rooms. In an interview on 08/05/25 at 10:45 AM, CNA-C stated she should have used hand sanitizer and changed her gloves after cleaning and removing Resident #54's dirty brief. She stated she got nervous and forgot to do it. She stated she did not see the wound on Resident #54's leg or she would not have put her dirty hand over the top of the wound while she assisted to hold Resident #54 in position for wound care. She stated touching the wound with her dirty glove could cause cross contamination and cause the resident to have an infection. In an interview on 08/05/25 at 3:05 PM, the ADON stated CNA-C should have used hand sanitizer and changed her gloves after cleaning and removing Resident #54's dirty brief, and she should have reminded her about hand hygiene and clean gloves as well as reminded her not to touch Resident #54's open wound. The ADON stated she was not sure why the 4th surgical area was not previously covered, and why it was not listed in the orders, so she had the order clarified, and went back and performed wound care on the area. She stated touching Resident #54's surgical wound with a dirty glove could have caused cross contamination and caused an infection. She stated she started an in-service with all staff regarding proper hand hygiene and proper incontinent care. The ADON stated Resident #54 should have previously been placed on EBP precautions, and she must have just overlooked it. Record review of the facility's EBP policy, revised 04/22/25, revealed The facility should use Enhanced Barrier Precautions (EBP) as an additional MDRO mitigation strategy for residents that meet the following criteria, during high-contact resident activities; 2. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. (A) Wounds generally include chronic wounds, to include pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Record review of the facility's Skin Management policy, issued 01/03/22 and revised 11/21/24 revealed 8. Wound care is provided utilizing a clean technique, while practicing Enhanced Barrier Precautions (EBP) when indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview, and record review the facility failed ensure, in accordance with accepted professional standards and practices, to maintain medical records on each resident that was complete and accurately documented for one resident 1 of 7(Resident #00) residents reviewed for medical records. The facility failed to ensure Resident #00's MARS was revised to reflect the accuracy of times the resident took hydrocodone-Acetaminophen Tablet 10-325 milligrams taken as needed for pain control on 04/09/2025.This failure could place residents at risk for not receiving appropriate and timely pain care relief to meet their current needs.The findings included:Record review on 08/06/25 of Resident #00's facesheet documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident # 00 had diagnoses which included diabetes(a group of diseases that result in too much sugar in the blood), necrotizing fasciitis (a serious bacterial infection that destroys the tissue under your skin called fascia) , pressure ulcers(injury to skin and underlying tissue resulting from prolonged pressure on the skin) of heel unstageable, pressure ulcer of sacral region(the anatomical area located at the base of the spine, where the lower back meet the pelvis) stage 4 cutaneous(skin) of limb, skin transplant, encounter of sepsis aftercare.Record review of Resident #00's Minimum Data Set, dated )03/03/25 documented Resident #00 had a BIMS of 14, which indicated the resident's cognitive function was intact. Resident #00 required assist with one-person physical assist for transfers, dressing, toileting, and personal hygiene. Resident #00 had 2 stage 4 pressure ulcers and 2 unstageable pressure ulcers due to coverage of wound bed by slough (dead tissue that accumulates on the surface of a wound, often appearing as a moist, yellow, tan or white layer)or eschar(dead tissue that eventually sloughs off healthy skin after an injury). Resident #00 was receiving insulin injections and IV medications. Record review of resident #00's Care Plan dated 03/22/25 revealed Resident expresses chronic pain related to immobility, limited range of motion to joints, wounds and neuropathy. The Resident is on pain Medication therapy related to wounds and neuropathy. Administer ANALGESIC medications as ordered by physician. Observe for side effects and effectiveness every shift. Record review of Resident's #00's March 2025 Physician's Orders revealed Resident's #00 was prescribed hydrocodone-Acetaminophen tablet 10-325 MG give1 tablet by mouth every 4 hours as needed for pain. The MARS and the Narc Sheet did not match as the Narc sheet showed dates the medication was removed from blister pack. The blister pack did have medication missing and matched the Narc sheet. Record review of the MARs is did not have dates documented on the days the Narc sheet documented medication administered. Record review of the of the narcotic sheet reveal that on 04/09/25 the time of 7:20 pm a pill was documented to be administered to Resident #00 and was signed out by the [NAME] LVN at 7:20 shift ended at 7:00pm.In an interview on 08/06/2025 at 1:30 pm, the Administrator stated the MARs and Narcotic sheet were to match up when compared. The Administrator said the nurse or med aid were to document in these days areas when a narcotic was dispensed to the resident in order to keep accurate account of the amount and the time the resident received their narcotic medication. The Admin stated if the two forms of documentation did not match it could cause an error in dispensing the medication that could put the resident at risk of overdosing and possibly death. In an interview on 08/06/2025 at 2:47 PM with the ADON she stated keeping the narcotic sheet and the resident's MAR accurate kept the resident safe and free of medication mistakes. The ADON stated the nurses were to document in both records as the medication was given to the resident. The ADON stated correctly documented dates and times of resident receiving medication help track drug diversion.The ADON stated she would recheck and match the both records themselves randomly this incident occurred between the time she checked them twice a month In an interview on 08/07/25 the DON stated it was of great importance to maintain accuracy in all aspects of the resident's records but more with the correct documentation of the Narcotic sheet and MAR. The DON stated inconsistencies in the documentation of date and times could keep the resident from getting their medications or getting their medication too early that could cause the resident to have an overdose which could result in hospitalization or death. The DON stated surprise audits of residents records with narcotics were done to prevent such errors from occurring. Record review of the facility policy stated It is the policy of this facility that reports allegations of drug diversion are promptly and thoroughly investigated. Residents have the right to live at ease in a safe environment. Complaints and grievances will be investigated and will be reported as required by law if the investigation reveals any alleged violations and /or misappropriation of resident property.

Based on observation, interviews, 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 reviewed and 1 of 1 nutrition room for storage, preparation, and sanitation.1.The facility failed to ensure dinnerware was cleaned and dried properly.2.The facility failed to ensure the pots, pans, and utensils used to cook and prepare food were in good working condition. 3.The facility failed to ensure items in the refrigerator and freezer were labeled, dated, and sealed properly.4.The facility failed to ensure items in the refrigerator and freezer were not expired.5.The facility failed to ensure boxes in the freezer were not stacked to the ceiling.6.The facility failed to ensure the steam table wells were clean.These failures could place residents at risk for food contamination and foodborne illness.Findings were:Observation and initial tour of the kitchen on 08/04/25 at 10:05 am revealed 24 of 31 clear plastic drinking glasses that had a thick removable whitish substance on the inside bottoms and sides and were wet inside on the clean rack. The trays had no drainage mats under the glasses. There were approximately a hundred plastic plate covers on clean racks that had a removable whitish substance on the tops where the hand holds were, the sides, and around the inner edge where the plastic cover rested on the plates. There were 2 non-stick type pans with flaking coating in the bottoms and sides and were hanging on the clean rack. One of them was badly dented. There were 2 large cooking pots that were badly pitted around the bottoms of the insides. The pits were dark brown/black. There was a dirty metal spatula, a dented and bent metal pastry scraper, and a plastic spatula with chips around the edges in a clean bin. There were multiple trays of glasses with different beverages in them and several pitchers filled with brown liquid in the refrigerator. The trays and pitchers were unlabeled and undated in the refrigerator. There were 6, 4-ounce containers of apple juice in a pan dated 06/01-06/07 in the refrigerator. There was a 20-pound box of frozen hash browns, a large box of frozen breaded yellow squash, and a large box of sweet corn on the cob that were not tightly sealed and opened to the air in the freezer. The hash browns were covered with ice crystals. There was a 1-gallon zip type bag of what appeared to be shredded cheese that was opened to the air and a 1-gallon zip type bag of what appeared to be cheese slices opened to the air in the walk-in freezer. There was a large accumulation of ice hanging from the ceiling onto a large box of an unknown product. Boxes in the walk-in freezer were stacked to the ceiling. 4 of 4 steam table wells had a flaking, yellow/white substance on the bottoms, sides, and floating in them. Observation during a return visit to the kitchen on 08/06/25 at 1:30 pm revealed the same boxes in the freezer were stacked to the ceiling.In an interview with the DM on 08/04/25 at 10:27 am, she said she did not know what the removable white substance was inside the drinking glasses, or the plastic plate covers. She said the glasses should have drying mats under them to drain properly. She said the plastic plate covers were in use. She said if the residents touched the cover to remove it from the plate, it could cause cross contamination as well as the edges of the plates where the cover rested on them. She said the non-stick type pans on the dry rack were only used for making grilled cheese sandwiches. She said kitchen staff used metal utensils in the non-stick type pans and had not been trained on using non-metal utensils in non-stick type pans. She said the flaking coating in the pans could get into the food and possibly make the residents sick. She said she guessed the large cooking pots were pitted inside. She said she did not know why there were brown/black substances in the pits. She said, If it was food in the pits, I guess it could get in the food. She said cross contamination could occur and make residents sick. She said the metal spatula was in a clean bin and did not look clean. The DM said the dented and bent metal pastry scraper did not look safe to use because the metal was sharp and could cut someone. She said it should have been thrown away. She said the plastic spatula with chips around the edges should have been thrown away because the plastic was coming off, could get in the food and make residents sick. She said she was unaware of labeling and dating food and beverages on trays in the refrigerator and freezer when the products were going to be used that day. She said they did not always use all the products on the trays the same day. She said there was a box of the containers of apple juice in the freezer and the 6, 4-ounce individual containers of apple juice were thawing in the refrigerator. She said the box use by date was 14 days after thawing (verified). She said the containers of apple juice in the refrigerator were past their use by date. She said the expired apple juice could have made residents sick. She said she was unaware bagged frozen food inside boxes had to be tightly sealed after opening. She said nothing about the open zip-type 1-gallon bags of cheese. She said the ice build-up in the walk-in freezer had been there for a year. She said repairs for the kitchen were reported in the daily morning meetings. She said repairs for the freezer were on-going. She said the freezer had been repaired multiple times addressing the ice accumulation. She said she was unaware boxes could not be stacked to the ceiling and asked the state surveyor how far they had to be. She said she did not know how often the steam table wells were being cleaned. She said she provided routine training of kitchen staff. She said she was ultimately responsible for the kitchen. She said she let the registered dietician know the state surveyor was at the facility and would let her know she was requested for an interview. The registered dietician did not come to the facility and was unavailable for interview.In an interview with the ADM on 08/04/25 at 2:00 pm, she said the freezer was assessed by the company repairmen and it needed to be replaced. She said the main problem was finding a new freezer that fit in the same place as the current one. The ADM provided invoices for the walk-in freezer repairs.Record review of kitchen in-services, dated 06/27/25, reflected cooling and storing potentially hazardous hot foods, 07/22/25-mechanically altered & puree preparation, holding and guidelines, 08/04/25-importance of dating of food, 05/12/25-updated use-by date guide, 04/09/25-proper gloves, 04/11/25-importance of watching out for likes and dislikes on tray cards, seasoning of foods, 03/13/25-Snacks. Record review of the facility's expenditure request for the walk-in freezer repairs, dated 11/05/24 reflected air ducts leaking above walk in freezer creating a cone of water inside the freezer, icicles on sprinkler head, and slippery floor. The request was approved on 11/06/24.Record review of invoices for freezer repairs dated: 08/27/24 reflected on 07/23/24 the freezer was assessed for not keeping temp and needed verification of operation for state inspection. The exterior thermometer is reading inaccurately .The door gasket is sealing but recommend replacement as soon as possible. As of now unit is operating fully. 08/27/24 Returned to location, removed and replaced the door gasket, verified proper seal.Unit is in service. 09/13/24 reflected on 09/10/24 the freezer was assessed for leaking water inside. Drain pan was frozen solid.melted the ice. The freezer has a drain heater, but drainpipe is PVC not copper. This is freezer with plates holding the ceiling together.unit is back in service. 09/11/24 assessed for not running and found blown fuses at the condenser.Removed and replaced two fuses at the condenser and evaporator switch. 09/13/24 assessed for spark coming from around the fan.removed fan and found a wire practically cut in half, needed to replace the motor.unit is back in service.05/23/25 reflected on 05/22/25 the freezer was assessed for not reaching temp. Evaporator was frozen up.noticed walk-in in very poor condition and all ceiling panels are warped. Also found ceiling has holes that constantly drip water. Ice build-up on evaporator more likely due to condition of box. 05/23/25 freezer assessed for not keeping temp again.evaporator frozen over again.failed low pressure control not releasing.which kept defrost heaters from engaging.replaced worn parts and verified operations. Unit is back in service.07/07/25 reflected the freezer was assessed for not keeping temp.failed condenser fan motor.was replaced.verified operation. Unit is cooling at full capacity.Record review of the facility's undated kitchen policy titled, Use by Date Guide reflected: The following guide can be used to determine a use by date for labeling food (opened or unopened) that should be used within a certain time frame.this information is used when there are no guidelines on the containers of food.When counting, begin with the current date and use a calendar when determining the actual use by date. For example, on Dec. 18th, a can of applesauce was opened, the use by date is 7 days, therefore the date placed on the label will be Dec. 24th.guidelines for storing leftovers are 3 days (72 hours). Item/Category-Cheese, Processed, opened-Use By 30 days-store in enclosed container after opening. Cheese, Shredded, Cheddar, opened-Use By 14 days- store in enclosed container after opening. Leftover food-meat, cooked vegetables-use by 3 days. Record review of the facility's kitchen policy, revised 04/30/25, titled Safe Food Handling, revealed under Policy: All food purchased, stored, and distributed is handled with accepted food-handling practices, and per federal, state, and local requirements. Under Definitions: Cross-contamination means the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces.or utensils which are not cleaned.Under Food Contamination-means the unintended presence of potentially harmful substances, including, but not limited to, microorganisms, chemicals, or physical objects in food. Under Procedure 7. All cooking utensils, pans, dinnerware will be stored dry. All plastic ware that cannot be sanitized, is chipped and/or has lost its glaze will be discarded. All chipped and/or cracked dinnerware and glassware will be discarded.Record review of the facility's kitchen policy reviewed 05/01/25, titled, Prevention of Cross Contamination reflected under Policy: All Food and Nutrition Services associates are trained in infection control techniques to prevent the contamination of food and the spread of infection to ensure that food is stored, prepared, distributed and served in accordance with professional standards for food safety, and per federal, state, and local requirements. Under Procedure: 1.Categories of infection control training will include a minimum of a. Biological contamination b. Chemical contamination c. Physical contamination f. Equipment. 2. The director of food and nutrition services and registered dietician provide ongoing training on infection control and the prevention of food contamination. 3. The director of food and nutrition services or designee will check food storage, food preparation, and food service areas daily to ensure proper steps are being followed h. All refrigerated foods if removed from their original container are securely covered, labeled, and dated appropriately and if opened, the label will contain the appropriate use by date i. Leftovers are covered, labeled and dated appropriately, and used within 72 hours or discarded. Under Routine Housekeeping 2. Soiled equipment should never touch food. 3. All work surfaces, utensils, and equipment should be cleaned and sanitized after each use.References: FDA Food Code 2022 Ch. 2-102.20 Food Protection Manager Certification 2-103 Duties 2-103.11 Person in Charge. The person in charge shall ensure that: Ch. 4-202 Cleanability 4-202.11 Food-Contact Surfaces. (A) Multiuse food-contact surfaces shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; (4) Finished to have smooth welds and joints 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 4-602 Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. Equipment food-contact surfaces and utensils shall be cleaned throughout the day at least every 4 hours.

Based on interviews and record reviews, the facility failed to provide and document sufficient preparation and orientation of resident representatives to ensure safe and orderly transfer or discharge from the facility.The facility failed to provide written transfer notices to residents, representatives, and the local ombudsman in a language and manner they understand.This failure could place residents at risk of not receiving information regarding their options, rights, and protection from inappropriate transfers or discharges. Findings included:In an interview with the ADM on 08/05/2025 at 10:41 am, she said the facility had not been sending out written transfer notifications. In an interview with the Ombudsman on 08/05/25 at 2:15 pm, she said she had not been getting written notifications of transfer from the facility. In an interview and record review with the ADM on 08/05/2025 at 4:30 pm, she said she developed and provided a performance improvement plan regarding written transfer policies at this time. In an interview with the ADM on 08/06/2025 at 10:41 am, She said the BOM would have been responsible for sending the letters to the resident, the resident representative, and the ombudsman. She said she did not know why they were not sending out transfer notifications.Record review of the facility's discharge report dated 05/01/25-08/04/25 revealed 55 discharges: 21 to an acute care hospital, 6 to funeral homes, 1 to hospice, 3 to nursing homes, 19 to private homes with home health services, and 5 to private homes without home health services. Record review of the facility's policy reviewed on 11/19/24 titled, Area of Focus: Discharge Process and Bed Holds revealed under Notice before transfer, before a facility transfers or discharges a resident, the facility must: (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they can understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure residents were treated with respect and dignity and care for each resident in a manner and in an environment, that promoted maintenance or enhancement of his or her quality of life, for one Resident (Resident #2) of 5 residents reviewed for dignity issues.
On 04/29/2025 at 11:04AM and 11:55AM Resident #2's foley catheter drainage bag did not have a privacy bag, leaving the urine visually exposed to visitors and staff.
This failure could place residents at risk of feeling uncomfortable or embarrassed and could decrease a residents' self-esteem and/or quality of life.
Findings were:
Record review of Resident #2's admission record dated 04/29/2025 revealed Resident #2 was a [AGE] year-old-male who was admitted on [DATE]. Additionally, Resident #2 was admitted with a diagnosis of benign prostatic hyperplasia (urinary obstructions) with lower urinary tract symptoms.
Record review of Resident #2's Admissions MDS was not yet completed due to Resident #2 being admitted on [DATE].
Record review of Resident #2's Care Plan date initiated:04/25/2025 revealed the resident has Indwelling Foley Catheter: 18F/10cc bulb r/t BPH, bilateral hydronephrosis, and urinary retention. Goal: Will have no complications r/t indwelling catheter use. Interventions: Catheter care every shift, educate resident and/or family regarding indwelling catheter and care.
Record review of Resident #2's Physician Orders dated 4/24/2025 revealed, Indwelling catheter to straight drainage. Size: 18 Fr/ Bulb: 10 cc. Change for infection, obstruction or when the closed system is compromised. As needed for Change for infection, obstruction or when the closed system is compromised.
During an observation on 04/29/2025 at 11:04AM and 11:55AM Resident #2 was in bed, with call light within reach. Additionally, upon further observation there was a visible foley catheter with roughly 200-300ml of yellow urine in the foley bag. Furthermore, while in the immediate hallway, where Resident #2's room was situated, there were roughly 4-5 people including staff and visitors, who walked past Resident #2's room.
During an interview on 4/29/2025 at 12:09PM CNA A stated privacy bags were placed by nurses and not CNAs. CNA A stated CNAs were allowed to provide perineal care and incontinent care but could not place privacy bags. CNA A stated she did not know the reason as to why CNAs were not allowed to place privacy bags on foley catheters. CNA A stated privacy bags were utilized to ensure the resident maintained their right to privacy and to ensure resident's urine was not visible. CNA A stated if a foley catheter did not have a privacy bag, a resident could feel embarrassed or hurt. CNA A stated it was within the nurse's scope of practice to place a privacy bag on Resident #2's foley catheter. CNA A stated she did not recall when she attended an in-service regarding foley catheter care or privacy bags.
During an interview on 04/29/2025 at 12:17PM LVN C stated Resident #2 was moved to the 300 hall over the weekend. LVN C stated prior to his room change, Resident #2 was in the 100 hall for several weeks. LVN C stated, while observing Resident #2 in his room, Resident #2 should have a privacy bag on his foley catheter but did not. LVN C stated all clinical staff could place privacy bags and it was not the sole responsibility of the nurses. LVN C did not give a definitive answer as to how a resident could have been affected given that Resident #2 was cognitively impaired. LVN C stated privacy bags were utilized to ensure Resident #2's right to privacy and it could have been compromised due to the catheter being visible to visitors and staff. LVN C stated he would rectify the situation by placing a privacy bag on Resident#2's foley catheter. LVN C stated he could not recall the last in-service he attended regarding foley catheter care and privacy bags.
During a phone interview on 04/29/2025 at 2:23PM the DON stated the dignity bag or privacy bags were utilized to cover the urine output within the foley catheters. The DON stated the expectation was for all foley catheters to have some sort of covering. The DON stated privacy coverings were used to ensure that resident's urine output was not seen by the visitors to ensure the resident's right to privacy. The DON stated she could not definitively state how a lack of privacy covering could affect residents with foley catheters. The DON referenced her own familial experience to justify that a lack of privacy covering on a foley catheter may not compromise the psycho-social well-being of a person. The DON reiterated privacy bags/shields should be utilized for all foley catheters to ensure the resident's right to privacy. The DON stated she had been employed at the facility for roughly 1 week and did not recall attending an in-service regarding foley catheter privacy bags.
Requested foley catheter care/privacy bag in-services on 04/29/2025 at 1:54PM to the Administrator, did not receive by the time of the exit conference.
Record review of the facility's Dignity policy and procedure issued date: 05/19/2019; reviewed 09/26/2024 documented,
Procedure:
2. Promoting resident independence and dignity while dining, such as avoiding:
h. Refraining from practices demeaning to residents, such as leaving urinary catheter bags uncovered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all alleged violations involving the reasonable suspicion of a crime were reported immediately to a law enforcement entity for its political subdivision, within two hours if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, for 1 (Resident #1 ) of 5 residents reviewed for abuse/neglect.
The facility failed to report to the local law enforcement agency within the allotted time frame of 24 hours on 11/24/2024 around 2 PM when Resident #1 notified LVN A that LVN B allegedly had thrown her into a wheel chair.
This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse.
The findings included:
Record review of Resident #1's admission record dated 04/26/2025 revealed Resident #1 was a [AGE] year-old-female who was admitted on [DATE]. Additionally, Resident #1 was admitted with diagnoses Parkinson's disease (neurological disease that affected movement), and dysphagia (swallowing problem).
Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 15 which meant she was cognitively aware and needed setup or clean-up assistance for her ADLs.
Record review of Resident #1's care plan Date Initiated: 06/28/2024, The resident has an ADL self-care performance deficit r/t Confusion, impaired balance touch pad needed/ in place due to unable to press call bell. Observe and report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Praise all efforts at self-care. PT/OT evaluation and treatment as per MD orders .
Record review of the written statement by LVN A dated 11/24/24 revealed during an interview, Resident #1 stated [LVN B] grabbed her by her arm and leg and threw her into a wheelchair .
During a phone interview on 04/29/2025 at 2:23 PM the DON stated she had been employed with the facility for roughly 1 week. The DON stated once an allegation of abuse was made, the facility would activate their abuse protocols which would consist of protecting the resident, calling the police if needed, and reporting the allegation to state agencies. The DON stated she would assume any form of abuse would be a criminal offense and if proven true the person could get into a lot of trouble. The DON stated she could not speak to the actions or lack of actions regarding the previous DON, but in her professional opinion if there was an allegation of physical abuse, she would notify local law enforcement. The DON did not definitively state what could transpire if the local law enforcement were not notified of the allegation of abuse.
During an interview on 04/29/2025 at 2:41PM the Administrator stated when she was made aware of the allegation on 11/24/2024, she enacted the facility abuse protocol. The Administrator stated she treated the allegation as a physical abuse allegation. The Administrator stated she ensured the LVN B who was the alleged perpetrator was removed from the facility and the facility schedule, pending the investigation results. The Administrator stated she notified Health and Human Services Commission of the allegation of physical abuse. The Administrator stated she directed her clinical staff to ensure the safety of Resident #1 and ensured the nursing staff performed a head-to-toe assessment. The Administrator stated Resident #1 stated the allegation of abuse transpired in June 2024 and therefore focused their record review for June 2024 to ensure there were no skin irregularities noted. The Administrator stated Resident #1 notified LVN A on 11/24/24 that LVN B threw her in a geriatric chair roughly in June 2024. The Administrator stated she did not contact the local law enforcement on 11/24/2024 regarding the allegation of physical abuse due to the allegation transpiring in June 2024. The Administrator stated her reason for not calling local law enforcement was due to the allegation timeframe of June 2024. The Administrator stated LVN B was allowed to return to the facility as there was no evidence of any physical abuse. The Administrator stated Resident #1 no longer resided within the facility. The Administrator did not verbalize a definitive answer when asked as to what could potentially happen if local law enforcement were not notified of an allegation of physical abuse. The Administrator stated once the investigation into Resident #1's allegation concluded there was no evidence of the physical abuse. The Administrator verbally clarified, going forward any allegation of abuse would be notified to the proper authorities and state agencies .
Record review of the facility's Abuse-Protection of Residents policy and procedure issued:10/04/2022; Reviewed: 06/17/2024 documented, Procedure: The following methods to ensure the protection of residents during an investigation may include but are not limited to; 5. Notification of the alleged violation to other agencies or law enforcement authorities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care.
The facility failed to have a nurse evaluate Resident #1 after an unwitnessed fall. Resident #1 sustained a left distal femoral shaft fracture and a right tibia and fibula fracture.
The noncompliance was identified as PNC. The PNC began on 08/29/24 and ended on 09/05/24. The facility had corrected the noncompliance before the investigation began.
The failure could affect residents, resulting in not receiving needed care to maintain optimal health and placing them at risk for injury or deterioration in their condition.
The findings included:
Record review of Resident #1's face sheet dated 03/04/25 revealed an [AGE] year-old female with an initial admission date of 02/29/24 and a current admission date of 09/16/24. Pertinent diagnoses included acquired absence of left leg above knee, unspecified dementia, and depression.
Record review of Resident #1's discharge MDS assessment dated [DATE] section C, cognitive patterns, revealed a BIMS score of 2 (severe impairment).
Record review of Resident #1's care plan dated 11/05/24 revealed the focus Resident is at risk for falls r/t impaired mobility, weakness, impaired cognition, and pain initiated on 09/17/24 and revised on 11/06/24. Interventions listed for the focus included:
Anticipate and meet the resident's needs initiated on 05/29/24 and revised on 11/06/24.
Assist with ADL's as needed initiated on 03/02/24 and revised on 11/06/24.
Call light within reach initiated on 03/02/24 and revised ono 11/06/24.
Complete fall risk assessment initiated on 03/02/24 and revised on 11/06/24.
Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs initiated on 06/04/24 and revised on 11/06/24.
May have [non-slip mats] to wheelchair initiated on 08/07/24 and revised on 11/06/24.
May have floor mats next to bed initiated on 06/04/24 and revised on 11/06/24.
Orient resident to room initiated on 03/02/24 and revised on 11/06/24.
Therapy evaluate and treat as ordered or PRN fall 05/28/24 resident currently on PT, therapy informed of fall resident DC'd off OT due to refusals initiated on 05/29/24 and revised on 11/06/24.
Will review medications for adverse reactions initiated on 06/04/24 and revised on 11/06/24.
Record review of the provider investigation report dated 09/05/24 revealed the following witness timeline:
Timeline - 8.29.24 [Resident#1]
Approximately 5:50 AM:
[CNA A], rounding on 400 hall and she hears resident saying help me help me.
[CNA A] attempts to get resident up. Resident states she cannot stand. [CNA A] leaves room to go get help.
[CNA A] gets other [CNA B] and asks her to help get [Resident #1] up off floor.
[CNA A] and [CNA B] enter [Resident #1's] room. Both get resident up from floor and assist her into wheelchair. Both aides then transfer her into bed and tuck her back into bed.
Both aides leave room and continue with final rounds. Neither report fall to nurse or other aides on their shift or oncoming shift.
Approximately 7:00 AM:
[CNA C] is rounding on 400 hall and goes to check [Resident #1].
[Resident #1] reports pain in her leg and wanting to see the Dr.
[CNA C] reports this to her nurse [RN D].
[RN D] calls doctor and Dr. order Xrays.
Xray results come in and [Resident #1] is transferred to hospital with acute left femur fracture.
Incident is reported to HHSC
All staff interviewed from night before, no one reports [Resident #1] having a fall.
[CNA B] and [CNA A] state they rounded on [Resident #1] was having increased weakness, however, was a self transfer and only required assistance to transfer into bed.
Staff inserviced on: Abuse/Neglect/Exploitation, Falls, and Transfers
Tuesday, September 2nd, 2024
Interview with aides [CNA A] and [CNA B] reveals that resident sometimes needed more assistance with transferring and toileting at night. [CNA B] states she asked [Resident #1] to pivot on transfer into bed but that there was no sign of pain [or] grimacing. [CNA A] agreed with interview.
Wednesday, September 3rd, 2024
Aides [CNA A] and [CNA B] interview along with Nurses [RN E] and [RN D]
[Resident #1] readmits to facility.
Interview of resident by [ADM] and DON. Resident revealed that she fell in door way when ambulating back to bed after having gone to restroom. She states she does not remember who came to help her but a nurse came to help her. When the resident stated she could not stand the nurse went to get another nurse and they both picked her up off the floor and transferred her to bed. Resident stated at the time she felt nothing and went back to sleep. Later, around 7a she felt pain and requested from a different nurse to see the doctor.
Aides interviewed again and statement of [CNA A] changes.
Aides [CNA A] and [CNA B] suspended pending investigation.
[CNA A] and [CNA B] terminated based off of investigation findings.
Record review of the provider investigation revealed the following interviews:
Resident #1 on 09/04/24
Around 7a I got up from bed to go to the restroom. I was going back to bed when I heard a pop and my leg gave out. I fell in my doorway. A nurse came right away and tried to help me off the floor but I could not stand. She left and came back with a second nurse. Both nurses helped get me off the floor and sat me in my wheelchair. They then wheeled me closer to my bed and transferred me into bed. I do not remember their names. I didn't feel any pain then. Later, another nurse came to check on me and I told her my leg was turned the wrong way and hurt and I needed to see the doctor. She said okay that she would tell someone. Another Nurse called the doctor and they did xrays on my leg and it was broken.
CNA A on 09/04/24
I was walking down 400 hall when I heard a resident saying help me help me. I entered [Resident #1's] room and found her on the floor in the doorway of the bathroom. I went to get the other [CNA B]. [CNA B] and I got her up. We put her in her wheelchair and then put her in bed. I asked [Resident #1] if she was okay and she said she was. We then kept rounding. We never told the nurse.
Record review of x-ray of Resident #1 dated 08/29/24 revealed a fracture through the left distal femoral shaft at the level tip of the intramedullary femoral stem, minimally comminuted (fracture that extends into the knee and up through the femur). Further review revealed a fracture of the right tibia and fibula.
Record review of a local hospital's patient records for Resident #1 dated 08/30/24 revealed the following plan: Regarding patient's left distal femur fracture, this fracture is not fixable and unfortunately is not convertible either. At this time [Doctor] has recommended a left above-knee amputation.
Interview was attempted with CNA A at 10:58 AM on 03/05/25, but CNA A could not be reached so a message was left.
Interview was attempted with CNA B at 11:00 AM on 03/05/25, but CNA B could not be reached so a message was left.
In an interview with the ADM at 11:22 AM on 03/05/25, the ADM stated they did not know Resident #1 had fallen from the incident on 08/29/24 until they interviewed her on 09/04/24. The ADM stated before they were able to interview Resident #1 they thought the breaks were from brittle bones. The ADM stated they originally thought the fractures caused the fall, and not the fall caused the fractures. The ADM stated Resident #1 had problems with her left knee, and she had several surgeries on it in the past few years. The ADM stated she believe the ultimate outcome of left leg above knee amputation of Resident #1 would not have changed even if the CNA's A and B had acted appropriately. The ADM stated CNA A and CNA B should have found a nurse to evaluate the resident on the floor before moving her at all. The ADM stated no employee had ever come to her to report another employee for possible abuse of a resident. The ADM stated the two CNA's involved in this incident had always been good CNA's. The ADM stated they conducted safe surveys after the incident and all residents reported they felt safe. The ADM stated they inserviced all employees on abuse, neglect, falls, and alerting staff if there was a fall. The ADM stated they made cards that all employees carried on their badges to inform them of the proper steps in case a resident fell.
In an interview with Witness #1 at 1:40 PM on 03/05/25, Witness #1 stated she was a good friend of Resident #1. Witness #1 stated she visited Resident #1 when she was in the hospital after her fall on 08/29/24. Witness #1 stated Resident #1 told her she went to the bathroom and fell. Witness #1 stated Resident #1 told her the CNA's tried to move her several times while she was in the bathroom, but her legs kept hurting more and more. Witness #1 stated the two CNA's had a tough time picking up Resident #1, but one of them bear hugged her and threw her in bed. Witness #1 stated Resident #1 told her she asked for the nurses to come back and check on her legs, but they left the room.
In an interview with the NP at 2:49 PM on 3/5/25, the NP stated Resident #1 had infective hardware with multiple revision surgeries (surgery to correct or modify the results of a previous surgery) on her left knee. The NP stated Resident #1 was on IV antibiotics for an extended period of time before the fall on 08/29/24. The NP stated she initially sent the resident out to the hospital for swelling and the fractures in her legs. The NP stated there was potential the CNA's could have caused more damage when they moved her. The NP stated in this condition Resident #1's leg was in, any fall or twist could have injured it. The NP stated she still had Resident #1 as her patient, and Resident #1 was doing much better with pain control after the amputation.
In an interview with Resident #1 at 10:48 AM on 03/06/25, Resident #1 stated she remembered the facility she was at when she had her fall at the end of August. Resident #1 stated she was leaving her bathroom when her feet came out from under her. Resident #1 stated she did not remember hearing a pop before falling. Resident #1 stated he hips faced one way while her legs faced the other. Resident #1 stated it was very painful. Resident #1 stated when she told the nurses about her pain they did not believe her. Resident #1 stated one of the nurses told her bite the bullet for a bit while she moved her back into bed. Resident #1 stated she told the first two nurses that she wanted to see the doctor but they laughed at her. Resident #1 stated once she was back in bed she positioned her legs so they did not hurt as bad. Resident #1 stated it was not until a 3rd nurse came in 30 minutes later that started helping her for the pain.
In an interview with CNA C at 1:59 PM on 03/06/25, CNA C stated when she entered Resident #1's room around 7:00 AM on 08/29/24 it looked like Resident #1 was in severe pain and very uncomfortable. CNA C stated Resident #1 told her she was in pain. CNA C stated she went and got the nurse as soon as she realized the condition Resident #1 was in.
Record review of the facility policy titled Incident and Reportable Event Management issues 07/19/21, revised 08/15/23 and reviewed 09/25/24 revealed the following:
Incident/Injury
1. The licensed nurse should evaluate the resident and render first aide if needed
a. The nurses evaluation should be completed prior to moving a resident who has fallen, to determine presence of injury.
2. The licensed nurse should create an event note and include the following details;
a. The assessment details of the resident (including location details of the resident)
b. Presence or absence of injury, and any treatments rendered
c. If resident is able to report what occurred, this should be included in the notes
d. Notification of family or responsible party
e. Notification of physician and any orders received
3. The licensed nurse should create a risk report in the electronic system and identify the most appropriate type of event from the available options in the system.
4. The licensed nurse should also notify the following in accordance with state and federal requirements
a. Supervisor on duty and/or DON
In interviews beginning at 2:12 PM on 03/04/25 with staff from multiple shifts, the DON, ADM, CNA C, CNA F, LVN G, CNA H, CNA I, CNA J, LVN K, LVN L, MA M, CNA N, CNA O, CNA P, and RN Q were able to identify the proper procedures to follow when responding to a witnesses or unwitnessed fall. All staff knew not to move the resident before getting the nurse and referenced the card attached to their name badges to demonstrate the proper protocol. All staff were familiar with different types of abuse and neglect.
Record review and verification of the corrective action implemented by the facility beginning on 08/29/25:
The facility terminated the employment of CNA A and CNA B effective 09/05/24 verified by record review of the provider investigation, staff roster, and interview with the ADM.
Resident #1 was discharged to another nursing facility on 11/05/24 verified through record review of Resident #1's face sheet and interview with the ADM.
teams
Re-educated and in-services staff beginning on 08/29/25 verified through interviews with carious staff members and record review of in-services.
Abuse and Neglect
Exploitation
Falls
Transfers
Ad-Hoc QAPI conducted on 09/05/24 regarding incidents/accidents verified by interview with the ADM.
Reviewed all policies regarding falls on 09/05/24 verified by interview with the ADM.
Badge cards created on 09/05/24 for all staff to be worn at all times detailing proper step-by-step procedures for what to do if a resident fell or was found on the ground verified by interviews with various staff.
The noncompliance was identified as PNC. The PNC began on 08/29/24 and ended on 09/05/24. The facility had corrected the noncompliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received adequate supervision for one Resident (Resident #2) of three residents reviewed for supervision.
The facility failed to ensure Resident #2 received adequate supervision and did not exit the facility through the front door.
This failure could place residents requiring supervision at risk for injury and accidents.
The findings include:
Record review of Resident #2's face sheet dated 03/05/35 reflected a [AGE] year-old male with an original admission date of 12/08/23. Diagnoses included heart failure, type two diabetes (insufficient insulin production in the body), Alzheimer's disease (disease that destroys memory and thinking skills), and Dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life). Resident #2 was discharged on 11/12/24.
Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 1 (severe cognitive impairment).
Record review of Resident #2's care plan dated 11/11/24 reflected Resident #2 was at risk for elopement related to confusion/disorientation to place, impaired safety awareness, and aimless wandering. Interventions included frequent monitoring and wandering behavior at times. The plan did not indicate any previous elopement attempts.
In an interview on 3/5/25 at 9:26am the Central Supply staff member stated on 11/09/24 she was going to do a transport and was parking the facility bus upfront in the driveway when she saw Resident #2 sitting on the bench by the front door with no attempt to get up and walk. The Central Supply staff member stated she parked the facility bus and redirected Resident #2 back inside without incident. The Central Supply staff member stated Resident #2 stated he was just enjoying the fresh air. The Central Supply staff member stated a former maintenance assistant was outside at the time and stated Resident #2 was sitting outside for about 3-5 minutes according to a previous maintenance assistant who was outside at the time working. The Central Supply staff member said the former maintenance assistant said Resident #2 did not attempt to go anywhere or was not in any danger and if so, he would have intervened and called for assistance.
In an interview on 3/5/25 at 9:38 am LVN G stated there was a new receptionist who went on break and did not set the door alarm correctly (no wander guard system in use at facility). LVN G stated Resident #2 was found sitting on the bench near front door by a Central Supply staff member and stated Resident #2 was brought back into the facility. LVN G stated a head-to-toe assessment was conducted with no noted injuries. LVN G said at the time of the assessment, Resident #2 stated he was just sitting outside getting some fresh air. LVN G stated Resident #2 was placed on one-to-one monitoring. LVN G stated the facility elopement protocols were conducted, and all other residents were accounted for. LVN G stated Resident #2 did not display any exit seeking behaviors prior but was discharged to a secured unit at another facility.
Through interviews and record review, no residents were exit seeking and only had risks for elopement.
In an interview on 3/5/25 at 2:12 pm the ADM stated Resident #2 was at the back station and the receptionist who was new was trying to leave for lunch and locked the door but did not realize the door only locks on the outside and not the inside. The ADM stated Resident #2 was outside for about 3-5 minutes the Maintenance Assistant (no longer employed with facility) saw Resident #2 sitting on the bench and watching him work. The ADM stated that a Central Supply staff member pulled up to the facility moments after and realized Resident #2 was not supposed to be outside and brought him back in immediately and notified the nurse. The ADM stated Resident #2 was found right by the front door sitting on the bench approximately 6-7 feet. The ADM stated Resident #2 was not trying to leave the facility and was simply sitting outside with no immediate danger noted at the time. The ADM stated Resident #2 was assessed with no injuries and was transferred to another facility with a secured unit. The ADM stated all staff were in-serviced on elopement and drills were conducted beginning on 11/09/24 with all staff on all shifts.
In an interview on 3/5/25 at 2:45 pm the ADON stated Resident #2 would wander about the facility but was not exit seeking. The ADON stated she heard Resident #2 had exited the facility and was found sitting on the bench by the front door. The ADON stated Resident #2 was allowed to go outside but with supervision and usually goes outside in the courtyard area. The ADON stated staff were in-serviced on elopement, exit seeking behaviors, and elopement drills conducted beginning on 11/09/24 (verified through record review).
In a phone interview on 3/5/25 at 4:40pm the previous Receptionist stated she was going to lunch and normally someone relieves her but, on that day, there was no one to relieve her at that moment and waited for someone to relieve her. The receptionist stated she spoke to a charge nurse who said she could leave but lock the front door. The Receptionist stated she locked the door but was fairly new and thought she locked it correctly but guess she didn't. The Receptionist stated when she returned after lunch, that was when she learned Resident #2 had exited through the front door. The Receptionist stated she was shown how to lock the door but guess she did not alarm it correctly.
Record review of the facility's Elopement policy dated 01/03/2022 and revised on 11/19/2024 reflected:
Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and
§483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation.
1.
The facility failed to ensure the ice machine was clean.
2.
The facility failed to ensure drinking glasses were clean.
3.
The facility failed to ensure non-stick pans were not eroded.
4.
The facility failed to ensure pots and pans were not dented.
5.
The facility failed to ensure pest control was effective.
6.
The facility failed to ensure personal items were not on prep carts or in walk-ins.
7.
The facility failed to ensure proper cleaning was done according to their daily
kitchen cleaning log.
8.
The facility failed to ensure the walk-in freezer was in good operating condition.
9.
The facility failed to ensure the lights in the walk-in refrigerator, freezer, and vent
hood were in good operating condition.
10.
The facility failed to maintain cleanliness of the ovens, floor, and air vents on the
ceiling.
These failures could place residents at risk of foodborne illnesses.
Findings included:
Observation and initial tour of the kitchen beginning on 07/01/24 at 9:05 am revealed the ice machine had a removable reddish substance along the entire edge of the ice chute. 25 of 25 drinking glasses had a heavily coated whitish yellow substance on the insides. There were 2 non-stick pans the finish was eroded from, one completely gone except the sides. The other non-stick pan was on the stove and had deep scratches throughout the center of the finish. There was one large pot that was heavily dented, and 5 small holding pans that had deep dents with crevices in the inside corners and scratches on the inside bottoms. There were ants on the prep table next to the stove. The ants were on and around the can opener attached to the prep table. The ants were crawling across the top of the prep table to the other side as well as up the back wall and into a moderate crack in the wall. There was a 25-pound container of powdered beef base on the lower shelf of the prep table (that had the ants on it) with the lid askew. There was a large block of ice build-up in the walk-in freezer that was so heavy, the ceiling of the walk-in freezer was drooping. There were 2 open, partially full 16-ounce sodas on the shelf of the walk-in refrigerator. There was a purse on the lower shelf of a prep cart. The walk-ins were dimly lit and there were no lights under the vent hood. The ovens were dirty with build-up inside and outside. There was a dark brown-black substance along the floor where it met the walls behind the stove and prep tables. There was an approximate 1-inch hole in the corner of the wall where it met the floor, with what appeared to be possible rodent droppings. The air vent and return air on the ceiling had thick layers of a dark brown/black substance covering them.
In an interview with the Assistant DM, on 07/01/24 at 9:15 am she stated she did not know what the stuff on the ice chute was and it looked dirty. She stated they were having issues with their water softener, and that caused the haziness in the drinking glasses. She stated the drinking glasses were on the clean rack for use. She stated she would not want to drink from any of the 25 glasses. She stated the residents could get sick from whatever was inside the drinking glasses. She stated the kitchen staff did not really use the large, damaged non-stick pan and said it should have been removed from the pot rack it was on long ago because that rack was for the pans they used. She would not say why she did not remove it or what the risk was to residents from using a non-stick pan with an eroded finish. She stated the other damaged non-stick pan on the stove was not that bad. She stated the large, dented pot on the pot rack was used for boiling water that was used for food such as potatoes. She stated the dented holding pans were not being used right now because of the low census. She stated she did not know bacteria could grow in crevice's the dents made, and she guessed the residents could get sick from that. Regarding the 25-pound container of powdered beef base on the lower shelf of the prep table (that had the ants on it) with the lid askew, she stated there was probably not ants in there. (She did not check the contents of the container prior to replacing the lid) She stated the kitchen staff followed a daily cleaning schedule for the floors, prep tables, the stove and microwaves. She stated she could not remember what else was on the daily cleaning schedule. She stated she did not know where or how the large block of ice came from in the walk-in freezer, and that it was maintenance's job to fix it. She stated she did not know what they were doing about the ice build-up in the walk-in freezer, but it had been there a while. She stated the lights in the walk-ins had always been very dim and it was difficult to see anything in the walk-ins because if food went bad, it was not noticeable. She stated the lights in the vent hood just went out one day. She stated she never reported any of the lights because she assumed the DM and maintenance already knew. She stated the air vents on the ceiling could use some cleaning. She stated kitchen staff were not allowed to have personal items in the walk-in refrigerator because it could cause cross contamination and make residents sick. She stated the purse on the prep cart was hers because she was in a hurry this morning and just tossed it there. She stated she was going to move it. She stated she would tell maintenance about the ants.
In an interview with the ADM on 07/03/24 at 5:20 pm, she stated she was aware the kitchen needed a lot. She stated she had been in the facility since 06/13/24 and was trying to get things done. She stated she was not aware of the extent of repairs the kitchen needed. She stated the MS had not made her aware of the condition of the walk-in freezer.
Record review of the kitchen daily cleaning log dated 04/2024-06/29/24 revealed there was no section for the ice machine. The section for stove top and grill was blank for 04/26/24, 06/19/24, and 06/26/24 and 06/28/24. The section for floors was blank for 05/04/24, 06/28/24.
Record review of kitchen in-services revealed no significant ongoing training on infection control and the prevention of food contamination, as stated in the facility's policy.
Record review of the facility policy titled Prevention of Cross Contamination revised 04/26/23 documented under Policy, All food and nutrition services associates are trained in infections control techniques to prevent the contamination of food and the spread of infection to ensure that food is stored, prepared, distributed, and served in accordance with professional standards for safety, and per federal, state, and local requirements. Under Procedure, 1. The director of food and nutrition or designee provides training to departmental new hires on infection control techniques. Categories of infection control training will include a minimum of a. Biological contamination, b. Chemical contamination, c. physical contamination, f. equipment. 2. The director of food and nutrition services and registered dietician provide ongoing training on infection control and the prevention of food contamination. 3. The director of food and nutrition or designee will check food storage, food preparation, and food service areas daily to ensure proper steps are being followed. 4. Foodservice associates may drink from a closed beverage container if handled to prevent contamination of a. The associates' hands, b. the container, c. exposed food, clean equipment, utensils, linens, and unwrapped items. 5. The following assists in preventing contamination of food and spread of infection. G. All equipment, utensils, counters, workstations, and cutting boards are cleaned and sanitized per department guidelines. 6. Ice used in connection with food or drink will be obtained from a sanitary source and handled and dispensed in a sanitary manner. F. Inside of bin will be cleaned according to facility cleaning schedule. Routine Housekeeping 7. Rodent and pest control must be provided on an established schedule, and as needed.
Record review of the facility policy titled, Cleaning Schedule revised 12/17/21 documented under Policy, The director of food and nutrition services develops a cleaning schedule, with assistance from the registered dietician, to ensure that the food and nutrition services department remains clean and sanitary at all times. Equipment and Utensil Cleaning and Sanitization, A potential cause of foodborne outbreaks is improper cleaning (washing and sanitizing) of equipment and protecting equipment from contamination via splash, dust, grease, etc., Procedure 1. The director of food and nutrition services develops a cleaning schedule to include all equipment and areas to be cleaned. 4. The director of food and nutrition services monitors the cleaning schedule to ensure the tasks are completed timely and appropriately.
The facility policy on Food Storage was not received.

Based on observation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 walk-in freezers, 1 of 1 walk-in refrigerators, 1 of 1 air intake vent, and 1 vent hood reviewed for essential equipment in the kitchen.
The facility failed to ensure the walk-in freezer was free of ice build-up, the door properly closed, and the inside light was bright enough.
The facility failed to ensure the light in the walk-in refrigerator was bright enough.
The facility failed to ensure the air intake and return air vent was clean.
The facility failed to ensure the vent hood lights and the exhaust fan worked.
These failures could place the residents at risk of potential fire hazards.
There findings were:
Initial observation of the kitchen on 07/01/24 at 9:05 am revealed a large block of ice build-up in the walk-in freezer appearing to be attached to the ceiling that was so heavy, the ceiling of the walk-in freezer was drooping. The door of the walk-in freezer did not close properly and there was a large gap between the door and the floor when shut. The walk-in refrigerator and the walk-in freezer were so dimly lit it was difficult to identify the contents. There were no lights under the vent hood. The air vent and return air on the ceiling had thick layers of a dark brown/black substance covering them. The air from the vents was directed at the center of the kitchen where the food holding table and plates were.
In an interview with the Assistant DM on 07/01/24 at 9:15 am she stated the lights in the walk-ins had always been very dim and it was difficult to identify what foods were in there. She stated the lights in the vent hood just went out one day. She stated the exhaust fan on the vent hood was making a screeching sound and she was not sure if the vent hood exhaust fan worked. She stated she never reported any of the lights because she assumed the DM and maintenance already knew. She stated the air vents on the ceiling could use some cleaning. She stated she did not know what they were doing about the ice build-up in the walk-in freezer, but it had been there a while. She stated the MS knew about the exhaust fan. She stated it was maintenance's job to fix things.
In an interview with the MS on 07/03/24 at 4:50 pm, he stated he did not know about the dim lighting in the walk-ins. He stated he spoke with an electrician about new fixtures for the vent hood lights and a new belt for the exhaust motor because it screeches. He could not say when he had spoken to an electrician, or the name of the electrician he spoke to. Regarding the air vent and return vent, the MS stated he started cleaning them 2 weeks ago but got pulled away to work on something else. He stated the ice build-up in the walk-in freezer had been like that since before he started working at the facility over 1 ½ years ago. He stated he spoke to regional (did not know the name) and was told by them to support the ceiling in the walk-in freezer by putting beams up to support the ceiling. The MS stated, The walk-in freezer was condemned by two restaurant supply companies a year ago. He stated, They wouldn't touch it. The MS stated the temperatures in the walk-ins were ok. He stated the ceiling in the walk-in freezer could collapse. He stated the walk-in freezer needed to be replaced.
In an interview with the DM on 07/03/24 at 5:10 pm, she stated she had not noticed the lights were dim in the walk-ins. She stated the walk-in freezer was a mess, meaning the door did not close properly and caused condensation. She stated the ice build-up in the walk-in freezer had been there 2-3 years. She stated the walk-in freezer could stop working at any time. The facility policy on food storage and maintaining equipment were requested.
In an interview with the ADM on 07/03/24 at 5:20 pm, she stated she was aware the kitchen needed a lot. She stated she had been in the facility since 06/13/24 and was trying to get things done. She stated she was not aware of the extent of repairs the kitchen needed. She stated the MS had not made her aware of the condition of the walk-in freezer.
Record review of the facility's paid kitchen invoices revealed the kitchen exhaust system was cleaned on 02/05/24 and 05/15/24. There were no invoices for the walk-in freezer, the walk-in cooler lights, or the vent hood.
Record review of the maintenance log reflected one entry dated 06/25 and was for a leaking sink in the kitchen.
The facility policy on Food Storage and maintaining equipment were not received.

Based on observations, interviews, and record reviews, the facility failed to maintain as effective pest control program for 1 of 1 kitchen reviewed for sanitation.
There were ants on a prep table on and around the can opener, all over the top of the prep table, and crawling up the wall into a crack.
There was evidence of rodent droppings on the kitchen floor adjacent to the wall.
There was a hole in the baseboard adjacent to the floor near the rodent droppings.
These failures could place residents at risk of living in an unsafe, unsanitary environment, and cross contamination of food.
Findings were:
Initial observation of the kitchen on 07/01/24 beginning at 9:05 am revealed there were ants on the prep table next to the stove. The ants were on and around the can opener attached to the prep table. The ants were crawling across the top of the prep table to the other side and up the back wall into a moderate crack in the wall. There was a 25-pound container of powdered beef base on the lower shelf of the prep table (that had the ants on it) with the lid askew. There was a dark brown-black substance along the floor where it met the walls behind the stove and prep tables. There was an approximate 1-inch hole in the corner of the wall where it met the floor, with what appeared to be possible rodent droppings.
In an interview with the Assistant DM on 07/01/24 at 9:15 am she stated she would tell maintenance about the ants. She would not answer regarding whether the ants were a problem, if they could get into any food type item, or what could happen to residents if the ants could get into any type of food type item. She did not answer as to whether she had ever seen mice or rodents in the kitchen. She stated she thought there were sticky traps in the kitchen, but she could not say where they were located, how long they had been there, or who was responsible for checking them.
In an interview with the MS on 07/03/24 at 4:50 pm, he stated the facility kept a pest control log he was responsible for. He stated the pest control company was at the facility on 07/02/24 to treat the ants and would be back in two weeks. He stated the pest control company sprayed for ants whenever they (they pest control company) were there. He stated he had not seen any mice for a while and could not determine what a while meant. He stated there were sticky traps usually by the bread and in the back room of the kitchen. He stated he did not know exactly where they were or if the sticky traps were even there. He stated the pest control company was responsible for them. He stated the maintenance logs were hand-written and the facility did not use an electronic work order system. He stated the maintenance logs were kept at the nurse's station. He stated he did not know how he knew when items were resolved because he did not keep the requests after he addressed the problem(s). The pest control log and maintenance log were requested.
In an interview with the DM on 07/03/24 at 5:10 pm, she stated the process of reporting problems in the kitchen was to go to maintenance. She stated there was a maintenance log specifically for the kitchen, separate from the other maintenance logs. She stated maintenance kept the kitchen maintenance log. She stated she had worked in the facility for 13 years. She said nothing when asked if she had ever seen mice, ants, or rodents in the kitchen.
In an interview with the ADM on 07/03/24 at 5:20 pm, she stated she was aware the kitchen needed a lot. She stated she had been in the facility since 06/13/24 and was trying to get things done. She stated she was not aware of the extent of repairs the kitchen needed. She stated the MS had not made her aware of the condition of the walk-in freezer.
Record review of the pest control service contract dated 07/14/16 included monthly interior and exterior service for insect control, rodent control, and fly control.
Record review of pest control services rendered dated 04/02/24, 05/07/24, and 06/04/24 reflected none of the invoices had detailed what kind of prevention the pest control company treated for. There was no invoice for 07/02/24.
Record review of the maintenance log reflected one entry dated 06/25 and regarded a leaking sink in the kitchen.
Facility policy regarding physical environment or pest control was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that seight residents (Resident #4, Resident #32, Resident #23, Resident #26, Resident #22, Resident #28, Resident #18, and Resident #38) of twenty-four residents reviewed for professional standards, received care in accordance with professional standards of practice and the comprehensive person-centered care plan.
1.) The facility did not ensure that the Physician Order for monthly weight was followed for Resident #4.
2.) The facility did not ensure that the Physician Order for weekly weights was followed for Resident #32.
3.) The facility did not ensure that the Physician Order for monthly weight was followed for Resident #23.
4.) The facility did not ensure that the Physician Order for monthly weight was followed for Resident #26.
5.) The facility did not ensure that the Physician Order for monthly weight was followed for Resident #22.
6.) The facility did not ensure that the Physician Order for weekly weight was followed for Resident #28.
7.) The facility did not ensure that the Physician Order for weekly weight was followed for Resident #18.
8.) The facility did not ensure that the Physician Order for weekly weight was followed for Resident #39.
These failures could affect residents who required regular weight monitoring and could result in severe weight loss or weight gain and place them at risk for not receiving the appropriate care and interventions resulting in a decreased quality of life.
The findings included:
1.) Resident #4
Record review of Resident #4's face sheet dated 7/1/24 reflected a [AGE] year-old-male with an original admission date of 1/2/24. Diagnoses included dementia (general decline in cognitive abilities that affect the person's ability to perform everyday activities), cerebral infarction (when blood supply to part of the brain is blocked or reduced), contracture (shortening or hardening of muscles tendons or other tissues often reach deformity and rigidity of joints) to the left hand, type two diabetes (insufficient insulin production in the body), muscle wasting and atrophy (waste away).
Record review of Resident #4's physician's orders dated 5/6/24 stated:
Monthly weights.
Record review of Resident #4's weight summary reflected weights of 199.4lbs on 5/4/24, and a weight of 196.1lbs on 7/2/24. A -1.65% weight loss. No weight was documented for the month of June 2024.
Record review of #4's care plan with an initial date of 1/11/24 and a revision date of 5/29/24 stated:
Resident #4 had a nutritional problem or potential nutritional problem: mechanically altered diet.
Interventions/Tasks included: Monthly weights.
Resident #4 was non-intervewable.
2.) Resident #32
Record review of Resident #32's face sheet dated 7/1/24 reflected a [AGE] year-old-male with an original admission date of 9/25/23. Diagnoses included cerebral palsy (group of conditions that affect movement and posture), scoliosis (sideways curvature of the spine), hypoglycemia (blood sugar/glucose level in the body is lower than the standard range), and muscle wasting.
Record review of Resident #32's physician orders dated 5/8/24 stated:
Weekly weights.
Record review of Resident #32's weight summary reflected a weight of 120.2 lbs on 5/30/24, and a weight of 123.0 lbs on 7/2/24. A 2.33% weight gain. No weight was documented for the month of June 2024.
Record review of Resident #32's care plan with an original date of 10/04/23 stated:
Resident #32 had a nutritional problem related to BMI below normal and history of intravenous hydration needs, presence of a feeding tube related to impaired swallowing.
Interventions/Tasks included: Weekly weights.
Resdient #32 was non-interviewable.
3.) Resident #23
Record review of Resident #23's face sheet dated 07/02/2024 reflected an [AGE] year-old female with an admission date of 08/31/2023. Pertinent diagnoses included Alzheimer's Disease (progressive brain disease that causes a mental decline affecting the quality of daily living) and Heart Failure (disease in which the heart can no longer pump enough blood to meet the body's needs).
Record Review of Resident #23's physician's orders dated 05/05/2024 stated: Monthly Weights
Record review of Resident #23's weight summary reflected weights of 147.4lbs on 04/10/2024, 155.4lbs on 05/05/2024, and 141.0lbs on 07/03/2024 resulting in an overall -4.34% weight loss. No weight was documented in June 2024.
Record review of Resident #23's care plan dated 05/13/2024 stated the resident was At risk for weight fluctuation related to current health status. Interventions included Monthly Weights.
4.) Resident #26
Record Review of Resident #26's face sheet dated 07/01/2024 reflected an [AGE] year-old male with an admission date of 11/30/2023. Pertinent diagnoses included Generalized Muscle Weakness, Nausea with Vomiting, and Paroxysmal Atrial Fibrillation (a type of irregular heartbeat in the upper chambers of the heart that can last up to a week but usually ends within 24 hours).
Record review of Resident #26's physician orders dated 05/06/2024 stated Monthly Weights
Record review of Resident #26's weight summary reflected weights of 103.6lbs on 04/10/2024, 108.4lbs on 05/05/2024, and 110.6lbs on 07/02/2024 resulting in an overall 6.76% weight gain. No weight was documented in June 2024.
Record review of Resident #26's care plan dated 05/24/2024 stated the resident was at risk for weight fluctuation related to current health status. Interventions included Monthly Weights.
5.) Record review of Resident #22's face sheet dated 05/22/23 reflected an [AGE] year-old female with an original admission date of 03/07/23. Pertinent diagnoses included dementia, stroke, depression, anxiety, and limited range of motion.
Record review of Resident #22's physician orders dated 05/08/2024 stated Monthly Weights.
Record review of Resident #22's weight summary reflected weights of 160.0 lbs. on 04/09/2024, 162.4 lbs. on 05/05/2024, and 160.6 lbs. on 07/02/2024 resulting in an overall 1.8 % weight gain. No weight was documented in June 2024.
Record review of Resident #22's care plan dated 06/06/2024 on page 4 reflected Resident #22 had a potential fluid deficit r/t impaired mobility/vision/communication, history of urinary tract infections with an initiation date of 06/06/23 and a revision date of 06/06/24. Interventions included observe and report as needed . recent/sudden weight loss .with an initiation date of 06/06/23. Page 7 reflected Resident #22 was at risk for weight fluctuation r/t current health status with an initiation date of 03/16/23. The goal indicated Resident #22 wished to maintain current weight through next review.
6.) Record review of Resident #28's face sheet dated 11/21/23 reflected a [AGE] year-old male with an original admission date of 07/06/21. Pertinent diagnoses included tracheostomy (a surgical hole through the neck into the trachea (windpipe) for breathing), throat cancer, protein-calorie malnutrition, a feeding tube, depression, anxiety, and diabetes.
Record review of Resident #28's physician orders dated 05/08/2024 stated Weekly Weights.
Record review of Resident #28's weight summary reflected weights of 139.0 lbs. on 04/09/2024, 140.0 lbs. on 05/05/2024, and 136.5 lbs. on 07/02/2024 resulting in an overall 1.5 % weight gain. No weight was documented in June 2024. A weekly weight was not done on May 14, 2024.
Record review of Resident #28's care plan dated 06/06/2024 on page 9 reflected Resident #28 required tube feeding with an initiation date of 08/01/22 and a revision date of 01/11/23. Interventions included weekly weights with an initiation date of 08/28/23. Page 12 reflected Resident #28 was at risk for weight fluctuation r/t current health status with an initiation date of 07/06/21. The goal indicated Resident #28 wished to maintain current weight through next review with an initiation date of 08/02/21 and a revision date of 03/28/24.
7.) Resident #18
Record review of Resident #18's face sheet dated 07/01/24 indicated a [AGE] year old male admitted [DATE]. Pertinent diagnoses included dysphagia (difficulty swallowing), unspecified protein-calorie malnutrition (inadequate intake of food as a source of protein, calories, and other essential nutrients), hypothyroidism (the thyroid gland does not make enough thyroid hormone), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).
Record review of Resident #18's Physician Order Summary dated 07/01/24 revealed an order that read, Monthly Weights that was dated 05/08/24 with order status, Active.
Record review of Resident #18's Weight Summary dated 07/01/24 revealed on 03/06/24 weight was 111.2lbs, on 04/09/24 weight was 104.8lbs, on 05/04/24 weight was 106.4lbs and on 07/02/24 weight was 111.1lbs which resulted in an overall even weight. There was no weight documented for the month of June 2024.
Record review of Resident #18's Care Plan revealed FOCUS: At risk for weight fluctuation r/t current health status initiated 01/25/24, GOAL: Resident (#18) wishes to maintain current weight through next review initiated 01/25/24, and INTERVENTIONS/TASKS: Assistance with meals as needed and Diet order regular/puree/nectar (regular diet, pureed, with nectar thick fluids), double portions all meals, meals served in bowls initiated 01/25/24 and revised 06/06/24. There was no intervention or task for weight monitoring.
8.) Resident #39
Record review of Resident #39's face sheet dated 07/01/24 indicated a [AGE] year-old male originally admitted [DATE] and re-admitted [DATE]. Pertinent diagnoses included apraxia (neurological disorder that causes difficulty with speech), dysphagia following cerebrovascular accident (difficulty swallowing after damage to the brain from an interruption of its blood supply), nausea with vomiting, and hemiplegia/ hemiparesis (one side of the body is weak/ paralyzed) following a non-traumatic subarachnoid hemorrhage (bleeding in the brain not caused by an external force).
Record review of Resident #39's Order Summary Report on 07/01/24 revealed an order that read, Monthly weights that was dated 05/06/24 with order status, Active.
Record review of Resident #39's Weight Summary on 07/03/24 revealed on 04/09/24 weight was 177.8lbs, on 05/04/24 weight was 176.8lbs, and on 07/03/24 weight was 159.8lbs, which resulted in an overall -10.12% weight loss over 3 months. There was no weight documented for the month of June 2024.
Record review of Resident #39's care plan revealed FOCUS: At risk for weight fluctuation r/t current health status initiated 05/17/22, GOAL: Resident (#39) wishes to maintain current weight through next review initiated 05/17/24, revision on 03/01/24, target date 06/19/24, and INTERVENTIONS/TASKS: Assistance with meals as needed. Date Initiated: 05/17/2022, Diet order: CCHO (Controlled carbohydrate) diet, regular texture, thin liquids, picante sauce with meals, divided plate, Double Portions per family request- Discontinued due to excessive weight gain, Date Initiated: 05/17/2022, Revision on: 10/03/2023, Educate resident and family regarding potential weight fluctuation, Date Initiated: 05/17/2022Monthly weights Date Initiated: 05/06/2024.
Record review of Resident #39's Quarterly Nutrition Data Collection signed on 05/23/24, the RD stated in the summary, Resident's weight is stable x180 days with no significant changes this review. Resident receives a therapeutic diet due to Diabetes Mellitus Type 2 (a form of diabetes where the pancreas does not make enough insulin and the body has trouble controlling blood sugar) diagnoses. Glucose checks do not appear to be well-controlled, usually ranging between 200-400. Noted started on new diabetes medication Mounjaro. Therapeutic diet remains appropriate as a support for management of glucose levels. Resident consumes 50-100% of meals per documentation. Skin is free of pressure injuries. Intake appears adequate to meet nutritional needs. Recommend continue current nutritional Plan of Care. The RD also documented in the space for Comments on any updates to focus, goals, and/or interventions: Goals: (1) Maintain current weight with no significant change >5%/30 days (2) Maintain skin free of pressure injuries (3) Maintain positive hydration status with no s/s of dehydration.
In an interview on 07/02/24 at 01:36pm the DON stated the facility's electronic patient chart was the only place weights should be recorded. The DON stated usually CNA A was in charge of weighing and recording resident weights. The DON stated CNA A got behind on weighing residents for the month of June 2024. The DON stated while CNA A was the main person who was in charge of weighing residents, any direct care and administrative nursing staff could weigh residents as well. The DON stated she and the Unit Manager were the ones to make sure resident weights were done as ordered. The DON stated it was unacceptable resident weights were not done as ordered. The DON stated there was no systematic approach to monitoring when and if resident weights were being done on a timely schedule other than verbal communication. The DON stated they became aware of the issues a couple days ago. The DON stated by not weighing residents as ordered, staff would not be aware of any significant issues with weight loss and residents could become ill.
In an interview on 07/02/24 at 01:43pm the Unit Manager stated usually weekly weights were done on Sundays and monthly weights were done by the 10th of every month. The Unit Manager stated the DON and himself were in charge of overseeing that weights were done and entered in a timely manner, and they failed to do so. The Unit manager stated it was brought to their attention last Thursday during a QAPI meeting but did not remember who mentioned the issue or what the outcome was. The Unit manager stated by not weighing residents, staff would not be aware of any significant issues with weight loss and residents could become ill due to a significant weight loss.
In an interview on 07/02/24 at 01:54 pm CNA A stated she was the main person that took and documented resident's weights but that anyone could take resident weights. CNA A stated she verbalized throughout the month of June 2024 to the Unit manager that she had fallen behind on taking resident weights and stated, everyone who was on shift was trying to help but they just did not get it done. CNA A stated she had no other explanation for why staff did not get resident weights done. CNA A stated that some weights were done but was unable to provide documentation of the resident weights that were taken for the month of June 2024. CNA A stated after resident weights were done, the RD usually went over the resident weights and if the RD had questions or concerns, the RD would follow up and ask questions regarding resident weights. CNA A stated the RD did not go to her about missing resident weights but that was usually discussed in the IDT meetings that were held once a week with administrative personnel. CNA A stated during the month of June, no administrative staff came to her with concerns about the missing resident's weights.
In an interview on 07/02/24 at 02:06pm the ADM stated monthly weights were usually done by the 10th of every month. The ADM stated when she found out about resident weights not getting done for the month of June 2024, it was discussed in a QAPI meeting and the weight policy was reviewed with the IDT team. The ADM stated it was decided in the QAPI meeting that the resident weights would resume in July 2024. The ADM stated the medical director was part of the QAPI team and agreed to start resident weights in July 2024. The ADM stated the medical director did not express any concerns for any residents who resided in the facility. The ADM stated adverse effects of weight loss could happen such as loss of muscle mass, overall decline in resident health, and possible skin breakdown.
In an interview on 07/02/24 at 02:14pm the RD stated she was usually at the facility once a week to see new and readmissions residents as well as conduct a full comprehensive assessment, resident BMI's, ideal body weight ranges, diet, diagnoses, and assess resident skin integrity. The RD stated she noticed the resident weights were not done for June 2024 and told the ADM approximately last week. The RD stated around the 10th of June 2024 she started to get concerned the resident weights were not done. The RD stated she usually ran the monthly weight report around the 10th of every month and completed a weight variance report on the residents that was automatically sent as a report to the facility administration. The RD stated she worked from home and was only in the facility once for the month of June 2024. The RD stated an email was sent on 6/20/24 to DON and the Unit Manager concerning the missing resident weights for the month of June. The RD stated she did not see a response from administration about her summary visit but usually did not get a response about her reports. The RD stated she expected to get a response from the facility since June 2024 resident weights were not entered but did not receive one. The RD stated severe weight loss could result in loss of muscle mass and overall decline in health, and skin breakdown.
In an interview on 07/03/24 at 01:36 PM the RD stated weight range for Resident #39 was between 144-176 pounds. The RD stated Resident #39 is in his ideal weight class and she did not feel the weight loss had adversely affected the resident because he was in his ideal weight range. RD stated sugars have been more controlled and BMI is 24.2, which is considered normal for his age. RD stated resident was assessed 07/03/24 and was communicating at his baseline and did not display any signs or symptoms of a person who was experiencing severe weight loss.
In an interview on 07/03/24 at 01:56 PM, the ADM stated that resident had uncontrolled blood sugars and was put on Mounjaro to control his blood sugars and that he had been refusing medications. The ADM stated a weight below 144 was when adverse effects of weight loss could happen like loss of muscle mass, overall decline in health, and skin breakdown. The ADM stated she felt the weight loss had not affected the resident but felt like the medication Mounjaro had been affecting his weight. ADM stated resident had been feeling nauseous and had been vomiting and was prescribed Zofran which he had been taking daily since 6/24/24. The ADM stated when she found out about weights not getting done, it was QAPI'd and policy was reviewed. The ADM stated it was decided that the weights would resume in July. The ADM stated the medical director was part of the QAPI team and was there when the missed weights were discussed, and he agreed to start the weights in July. The ADM stated the MD did not express any concern for any residents at that time.
In a phone interview on 07/03/24 at 02:42 PM Resident #39's doctor stated that resident is being seen by the nurse practitioner and that the doctor had not seen him yet. The doctor stated that severe weight loss means, in general, a weight loss of 100lbs in 6 months. The doctor stated he was not aware of the weights not being done in June until someone in the facility told him. The doctor stated the facility definitely should have contacted someone about Resident #39's weight loss. The doctor stated severe weight loss, could shorten a resident's life span and cause malnutrition, skin issues, wounds, and so on. The doctor stated he would expect the facility to care plan things like weight monitoring and management.
In a phone interview on 07/03/24 at 04:53 PM with the NP, she stated that Resident #39's weight loss was not unexpected because he was on Mounjaro and his double portions had been stopped. The NP stated that his blood sugars were doing better and his A1C (Hemoglobin AIC- test that measures the average amount of glucose attached to hemoglobin in red blood cells over the past three months) was lower. The NP stated Resident #39's labs were looking better also. The NP stated she did not believe that there were any adverse effects from his weight loss since he is still within his ideal body weight. She stated that if a resident had a large, unexpected weight loss, she would expect to be notified about it. She stated she was not aware of the weights not being done in June. She stated that a large, unexpected weight loss could lead to malnutrition, skin breakdown, delayed wound healing, possible hospitalization. The NP stated If residents were not weighed as ordered, it would not be possible to track if they were gaining or losing weight and the resident could have an unexpected significant or severe weight loss.
Record review of the facility's Weights and Heights Policy dated 8/23/23 stated:
Policy
All residents are weighed within 24 hours of admission and weekly for 4 weeks and as needed thereafter or more as determined by the RAR committee and/or physician order. Height is measured on admission and annually.
Documentation
Documentation associated with weight measurement includes:
Patient's weight in kilograms
Date and time of measurement

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy for 1 of 10 residents (Residents #22] reviewed for privacy.
The facility failed to ensure Resident #22's bedroom door was closed for privacy as she requested.
This failure could place residents at risk of having their bodies exposed to the public, resulting in emotional distress and a diminished quality of life.
The findings included:
Record review of Resident #22's face sheet dated 05/22/23 reflected an [AGE] year-old female with an original admission date of 03/07/23. Pertinent diagnoses included dementia, stroke, depression, anxiety, and limited range of motion.
Record review of Resident #22's quarterly MDS assessment dated [DATE] reflected a BIMS score of 13, indicating she was cognitively intact. She required moderate assistance with oral and personal hygiene, substantial assistance with dressing and positioning, and was dependent on staff with toileting, showering, and footwear. She was incontinent of bladder and bowel. Her active diagnosis was medically complex conditions.
Record review of Resident #22's care plan dated 06/06/2024 on page 1 reflected Resident #22 preferred that her door be kept closed with an initiation date of 03/16/23 and a revision date of 06/06/24. The goal documented resident will have her preference to keep door closed met with an initiation date of 03/16/23 and a revision date on 06/06/24. Interventions indicated close door after care, food delivery, any interactions with an initiation date of 03/16/23.
Observation of Resident #22's door beginning on 07/01/24 at 11:00 am through 07/03/24 throughout all days of the survey revealed her door was open wide.
In an interview with Resident #22 on 07/01/24 at 4:05 pm, Resident #22 stated she had requested her door be kept shut ever since she was admitted because she did not like the noise that came from the hallway. She stated the staff never shut her door and that made her angry.
In an interview with the DON on 07/03/2024 at 2:29 PM, the DON stated residents should have their preferences acknowledged. The DON stated that if resident's privacy was not protected, they could get embarrassed, ultimately leading to emotional distress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #23) residents reviewed for respiratory care.
The facility failed to ensure Resident #23's oxygen tubing was changed every night shift on Sunday as ordered.
This failure places residents at an increased risk of infection leading to a decline in health.
The findings included:
Record review of Resident #23's face sheet dated 07/02/2024 reflected an [AGE] year-old female with an admission date of 08/31/2023. Pertinent diagnoses included Alzheimer's Disease (progressive brain disease that causes a mental decline affecting the quality of daily living) and Heart Failure (disease in which the heart can no longer pump enough blood to meet the body's needs).
Record review of Resident #23's MDS assessment section C, cognitive patterns, dated 04/30/2024 reflected a BIMS score of 7 (severe cognitive impairment).
Record review of Resident #23's MDS assessment section O, Special Treatments, Procedures and Programs, dated 04/30/2024 reflected no oxygen use.
Record review of Resident #23's order summary report revealed an active order to Change oxygen tubing and nebulizer circuit every night shift every Sun[day] with a start date of 05/05/2024. The same order summary report also revealed an active order to Clean oxygen concentrator filter with soap and water every night shift every Sun[day] with a start date of 05/05/2024. The same order report summary also revealed an active order for Oxygen at 2 liters/minute continuously via nasal cannula while in bed with a start date of 06/23/2024.
During an observation on 07/01/2024 at 10:10 AM, the tubing on the oxygen concentrator (medical device used to give an individual extra oxygen) in Resident #23's room contained a label dated 06/16/2024. At this time, the resident was lying in bed sleeping with the nasal cannula in place with 2 liters/minute flow rate.
During an observation of the oxygen concentrator on 07/02/2024 at 1:34 PM in Resident #23's room, the tubing on the device contained the same label dated 6/16/2024.
During an observation of the oxygen concentrator on 07/03/2024 at 11:01 AM in Resident #23's room, the tubing on the device contained the same label dated 6/16/2024.
In an interview with Resident #23 on 07/01/2024 at 11:15 AM, Resident #23 was unable to remember if the oxygen tubing had been changed recently.
In an interview with the DON on 07/03/2024 at 2:29 PM, the DON stated that they date oxygen tubing at the facility weekly. The DON stated that they try to change the tubing on Sundays, but that sometimes it may occur on a different day as necessary. The DON stated that if the oxygen tubing was not changed on time the resident could get sick from dirty tubing.
In an interview with LVN D on 07/03/2024 at 3:00 PM, LVN D stated that oxygen tubing should be changed out every Sunday during the 10:00 PM - 6:00 AM shift. LVN D stated that the tubing should be dated when it was changed out. LVN D stated that if the tubing was not changed when ordered then the resident could get sick.
Record Review of facility policy Oxygen Administration (Safety, Storage, Maintenance) last revised on 2/27/24 stated: Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with patient name and dated when setup or changed out.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked treatment cart for 1 of 1 treatment cart reviewed for storage of drugs.
The facility's treatment/medication cart was left unlocked by the nurse's station (only one nurse's station) with the drawers facing outward.
This deficient practices could affect residents who have medications in the nurse's treatment/medication cart and could result in lost medications, drug diversion, harm due to accidental ingestion of unprescribed medications.
Findings included:
Observation on 07/01/24 at 10:30am revealed an unlocked medication/treatment cart located by the nurse's station. The medication/treatment cart was against the nurse's station and one staff member (LVN B) was located at the nurse's station. There were two residents by the nurse's station near the treatment cart. This surveyor opened the top drawer recognizing the treatment cart being unlocked. Multiple medications in bulk bottles were easily assessable and removable. This surveyor was able to open all drawers and go through various medications and treatment supplies.
In an interview on 07/01/24 at 10:31am, LVN B stated he did not know the treatment cart was unlocked. LVN B stated the treatment cart belonged to the LVN F and was unlocked because a resident was bleeding down the hall and LVN B came to grab supplies and left to tend to resident. LVN B stated all treatment/medication carts should be locked at all times so residents or visitors could not have access to supplies and medications.
In an interview on 07/01/24 at 10:37am LVN F stated she was alerted there was a resident who was possibly bleeding. LVN F stated the resident just had a surgical procedure and had a history of picking at the surgical staples. LVN F stated all staff went to the resident's room to assist and she grabbed supplies needed and forgot to lock the treatment cart. LVN F stated the cart should be locked at all times for resident safety and so residents could not get into the treatment cart and gain access to supplies and medications. LVN F stated the last in-service on locked treatment/medication carts was approximately sometime last month but could not remember.
In an interview on 07/01/24 at 10:53am the DON stated all treatment/medication carts should be locked at all times for the safety of residents and other unauthorized people. The DON stated anytime a staff member leaves the treatment/medication carts unattended, the treatment/medication cart should be locked even if there was a resident emergency. The DON stated the last in-service on locking treatment/medication carts was about a month ago.
Record review of General Dose Preparation and Medication Administration Policy dated 1/1/22 stated:
7. Facility should ensure that medication carts are always locked when out of sight or unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services with reasonable accommodation of resident needs and preferences, for 1 of 5 residents (Resident #300) reviewed for accommodation of needs.
The facility did not provide Resident #300 an accessible call light that she could physically use.
This failure could place residents who utilized call lights at risk for not having his/her needs met, help in event of an emergency or place residents with a history of falls at risk for additional falls and injuries.
Findings included:
Record review of the admission record for Resident #300 reflected Resident #300 was admitted to the facility on [DATE], was a [AGE] year-old female with diagnoses that included Parkinson's disease (chronic and progressive movement disorder that causes tremors, stiffness or slowing of movement), neuralgia (nerve pain) and neuritis (inflammation of the peripheral nervous system), lack of coordination, muscle weakness, anemia, muscle spasm, disorientation, and history of falling.
Record review of Resident #300's Care Plan revised on 06/28/24 reflected a focus on the resident has an ADL self-care performance deficit r/t confusion, impaired balance with interventions/task, encourage the resident to use bell to call for assistance and observe and report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function.
Record review of Resident #300's Skilled Nursing Documentation dated 06/30/24 noted primary reason for admission #2 as neurologic, section 6, musculoskeletal, abnormal. Section 6b. Muscle tone is mixed with Parkinson tremors.
Record review of Resident #300's Incomplete MDS assessment dated for 07/05/24 reflected Section GG Functional Abilities and Goals was blank. MDS Section O 400, listed 70 minutes of Occupational Therapy given for 2 days started on 06/27/2024 and 61 minutes of Physical Therapy given for 2 days started on 06/27/2024. Section O 0500 Restorative Nursing Programs was blank.
Observation on 07/03/24 at 08:43 AM Resident #300 was observed in bed, with the call light wrapped on the right-side rail.
Observation on 07/03/2024 at 08:50 AM., LVN D administered medications to Resident #300. The call light was wrapped on the right-side rail.
Observation on 07/03/24 at 09:03 AM, Resident #300 observed unable to get or use her call light that was on the right bedrail.
Interview and observation on 07/03/24 at 09:28 AM DON observed Resident #300 in the room. DON asked resident to press call light, and resident attempted again to get the call light and was able to get the call light cord but was unable to grasp the portion of the call light and press for assistance. DON stated they would get Resident #300 a touch pad call light. DON stated that the resident would not get the help they need and could result in harm if they were unable to use the call light. She replied that the resident had two falls. DON stated that mobility issues or limited range of motion should be documented in the comprehensive assessment and MDS assessments, by admitting nurse or MDS nurse.
Interview on 07/03/24 at 10:02 AM Resident #300 stated she has had not been able to push the button on the call light since she came into the facility but still tried to use it. She stated she would call out and the staff sometimes heard her and came or sometimes another resident heard her and called the staff.
Interview on 07/03/24 at 10:14 AM CNA A stated that Resident #300 would call out or they would ask the resident during rounds if she needed anything prior to the resident getting the touch pad call light.
Interview on 07/03/24 at 03:35 PM Administrator stated Resident # 300 was able to utilize the call light when she was first admitted , but that she has had seizures almost daily so that may be why she cannot now. She stated that when a resident has a change in condition, there is an assessment done in general where vitals are documented, and the physician notified but not specifically for the use of the call light. ADM stated that if a resident is unable to use the call light, they would be assisted during rounds, and what can happen is it may take a little longer than normal.
Interview on 07/03/24 at 03:48 PM DON stated that in-service on call lights and rounds is done at least once a month, with last in-service done in June or end of May 2024.
Interview on 07/03/24 at 05:10 PM Administrator stated that comprehensive assessments, change in condition assessments and MDS assessments are completed but that there is no specific item to assess a resident's ability to use the call light. Although assessment dated [DATE] documented Resident # 300 required assistance to eat, it is not the same losing fine motor skills to losing gross motor skills and Resident # 300 had her call light withing reach.
Interview on 07/03/24 at 05:17 PM RN C stated she only had Resident #300 yesterday, and today. As far as she can tell Resident #300 was not able to use a call light. She does frequent checks to make sure Resident #300 is ok, every 30 minutes, besides the 2 hour rounds that CNAs do, but this is her self-practice. RN C said there is no procedure or policy for ensuring a resident can use the call light. The times she has had Resident #300, she has not seen her able to use the call light due to both cognitive and physical changes. RN C said most of the time in her shift Resident # 300 is asleep and has minimal communication.
Interview on 07/03/24 at 05:22 PM LVN B stated Resident #300 would press her call light prior to today, and that today with the touch pad, she called about four times.
Record review of the facility policy titled Resident Call System revised 01/04/23 and reviewed 01/15/24 reflected, the facility must be adequately equipped to allow residents to call for assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident beside. Procedure: Facility associates should always be aware of call lights; associates should answer call lights whether they are assigned to provide care to that resident. The call light should be positioned within reach of the resident. Return demonstration may be used when educating the resident about call light use. If the resident is unable to demonstrate appropriate call light use, the nurse must be notified to determine an adequate alternative. The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on observation, 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, which included measurable objectives and time frames to meet resident's medical, nursing, and mental and psychological needs that were identified in the comprehensive assessment for 1 out of 3 residents (resident #1) reviewed for care plans.
The facility failed to ensure care plans used by the hospice agency contained two person Hoyer lift transfer instructions. The hospice agency staff transferred Resident #1 using one person and no Hoyer lift, and because of that Resident #1 was injured.
This failure could place residents at risk for their medical, physical, and psychosocial needs not being met.
The findings were:
Record review of a facility investigation report reflected Resident #1 was observed with a bruise to her left outer breast area on 8/28/2023. Nursing notes written on 8/28/2023 indicated a hospice CNA notified facility staff. Resident #1 was again found with a bruise on 9/4/2023, and the hospice CNA notified facility staff. Resident #1 was a 96 y/o female with diagnosis which included arthritis, osteoporosis, abnormalities of gait and mobility, lack of coordination, major depressive disorder, dementia, unspecified psychosis, and anxiety. Resident #1 has a BIMS score of 00 which indicated severe cognitive impairment.
During an interview on 10/5/2023 at 4:45 PM with the DON, she said the hospice staff learned about the resident when they came in to provide care.
During an interview on 10/6/2023 at 8:15 AM with the DON she said hospice staff evaluated the residents, looked at the resident's chart, and created their own care plan. The DON said the hospice chart did not have a care plan for Resident #1, but it should have one that was developed by the hospice agency. The DON said the hospice chart was separate from the facility chart. The DON said she was responsible for the staff who take care of Resident #1 which included hospice staff.
During an interview on 10/6/2023 at 10:00 AM with the ADON, he revealed he did not train hospice CNAs. The ADON said Resident #1 was a two person lift for at least 4 years and it was in the resident's care plan. The ADON said he conducted the investigation of the bruises on Resident #1 and the facility CNAs knew Resident #1 was a two-person lift. The ADON said the hospice CNA was not aware Resident #1 was a two-person lift.
During an interview on 10/6/2023 at 11:00 AM with the DON she said the facility needed to educate hospice CNAs on proper care for the residents. The DON said the facility notified the hospice nurse after discovery of the second bruise on 9/4/2023. The DON said the hospice nurse should have known the resident was a two person lift before giving care. The DON said there was supposed to be a hospice care plan in the hospice chart and there was not. The DON said if there was not a care plan in the hospice chart, the hospice CNA would not know what the resident needed.
During an interview on 10/6/2023 at 1:00 PM, the DON said the hospice service should teach their CNAs their competencies. The DON said the facility nurses and CNAs discussed resident care with the hospice nurse, but there is no record of it. The DON said the bruises inflicted on Resident #1 were not her fault, the hospice nurse should have trained the hospice CNA in resident transfers. The DON said she was responsible for the staff that take care of Resident #1, including hospice staff earlier in the day.
During an interview on 10/6/2023 at 1:35 PM with the hospice CNA, she said she got her care plan from the hospice company. She said the resident care plan was downloaded to her tablet and no one reviewed it with her. She said she only used the hospice chart at the facility to sign in and out. The hospice CNA said Resident #1's care plan did not indicate she was a two-person lift, and the facility did not tell her. The hospice CNA did not know who made the care plan she used. The hospice CNA said the facility just told her where the resident was.
During an interview on 10/6/2023 at 2:00 PM with the hospice nurse, she said she had been seeing Resident #1 for more than a year and received an order on 9/6/2023 to increase Resident #1's transfer to 2 people. The hospice nurse said the hospice care plan was developed by the hospice interdisciplinary team, which included the nurse case manager, social worker, medical director, and possibly a chaplain. The hospice nurse said the resident was discussed every two weeks by the IDT. The hospice nurse said she did not know who wrote the initial hospice care plan, but the hospice care started on 3/1/2021. The hospice nurse did not know Resident #1 was a two person lift for more than 4 years.
During an interview on 10/6/2023 at 2:20 PM with the hospice patient care manager, she said the nurse who made the original care plan for Resident #1 was no longer with the company. She said the hospice nurse who saw the resident developed the care plan and the hospice patient care manager approved it. The hospice patient care manager said she started with the facility 18 months ago. She said the hospice care plan was not developed with the facility care plan. The hospice patient care manager said it was very difficult to coordinate with the facility.
Record review of facility nursing notes reflected Resident #1 was discovered with a bruise to her left upper arm on 9/4/2023. Nursing notes written on 9/4/2023 indicate a hospice CNA notified facility staff.
During a record review of facility in-services, dated 8/28/2023, it was revealed facility staff were trained on abuse and neglect, resident rights, proper transferring of residents and that all mechanical lifts are two person lifts after Resident #1 was found with a bruise. Hospice staff were not in-serviced on proper transfers at that time. Hospice staff transferred the resident without proper procedures and Resident #1 was bruised again on 9/4/2023.
Record review of the facility's Hospice policy, dated 11/23/2023, reflected the following:
Hospice care means a comprehensive set of services identified and coordinated by an interdisciplinary group to provide for the physical needs of a terminally ill resident as delineated in a specific resident plan of care.
The facility must designate a member of the interdisciplinary team to ensure hospice representatives are oriented to the facility and that the resident receives quality care in collaboration with the facility staff and the hospice staff.
Record review of the facility's care plan policy, dated 12/5/2022, reflected the following:
The baseline care plan must include the minimum health care information necessary to properly care for each resident immediately upon admission and a summary must be presented to the resident or their representative that includes initial goals of the resident, and treatments to be administered by the facility, and any updates.

Based on interview and record review the facility failed to develop and implement policies and procedures for screening through the employee misconduct registry to determine whether the individual is designated as unemployable for 14 of 19 staff (the DM, AD, LVN C, RN D, RN E, RN F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M and CNA N) reviewed for employment registry screenings, in that:
The DM, AD, LVN C, RN D, RN E, RN F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M and CNA N did not have current employment registry screenings.
This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.
The findings were:
Record review of the staff roster provided on 04/03/2023 by the facility for the DM revealed a hire date of 09/28/2011. Record review of the personnel file for the DM revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021.
Record review of the staff roster provided on 04/03/2023 by the facility for the AD revealed a hire date of 08/06/2018. Record review of the personnel file for the AD revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021.
Record review of the staff roster provided on 04/03/2023 by the facility for LVN C revealed a hire date of 12/20/2021. Record review of the personnel file for LVN C revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021.
Record review of the staff roster provided on 04/03/2023 by the facility for RN D revealed a hire date of 06/17/2011. Record review of the personnel file for RN D revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021.
Record review of the staff roster provided on 04/03/2023 by the facility for RN E revealed a hire date of 12/01/2016. Record review of the personnel file for RN E revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021.
Record review of the staff roster provided on 04/03/2023 by the facility for RN F revealed a hire date of 07/25/2006. Record review of the personnel file for RN F revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021.
Record review of the staff roster provided on 04/03/2023 by the facility for CNA G revealed a hire date of 01/17/2022. Record review of the personnel file for CNA G revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/13/2022.
Record review of the staff roster provided on 04/03/2023 by the facility for CNA H revealed an initial hire date of 11/14/1986 and a rehire date of 01/18/2022. Record review of the personnel file for CNA H revealed the most recent Employee Misconduct Registry (EMR) check was completed on 04/21/2021.
Record review of the staff roster provided on 04/03/2023 by the facility for CNA I revealed a hire date of 02/01/2021. Record review of the personnel file for CNA I revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021.
Record review of the staff roster provided on 04/03/2023 by the facility for CNA J revealed a hire date of 08/09/2019. Record review of the personnel file for CNA J revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021.
Record review of the staff roster provided on 04/03/2023 by the facility for CNA K revealed a hire date of 02/04/2019. Record review of the personnel file for CNA K revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021.
Record review of the staff roster provided on 04/03/2023 by the facility for CNA L revealed a hire date of 03/30/2005. Record review of the personnel file for CNA L revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021.
Record review of the staff roster provided on 04/03/2023 by the facility for CNA M revealed a hire date of 04/28/1988. Record review of the personnel file for CNA M revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021.
Record review of the staff roster provided on 04/03/2023 by the facility for CNA N revealed a hire date of 04/16/2020. Record review of the personnel file for CNA N revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021.
In an interview with the HR Coordinator on 04/06/2023 at 12:45 p.m., the HR Coordinator revealed that in the past the facility staffing coordinator would complete background checks. The HR Coordinator stated employee screenings was a role she was recently assigned but the annual checks must have been missed during the transition.
In an interview with the Administrator on 04/06/2023 at 1:05 p.m., the Administrator stated the facility had been without a staffing coordinator but that he did not know the EMRs had been missed.
Record review of the facility's policy titled, Background Screening Policy: Associates, effective date 08/20/2018, revealed, [Facility name] shall conduct background investigations on the following, in accordance with the Department of Health and Human Services (DHHS) Centers for Medicare and Medicaid Services (CMS): * All candidates who have accepted a conditional offer of employment (i.e., full-time, part-time, PRN, temporary, and/or interim Associates). * Associates seeking a job change if the new position requires additional searches (e.g., professional license verification and/or motor vehicle search).

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 supply room on the facility's 300 hall, in that:
The doorknob and locking mechanism on the supply room door on the facility's 300 hall was inoperable and as a result, the door was unable to be secured. The supply room contained potential hazardous materials.
This failure could place residents at risk of living in an unsafe environment.
The findings were:
Observation on 04/03/2023 at 2:16 p.m. revealed the supply room door on the facility's 300 hall was unlocked. Further observation revealed the supply room container razors, shampoo, body wash, and liquid cleaning agents.
During an interview with CNA I on 04/03/2023 at 2:18 p.m., CNA I stated the supply room door was unlocked, and further stated that the locking mechanism and doorknob were inoperable, and as a result, the door was unable to be secured. CNA I further stated the supply room contained materials which were potentially hazardous to residents including: razors, shampoo, body wash, and liquid cleaning agents.
During an interview with the DON on 04/06/2023 at 10:05 a.m., the DON stated a resident may be harmed by having access to items such as razors, shampoo, body wash, and liquid cleaning agents, and the supply room should have been secured.
During an interview with the Maintenance Director on 04/06/2023 at 11:57 a.m., the Maintenance Director stated the facility's procedure regarding needed repairs was to log such repairs in the Maintenance book which was found at the nurses' desk. The Maintenance Director also stated that facility staffshould notify him immediately of high priority repairs, such as the inoperable supply room locking mechanism. The Maintenance Director stated he had been immediately notified of the inoperable lock and the lock had been repaired.
Record review of the facility policy, Plant Operations - General Policy reviewed 07/28/2022, revealed, A safe, clean, and structurally sound environment shall be achieved in the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed, in that:
The facility, licensed for 146 beds, did not employ a full-time qualified social worker with a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and psychology and one year of supervised social work experience in a health care setting
working directly with individuals.
This failure could place residents at risk of social service and psychosocial needs not being met.
The findings were:
Record review of the Facility Summary Report, undated, revealed the facility had a total licensed capacity for 146 beds.
Record review of the staff roster, provided by the facility, dated [DATE]:46, revealed SSD was listed as Social Services Director. Further review revealed SSD was hired on 12/30/2022.
In an interview with the SSD on 04/06/2023 at 1:05 p.m., the SSD revealed she had completed her social work degree program in May of 2022, graduated in December of 2022 and was currently studying to take the Social Worker licensing exam. The SSD stated there was another SW at a sister facility that was available to support her if she had questions regarding any SW issues at the facility.
In an interview with the SW from the sister facility on 04/06/2023 at 1:09 p.m., the SW revealed she was available by telephone to answer questions from the SSD however did not come to this facility or supervise the SSD's work. The SW further revealed her SW license was due for renewal in February of 2023, and she had paid the renewal fee however was not aware she needed fingerprints this renewal period and therefore her renewal was listed as delinquent at this time.
In an interview with the Administrator on 04/06/2023 at 4:25 p.m., the Administrator revealed he was unaware the full-time social worker requirement was based on bed capacity and thought facilities with less than 120 residents did not require a full-time social worker as long as the designee was supervised by a licensed Social Worker. The Administrator further revealed the licensed SW was monitored by the sister facility HR department and he had not been informed her license had not completed the renewal process.
Record review of the Texas Administrative Code 554.703, transferred effective January 15, 2021, revealed in part .(a) the facility must provide medically-related social services to attain the highest practicable physical, mental, or psychosocial well-being of each resident. (1) A facility with more than 120 beds must employ a qualified social worker on a full-time basis. (b) A qualified social worker is an individual who is licensed, including a temporary or provisional license, by the Texas State Board of Social Worker Examiners as prescribed by Texas Occupations Code, Chapter 505, and who has at least: (1) a bachelor's degree in social work, or a bachelor's degree in a human services field, including sociology, gerontology, special education, rehabilitation counseling, and psychology; and (2) one year of supervised social work experience in a health care setting working directly with individuals.
Record review of facility's policy, Social Services Personnel, reviewed 09/30/2022, All facilities are required to provide medically related social services for each resident. Facilities must identify the need for medically related social service and ensure that these services are provided. It is not required that a qualified social worker necessarily provide all of these services, except as required by State law. Each facility has a Director responsible for the provision of social services. Each facility must abide by all state regulations in addition to Federal regulations. Any facility with more than 120 beds must employ a qualified social worker on a full-time basis. A qualified social worker is: An individual with a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field including, and one year supervised social work experience in a health care setting working directly with individuals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 14 residents (Residents #38) reviewed for respiratory care, in that:
Resident #38's nebulizer mask was unbagged and resting on top of the resident's bedside table.
This failure could place residents who required respiratory treatments at risk of receiving inadequate respiratory treatments and could result in a decline in health.
The findings were:
Record review of Resident #38's face sheet, dated 04/04/2023, revealed the resident had an initial admission date of 07/06/2021 and was readmitted on [DATE] with diagnoses that included: tracheostomy status, malignant neoplasm of pharynx, dysphagia, speech disturbances and dementia.
Record review of Resident #38's Annual MDS, dated [DATE], revealed a BIMS score of 10, which indicated moderate cognitive impairment.
Record review of Resident #38's Care Plan, dated 03/22/2023, revealed a focus area, the resident has a tracheostomy r/t surgery (S/P Esophageal Cancer) with intervention administer nebs via trach collar PRN SOB/congestion initiated 02/16/2022.
Record review of Resident #38's electronic medical record Order Summary Report, Active Orders as of 04/04/2023, revealed an order dated 01/26/2023 for Budesonide Suspension 0.5 MG/2ML 2 ml inhale orally two times a day for COPD Lung sounds with no end date. Further review revealed an additional order dated 02/07/2023 for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally via nebulizer every 6 hours as needed for Shortness of breath lung sounds with no end date.
During an observation and interview with Resident #38 on 04/03/2023 at 4:10 pm, revealed Resident #38's nebulizer mask lying on the resident's bedside table unbagged. Resident #38 was asked if nursing staff assist with nebulizer treatments and Resident #38 nodded and in an airy voice d/t his trach attempted an answer however speech was too difficult to understand.
During an interview with LVN A on 04/03/2023 at 4:18 pm, LVN A stated the nebulizer mask should have been bagged and the bag dated. LVN A stated Resident #38 has scheduled nebulizer treatments twice a day. LVN A added that the last scheduled treatment would have been early this morning prior to this shift. LVN A stated, any pathogen could enter the tubing and then cause an upper respiratory infection if the mask was left unbagged.
During an interview with the DON on 04/05/2023 at 9:12 a.m., the DON stated a nebulizer mask should always be in a bag that was dated when not in use to protect it from the environment and to prevent infection.
Record review of the facility's policy titled, Small Volume Nebulizer Therapy, effective 11/10/2022, revealed, The facility will provide Small Volume Nebulizer Therapy in accordance with professional standards of practice. Review of an additional procedure provided by the DON titled, Nebulizer therapy, small volume, revised May 20, 2022, revealed, Critical Notes! [Corporate name] has approved the following information as an addendum to the Lippincott procedure. Nebulizer circuit should be stored in a patient-care set-up bag, labeled with the patient's name, and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the care plan was revised in a timely manner for 1 of 18 residents (Resident #15), in that:
Resident #15's care plan had not been revised to reflect the discontinuation of her hemodialysis treatment.
This failure could affect residents who receive care at the facility and could result in missed or inadequate care.
The findings were:
Record review of Resident #15's face sheet, dated 04/06/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Hyperkalemia, Chronic Kidney Disease, and Type 2 Diabetes Mellitus.
Record review of Resident #15's comprehensive MDS, dated [DATE], revealed a BIMS score of 99 which indicated the resident was unable to complete the interview. Further review revealed a staff assessment was completed and indicated the resident had short-term and long-term memory problems.
Record review of Resident #15's care plan, revised 02/07/2023, revealed, hemodialysis r/t chronic renal failure.
Record review of Resident #15's progress notes, dated 02/18/2023, revealed, Went to dialysis today, received call from [nephrologist] office .patient is to stop going to dialysis until further notice .
During an interview with the DON on 04/06/2023 at 12:12 p.m., the DON stated Resident #15 no longer received dialysis treatments due to an improvement in her condition.
During an interview with the MDS/Care Plan Coordinator on 04/06/2023 at 12:12 p.m., the MDS/Care Plan Coordinator stated Resident #15 has been discharged from dialysis on 02/17/2023 and the treatment had not been removed from her plan of care as of 04/06/2023. The MDS/Care Plan Coordinator stated the omission was an oversight and would be immediately rectified and stated that residents' plans of care should be revised in an accurate and timely manner to ensure the residents receive appropriate care.
Record review of the facility policy, Care Planning - Baseline, Comprehensive, and Routine Updates, reviewed 12/05/2022, revealed, Monitoring of Progress: Identify the individual's response to interventions and treatments .Define of refine prognosis, Define or refine when to stop or modify interventions, Identify when care objectives have been achieved sufficiently to allow for discharge, transfer, or change in level of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's a right to a dignified existence for 1 of 18 residents (Resident #51) reviewed for dignity, in that:
Resident #51's catheter bag did not have a privacy cover while the resident was in a common area of the facility.
This failure could lead to residents' loss of self-esteem and feelings of dignity.
The findings were:
Record review of Resident #51's face sheet, dated 04/05/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Cerebral Palsy, Epilepsy, and Hypotension.
Record review of Resident #51's comprehensive MDS, dated [DATE], revealed a BIMS score of 5 which indicated severe cognitive impairment.
Record review of Resident #51's of care plan, revised 02/28/2023, The resident has Indwelling Catheter .
Observation on 04/05/2023 at 10:46 a.m. revealed Resident #51 was sitting in a common area of the facility, near the nurses' station, and was greeted by several staff members and fellow residents. Further observation revealed Resident #51's catheter bag did not have a privacy cover and the urine which had collected in the bag was clearly visible.
The resident was not able to be interviewed due to cognitive deficit.
During an interview with LVN O on 04/05/2023 at 10:48 a.m., LVN O stated Resident #51's catheter bag did not have a privacy cover and the urine which had collected in the bag was clearly visible. LVN O further stated Resident #51's catheter bag should have a privacy cover to ensure the resident's privacy and dignity.
During an interview with the DON on 04/06/2023, the DON stated her expectation was that all residents with catheters have privacy covers to ensure their privacy and dignity.
Record review of the facility policy, Resident Rights, reviewed 11/21/2022, revealed, The resident has a right to a dignified existence .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 2 of 4 residents (Resident #8 and #38) reviewed for advanced directives, in that:
1. Resident #8's DNR was executed incorrectly and was therefore invalid.
2. The facility failed to ensure Resident #38's OOH-DNR was reinstated by obtaining a DNR order upon readmission following a recent hospitalization.
This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.
The findings were:
1. Record review of Resident #8's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: Type 2 Diabetes Mellitus, Transient Cerebral Ischemic Attack, and Hypertensive Heart Disease with Heart Failure.
Record review of Resident #8's quarterly MDS, dated [DATE], revealed a BIMS score of 13 which indicated intact cognition.
Record review of Resident #8's care plan, revised [DATE], revealed, Resident [#8] has Advance Directives DNR - Do Not Resuscitate.
Record review of Resident #8's order summary report, dated [DATE], revealed a physician's order, Do Not Resuscitate dated [DATE].
Record review of Resident #8's OOH-DNR form, dated [DATE], revealed the physician did not sign in the last section which read, All persons who have signed above must sign below, acknowledging that this document has been properly completed.
During an interview with the SSD on [DATE] at 10:18 a.m., the SSD stated Resident #8's OOH-DNR form had not been signed twice by the resident's physician.
During an interview with the DON on [DATE] at 10:05 a.m., the DON stated the SSD and Medical Records Director were responsible for ensuring the accuracy of residents' advanced directives and that OOH-DNR forms should be correctly executed.
2. Record review of Resident #38's face sheet, dated [DATE], revealed the resident had an initial admission date of [DATE] and was readmitted on [DATE] with diagnoses that included: tracheostomy status, malignant neoplasm of pharynx, dysphagia, speech disturbances and dementia. Further review of Resident #38's face sheet, revealed under the section ADVANCE DIRECTIVE: FULL CODE
Record review of Resident #38's Annual MDS, dated [DATE], revealed a BIMS score of 10, which indicated moderate cognitive impairment.
Record review of Resident #38's Care Plan, dated [DATE], revealed a focus area, Resident has Advance Directives DNR - Do Not Resuscitate and a goal Resident's Advance Directives will be honored. Further review revealed interventions code status will be reviewed on a quarterly basis and PRN and Resident has signed Do Not Resuscitate (DNR).
Record review of Resident #38's electronic medical record Order Summary Report, Active Orders as of [DATE], revealed an order dated [DATE] for FULL CODE. Further review of Resident #38's electronic medical record, main screen for resident information revealed a section, Code Status: FULL CODE.
Record review of Resident #38's clinical record at the nurse's station, revealed a red sheet of paper the front of the binder with the words DNR. Further review revealed an OOH-DNR signed by Resident #38's family member, physician and two witnesses.
In an interview with the SW on [DATE] at 1:05 p.m., the SW revealed Resident #38's OOH-DNR was completed prior to her starting at the facility. The SW stated sometimes the MDS Coordinator assisted residents at times with completing documents and may have information about Resident #38's OOH-DNR.
In an interview with the MDS Coordinator on [DATE] at 1:10 p.m., the MDS Coordinator revealed Resident #38 had been hospitalized from [DATE] to [DATE]. The MDS Coordinator stated that in the electronic record the resident had been noted as DNR up until [DATE] however when he returned on [DATE] an order for FULL CODE was entered by LVN B.
In an interview with LVN B on [DATE] at 1:18 p.m., LVN B revealed that he recalled a conversation with the hospital regarding code status at the time Resident #38 transferred to the hospital and the hospital staff told him regardless of the OOH-DNR, the resident would be considered FULL CODE at the hospital. LVN B stated when Resident #38 returned with hospital discharge orders that listed him as FULL CODE the order was not changed back at that time and was entered incorrectly. LVN B stated he would call the family right away to ensure Resident #38's DNR code status had not changed.
In an interview with the DON on [DATE] at 1:56 p.m., the DON stated Resident #38's code status should have been confirmed by the admitting nurse upon return from the hospital and the order would then correspond with all other areas in the resident's record.
Record review of the Texas Health and Safety Code Title 2 Health, Subtitle H Public Health Provisions, Chapter 166 Advance Directives, Section 166.083 Form of Out-Of-Hospital DNR order, effective [DATE], revealed, (a) A written out-of-hospital DNR order shall be in the standard form specified by department rule as recommended by the department. (b) The standard form of an out-of-hospital DNR order specified by department rule must, at a minimum, contain the following: . (13) a statement at the bottom of the document, with places for the signature of each person executing the document, that the document has been properly completed.
Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly.
Record review of the facility's policy titled, Area of Focus: Advance Directives, reviewed: [DATE], revealed, An advance directive is a written document prepared by the resident as to how he/she wants medical decisions to be made should he or she lose the ability to make decisions for him or herself. All residents or their responsible parties receive materials concerning their rights under applicable laws to make decisions regarding their medical care, including the right to accept or refuse medical care, the right to accept or refuse medical/surgical treatment, organ donation requests, and the formation of advance directives upon admission.