Arboretum Nursing And Rehabilitation Center Of Win

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician was consulted regarding a need to alter treatment for 1 of 4 residents reviewed for notification of changes. (Resident #6) The facility failed to consult with Resident #6's physician regarding the pattern of Resident #6's refusal to wear an arm sling related to her fractured right clavicle for 21 out of 30 opportunities on the a.m. shift and 17 out of 30 opportunities on the p.m. shift for September 2025. This failure could place residents at risk for complications due to delayed or failed physician intervention. Findings included: Record review of Resident #6's face sheet dated October 1, 2025, indicated Resident #6 was an 80- year-old female initially admitted on [DATE] and re-admitted on [DATE] with diagnoses of fracture of unspecified part of right clavicle (broken right collarbone), contusion on right hip (deep bruise), and muscle weakness. Record review of Quarterly MDS assessment dated [DATE], for Resident #6 indicated: a Brief interview mental status score of 03 (severe cognitive impairment). An impairment on one side was listed; it does not list which side is impaired.Record review of Resident #6's care plan dated 09/30/2025 indicated: Resident #6 had a history of fractures. The interventions included Monitor/document/report to physician PRN: edema, bruising/discoloration of skin, skin temperature changes, loss of sensation distal to fracture, presence/absence of pulses distal to fracture, if cast is present, skin breakdown or trauma at cast edges.Record review of physician orders dated September 2025 for Resident #6 indicated: Use right arm sling. May wrap and adjust sling for comfort as tolerated. Every day and every night shift for Fractured right clavicle. Record review of Resident #6's Medication administration record dated August 2025 indicated: no right arm sling refusals. Record review of Resident #6's Medication administration record dated September 2025 indicated: Resident #3 refused 21 times out of 30 a.m. administration opportunities and 17 refusals out of 30 p.m. administration opportunities. Record review of Resident #3's Progress notes dated 09/01/2025- 10/1/2025 did not indicate the physician was made aware of Resident #6's arm sling treatment refusals. During an observation on 9/29/2025 at 9:18 a.m., Resident #3's right shoulder was approximately 4 inches lower then her left shoulder. Resident #3 did not have a right arm sling on. During observation on 09/30/2025 at 10:00 a.m., Resident #6 did not have the right arm sling on. During observation on 09/30/2025 at 2:55 p.m., Resident #6 did not have a right arm sling on. During observation on 10/1/2025 at 1:00 p.m., Resident #6 did not have a right arm sling on. During interview on 10/01/2025 at 4:00 p.m., LVN A said she had not notified the physician of Resident #6's pattern of refusing to wear the arm sling for her arm. She said she should have notified the physician of the pattern of refusal so he could have ordered a different treatment. She said Resident #6 not wearing her right arm sling could potentially cause further shoulder misalignment. During an interview and record review on 10/01/2025 at 3:05 p.m., indicated the Regional Nurse said the physician should have been notified of Resident #6's arm sling refusals so an alternative treatment could have been put in place. She said she could not find any documentation showing the physician was notified of resident's refusal. The Regional nurse said her expectation is for all nurses to follow policy and notify the physician of any pattern of refusal to ensure no potential harm came to the residents from not getting ordered treatment or alternative treatment. During an interview on 10/01/2025 at 3:17 p.m., the Administrator said the physician must be notified of any refusals to ensure the residents needs were being met, and no harm came to the residents by not receiving ordered treatment or a potential alternative treatment. Record review of the facility's undated policy Notifying the Physician of Change in Status,indicated: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Workday notification of the physician.The nurse will notify the physician or their delegated nurse practitioner or physician assistant with change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident 's clinical record.

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 (Hall B) of 4 hallways reviewed for environment. The facility failed to ensure the janitor closet, that contained potentially unsafe chemicals, on Hall B was secured on 09/29/25. This failure could result in residents coming into contact with potentially unsafe items.The findings were: During an observation on 09/29/25 at 9:35 a.m., during the initial tour on hall B, a janitor's closet's door knob was locked , however the door just opened when pushed on. The closet contained a 1/2 full bottle of multipurpose cleaner on the floor. The container had a label which indicated to keep out of the reach of children and animals. There was no staff in sight. During an interview on 09/29/25 at 9:45 am, the Maintenance Supervisor walked down the hall and met the surveyor at the unlocked room. He said someone must have forgotten to pull the door hard so the lock would latch. He said all chemicals should be in the sight of the staff or locked up to prevent residents from having accidents. The Maintenance Supervisor said all the staff was responsible for securing chemicals. During an interview with the Administrator on 09/30/25 at 1:30 p.m., the Administrator said the maintenance supervisor tightened the self-shutting mechanism to shut the door so it would lock and adjusted the lock. Record review of the Daily Common Area Cleaning policy dated 2021 indicated . Housekeeping carts/chemical must be locked when not within eyesight of a staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, 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 one (Resident #76) of 22 residents reviewed for infection control. The facility failed to ensure CNA C performed hand hygiene before she applied clean gloves during incontinent care for Resident #76. This failure placed residents at risk for healthcare associated cross contamination and infections.Findings included: Record review of face sheet, dated 10/01/25, indicated Resident #76 was a [AGE] year-old male admitted on [DATE] with diagnoses which included Parkinson's disease (a disorder of the central nervous system that affects movement) and dementia (disease of the brain with impairment of memory and abstract thinking). Record review of quarterly MDS assessment dated [DATE] indicated Resident #76 was severely impaired with cognition and was frequently incontinent for bladder and bowel. Resident #76 required partial/moderate assistance with toileting hygiene. Record review of comprehensive care plan dated 08/08/25 indicated Resident #76 required extensive assistance of 1 person for occasionally incontinent of bladder and bowel. Resident #76 had an ADL self-care performance deficit and required staff to provide incontinent care after each episode. During an observation on 09/30/25 at 10:30 a.m., CNA C and CNA D washed their hands, donned gowns and gloves. CNA C cleaned the pubis area (below the abdomen) and the genital area of Resident #76. CNA C did not push back the foreskin and did not clean under the foreskin. CNA C changed her gloves and did not perform hand hygiene. CNA D turned Resident #76 on his left side. CNA C cleaned Resident #76's buttocks and placed a clean brief on the resident. During an interview on 09/30/25 at 10:45 a.m., CNA C said she had been trained on incontinent care for males. She said she should have used hand sanitizer with a glove change. She said not cleaning her hands could spread germs. During an interview on 4/7/25 at 11:15 a.m., the ADON B said her expectation was for all the staff to perform hand hygiene when gloves were removed to prevent infections. She said all of the nursing staff had been trained on hand hygiene when they removed gloves on hire and at least annually. Record review of The Perineal Care Male policy dated 12/08/09 indicated . if gloved , remove and discard gloves. Wash hands. Provide for resident's comfort .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 3 of 22 residents (Residents #8, 42, and 59) reviewed for resident assessments. 1. The facility failed to refer Resident #8 for a PASRR review following a new mental illness diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) on 03/28/25. 2. The facility failed to refer Resident #42 for PASRR review following a new mental illness diagnosis of psychosis (a mental disorder characterized by a disconnection from reality) on 11/04/24. 3. The facility failed to refer Resident #59 for PASRR review following a new mental illness diagnosis of bipolar disorder on 07/22/25. These failures could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.Findings included: 1. Record review of a face sheet dated 10/01/25 indicated Resident #8 was an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses included bipolar disorder, cognitive communication deficit (a difficulty in communication caused by impaired thing processes, such as memory, attention, problem-solving, and organization), and dementia (a group of thinking and social symptoms that interfere with daily functioning). Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #8 had clear speech and was able to express her needs and comprehend others. She had a BIMS score of 7 indicating she had severe cognitive impairment, required substantial/maximal assistance with most ADLs, and had an active diagnosis of bipolar disorder. Record review of a care plan dated 04/07/25 indicated Resident #8 had a diagnoses of psychosis, bipolar disorder, and attention deficit hyperactivity disorder (a chronic condition including attention difficulty, hyperactivity, and impulsiveness). Interventions included administering medications as ordered by the physician and psych services as indicated. During record review of the physician orders dated September 2025 indicated Resident #8 received Risperdal oral solution at bedtime for attention deficit disorder with start date of 04/09/25. During an interview on 10/01/25 at 9:06 a.m., the MDS Nurse said that Resident #8's diagnosis of bipolar disorder was unknown to the facility until her physician ordered a gradual dose reduction and the discontinuation of her Risperdal (an antipsychotic medication used to treat bipolar disorder). She said Resident #8's family questioned why her Risperdal had been discontinued because the resident had been taking the medication for more than 10 years to manage her bipolar disorder and attention deficit hyperactivity disorder and they did not want the medication discontinued. The MDS Nurse said Resident #8's physician reordered the Risperdal per the family's request. She said the facility failed to complete a 1012 form (a form that assists the NF in determining whether a resident with a negative PASRR level 1 screening needs further evaluation for mental illness). She said the Social Worker was responsible for PASRR evaluations at the facility. During an interview on 10/01/25 at 9:45 a.m., the Social Worker said that she was responsible for coordinating PASRR for the facility. She said she had been doing PASRR for a year and had received PASRR training through webinar classes given by HHSC. She said she was not aware that if a resident was diagnosed with a new mental illness or the facility learned of a history of mental illness that a 1012 form should be submitted to the physician to determine if a resident should be screened for PASRR services. She said the 1012 form for a new mental illness was probably included in the training she attended, but she missed it. She said she should have submitted a 1012 form to Resident #8's doctor when the facility learned of her bipolar diagnosis, but she didn't. She said she would fill out a 1012 form and send it to Resident #8's physician. She said the possible negative outcome of not completing a 1012 form and sending it to the doctor could be that Resident #8 would not receive needed services that she could qualify for through PASRR. During an interview on 10/01/25 at 3:35 p.m., the MDS Nurse said that a 1012 Mental Illness/Dementia Resident Review form had been completed (after surveyor intervention) for Resident #8. Record review of a 1012 form dated 10/01/25 and signed by Physician A indicated that Resident #8 had a primary diagnosis of dementia and a new PL1 was not needed at that time. 2. Record review of a face sheet dated 10/01/25 indicated Resident #42 was an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses included cerebral infarction (a condition where blood flow to the brain is interrupted, leading to brain cell damage), psychosis, and dementia. Record review of the most recent MDS assessment dated [DATE] indicated Resident #42 had clear speech and was able to express her needs and comprehend others. She had a BIMS score of 4, indicating she had severe cognitive impairment, required substantial/maximal assistance with most ADLs, and had an active diagnosis psychotic disorder. Record review of a care plan last revised 04/17/25, indicated Resident #42 required anti-psychotic medications related to her dementia with psychosis. Interventions included administering medications as ordered by the physician and psych services. During an interview on 10/01/25 at 1:51 p.m., the Social Worker said that she did not complete the required 1012 form for Resident #42 when she received the new mental illness diagnosis of psychosis. She said the negative outcome of not completing the required 1012 form was that the physician had not reviewed Resident #42 to determine if she should be evaluated for receiving specialized services through PASRR. During an interview on 10/01/25 at 3:35 p.m., the MDS Nurse said that a 1012 Mental Illness/Dementia Resident Review had been completed (after surveyor intervention) for Resident #42. Record review of a 1012 form dated 10/01/25 and signed by Physician A indicated that Resident #42 did not have a primary diagnosis of dementia and a new PL1 was needed so the resident could be evaluated for PASRR services. 3. Record review of a face sheet dated 10/01/25 indicated Resident #59 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of bipolar disorder [chronic mental health condition characterized by extreme mood swings between mania high (energy, euphoria, and impulsivity) and depression (low mood, fatigue, and hopelessness)] with onset date of 07/22/25. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #59 had clear speech with a BIMS score of 00 indicating she had severe cognitive impairment and an active diagnosis bipolar disorder. Record review of a care plan dated 07/22/25 indicated Resident #59 requires anti-psychotic medications for diagnosis of bipolar disorder. Interventions included administering medications as ordered by the physician. Record review of a PASRR level 1 screening for Resident #59 dated 01/31/25 indicated Resident #59 was negative for mental illness, intellectual disability, and developmental disability. No PASRR Level II (PE) Screening or a form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record. During an interview on 10/01/25 at 2:15 p.m., the Social Worker said that she did not complete the required 1012 form for Resident #59 when she received a new mental illness diagnosis of bipolar disorder. While looking at Resident #59's medical record face sheet, the Social Worker stated Resident #59 had a diagnosis of Bi-polar that had an onset date of 07/22/2025. The Social Worker acknowledged Resident #59's PASRR was inaccurate and another PASRR screen or form 1012 would be completed for Resident #59 and uploaded to the portal. She said the negative outcome of not completing the required 1012 form or updating the PASRR could put the resident at risk of not receiving specialized services offered through the PASRR program. In an interview on 10/01/25 at 2:45 p.m. with the Administrator, she said her expectations were for the Social Worker to complete PASRR screenings according to regulatory guidelines and that Residents #8, #42 and #59's PASRR Level 1 screenings needed to be updated to include the new diagnosis. The Administrator stated that not having an accurate Level 1 put the resident at risk of not getting psych services and/or not getting the treatment they needed that was offered through the PASRR program. During an interview on 10/01/25 at 3:35 p.m., the Social Worker said that a 1012 Mental Illness/Dementia Resident Review had been completed (after surveyor intervention) for Residents #8, #42 and #59. Record review of the facility's undated policy titled Form 1012 Policy & Procedure with Instructions read in part: Purpose: Form 1012 assists nursing facilities (NF) in determining whether a resident with a negative Preadmission Screening and Resident Review (PASRR) Level I(PL1) Screening form submitted into the Long-Term Care (LTC) Portal, needs further evaluation for Mental Illness (MI).Section C. Mental Illness (MI) Indication. Examples of MI are: .mood disorder(bipolar disorder.).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents who enter the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable for 1 of 4 (Resident #10) reviewed for range of motion. 1.The facility failed to implement interventions to prevent the decline of Resident #10's range of motion to her left hand on 10/1/2 025. 2. The facility failed to document Resident #10's change of condition to her left hand from within functional limit to a decreased range of motion. These failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included: Record revied of Resident #10's face sheet dated 10/01/2025 indicated she was a [AGE] year-old female that was admitted to the facility on [DATE], with diagnoses of muscle weakness (generalized), Dementia (a decline in cognitive abilities, such as memory, thinking, problem-solving, and language), Alzheimer's disease (loss of cognition), Osteoporosis (weakens bones, making them more prone to fractures). Record review of Resident #10's Quarterly minimum data set assessment dated [DATE] indicated she had no upper extremity impairment (shoulder, elbow, wrist, hand). In Section O of the MDS entitled- Special Treatments, Procedures, and Programs indicated Resident #10 started Occupational therapy 08/14/2025. Record review of Resident #10's therapy screen dated 08/13/2025 at 5:12 p.m., indicated Resident #10 exhibited a decrease in her upper extremities range of motion and strength. In section C- (Immobilizing Device) indicated Resident #10 did not have a splint, brace, nor a placed cast on any extremity. The Occupational therapist registered #1 made a recommendation for Resident #10 to have an Occupational therapist registered and Physical therapist evaluation. Record review of Occupational therapy evaluation & plan of treatment dated 08/18/2025 at 12:55 p.m., indicated the reason for referral to occupational therapy was due to her decline in ability to perform functional activities without physical assistance, activities of daily living participation and strength. The Musculoskeletal System Assessment section indicated Resident #10's upper extremity range of motion and strength was within functional limits on both her left and right side. She also had no contractures present. In the Assessment Summary it listed risk factors such as further decline in her function and compromised general health to Resident #10 if she does not receive Occupational therapy. Record review of Resident #10's treatment administration record for the month of September 2025 did not reflect that any resting hand splint had been used on Resident #10's left hand. Record review of Resident #10's current physician orders did not indicate an order for a soft resting hand splint or hand roll for her left hand. Record review of Resident #10's Occupational therapy treatment encounter notes dated 08/14/2025- 09/27/2025 did not mention any updates on Resident #10's left hand to reflect her current decrease in range of motion. An observation on 09/29/2025 at 9:20 a.m., indicated Resident #10 did not have a hand roll or splint in her left hand. Resident #10's left hand was balled in a tight fist while sitting in her wheelchair during activities. An observation on 09/29/2025 at 3:45 p.m., indicated Resident #10 did not have a hand roll or splint in her left hand. Resident #10's left hand was balled in a tight fist resting on her lap while sitting in her wheelchair at the dining table. An observation on 09/30/2025 at 8:45 a.m., indicated Resident #10 did not have a hand roll or splint in her left hand. Resident #10's left hand was balled in a tight fist resting on her lap while sitting in her wheelchair. An observation on 09/30/2025 at 3:00 p.m., indicated Resident #10 did not have a hand roll or splint in her left hand. Resident #10's left hand was balled in a tight fist resting on her lap. An observation on 10/01/2025 at 12:00 p.m., with Registered Occupational therapist and the Director of Rehabilitation indicated Resident 10's left hand was balled up in a tight fist resting on top of her lap. Resident #10 was unable to open her left hand on her own. The Registered Occupational therapist attempted to open Resident #10's left hand but was met with resistance. She massaged Resident #10's left arm to relax the arm muscle to open her hand. The Registered Occupational therapist was unable to completely open her hand. An observation on 10/01/2025 at 1:45 p.m., indicated Resident #10 had a soft resting hand splint on her left hand. An interview on 10/1/2025 at 12:20 p.m., indicated the Registered Occupational therapist said she had not documented any decreased range of motion to Resident #10's left hand in her notes. She said she should have documented the change and reported it to the Director of Rehabilitation to ensure Resident #10 received a resting hand splint to prevent further limited range of motion. An interview on 10/1/2025 at 12:45 p.m., indicated the Director of Rehabilitation was not aware that Resident #10 had a decreased range of motion in her left hand that required a resting hand splint. She said she had expected the Registered Occupational therapist to report any change of conditions on any resident to her and document it in her notes. The Director of Rehabilitation said by Resident #10 not receiving a resting arm splint could potentially worsen her range of motion and overall health. An interview on 10/1/2025 at 2:15 p.m., indicated the Administrator said she expected therapy staff to follow facility policy by documenting resident's' changes, communicating resident needs to nursing staff/ management, and ordering needed resting arm splints. She said not following the policy could potentially cause limited range of motion that residents did not previously have. Record review of the facility's policy Immobilization Devices, Splints/ Slings/ Collars/Straps. dated year 2003 indicated: Splints are rigid devices that can be used to treat a bone fracture, dislocation, or to prevent further damage of bones, joints, and muscles following injury or during acute phases of chronic diseases such as arthritis.15. Document all care and the residents response to treatment in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #76) of 22 resident reviewed for incontinent care. The facility failed to ensure that CNA C cleaned under the foreskin (the retractable roll of skin covering the tip of the penis) for Resident #76 while incontinent care was provided on 09/29/2025. This failure could place the residents at risk of cross-contamination and development of urinary tract infections.Findings included: Record review of face sheet, dated 10/01/25, indicated Resident #76 was a [AGE] year-old male admitted on [DATE] with diagnoses which included Parkinson's disease (a disorder of the central nervous system that affects movement) and dementia (disease of the brain with impairment of memory and abstract thinking). Record review of quarterly MDS assessment dated [DATE] indicated Resident #76 was severely impaired with cognition and was frequently incontinent for bladder and bowel. Resident #76 required partial/moderate assistance with toileting hygiene. Record review of comprehensive care plan dated 08/08/25 indicated Resident #76 required extensive assistance of 1 person for occasionally incontinent of bladder and bowel. Resident #76 had an ADL self-care performance deficit and required staff to provide incontinent care after each episode. During an observation on 09/30/25 at 10:30 a.m., CNA C and CNA D washed their hands, donned gowns and gloves. CNA C cleaned the pubis area (below the abdomen) and the genital area. CNA C did not push back the foreskin and did not clean under the foreskin. CNA C changed her gloves and CNA D turned Resident #76 on his left side. CNA C cleaned Resident #76's buttocks and placed a clean brief on the resident. During an interview on 09/30/25 at 10:45 a.m., CNA C said she had been trained on incontinent care for males. She said she should have pushed the foreskin back,cleaned, and then replaced the foreskin. She said normally she did push back the foreskin, but said she was nervous. She said cleaning under the foreskin could prevent infections. During an interview on 09/30/25 at 11:15 a.m., the ADON B said her expectation was for the CNAs to pull back the foreskin and clean and dry for the uncircumcised male residents to prevent infections. Then put the foreskin back in place. She said all CNAs are trained on incontinent on hire and annually. Record review of the Perineal Care Male dated 12/08/09 indicated . I.Wipe across the pubis area. Retract foreskin of uncircumcised male. Wash the urethal area in a circular motion. Continue to wash down the penis and the rest of the perineal area .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation: 1. The facility failed to ensure opened food items stored in the walk-in dry pantry area were properly sealed in plastic bags to prevent exposure to the air. 2. The facility failed to ensure food items in the facility walk-in dry storage were dated or labeled.3. The facility failed to ensure that spoiled food items were discarded.4. The facility failed to ensure the outside of food containers were free of food particles.5. The facility failed to ensure dishes were sanitized properly prior to being stored in clean area. These failure could place residents at risk of food-borne illnesses.Findings Included: Observation and initial tour of the kitchen on 09/29/2025 at 8:30 a.m. indicated inside the dry food pantry were 1 gallon bottle of apple cider vinegar with an expiration date of 06/30/2025. Inside the bottle of vinegar there was dark brown and grey colored clumpy sediment inside. An opened 16-ounce bag of Fresh gourmet wonton strip inside an opened plastic bag with a best buy date of August 20,2024. An opened 35-ounce bag of Crisp [NAME] Cereal with a best buy date of November 17, 2024. An opened 2.2-pound bag of Cacao powder had a use before date of 03/16/2024. A 6-quart container with multi-colored circle cereal was unlabeled and had no date. An opened 16- ounce bag of uncooked noodles was not sealed inside a plastic bag, labeled, or dated. There were 13 unused bowls of cereal on a tray unlabeled. There were 2 of 10 food containers that had hard and sticky clumps of food on the outside of the containers. A 1- quart container labeled Thicker had no date on label. Observation on 09/29/2025 at 9:36 a.m. indicated the dishwasher had an internal temperature of 110 degrees Fahrenheit. Dishwasher A took 6 cups from the dishwasher and placed them on the tray of clean cups. The instructions on the dishwasher read for dishes to be washed and rinsed at 120 degrees or higher to ensure kitchenware were properly disinfected. Observation on 09/29/2025 at 10:00 a.m. indicated 6 large white debris spots located on the mixer counter. An interview on 09/29/2025 at 10:15 a.m., indicated the Dietary Supervisor said there shouldn't be any food items in kitchen past 6 months of the listed date on the product. She said the outside of all food containers should be wiped down after usage to prevent food borne illnesses. The Dietary Supervisor said all food items in the kitchen should be labeled and dated. She said the dishwasher must be at a temperature of 120 degrees Fahrenheit or greater to effectively disinfect kitchenware. The Dietary supervisor said she trained the kitchen staff on labeling items, discarding expired food items, cleaning the mixing station after use, and the dishwasher needing to be at 120 degrees Fahrenheit for the dishes to disinfected. She said her expectation was for all kitchen staff to follow facility policy and the training they have received on labeling and disinfecting kitchenware. An interview on 10/1/2025 at 2:13 p.m., indicated the Administrator said all expired food items or items past a year of the listed date should be thrown away to prevent residents being served expired food items. She said she expected kitchen staff to follow the facility's policy. The Administrator said if dishes were not washed at 120 degrees, the residents could potentially be harmed by cross contamination. An interview on 10/1/2025 at 2:45 p.m., indicated the Regional Nurse said residents could potentially be served expired food items because it's in the dry storage pantry with non-expired food items. She said if the residents were to consume the expired food items, they could potentially experience stomach issues, and diarrhea. The Regional Nurse said all dishes should be washed and rinsed at a temperature of 120 degrees Fahrenheit or higher. She said her expectation was for kitchen staff to follow facility policy. Record Review of the FDA Food and Code dated year of 2022 entitled: Mechanical Ware washing Equipment, Wash Solution Temperature. indicted: :The temperature of the wash solution in spray type ware washers that use hot water to SANITIZE may not be less than: The temperature of the wash solution in spray-type ware washers that use chemicals to SANITIZE may not be less than 49 C (120 F). Record Review of the facility's policy entitled Dietary Services Policy & Procedure Manual 2012 indicated (in part):Food Storage and Supplies- 3. Containers are labeled. Containers are cleaned regularly.4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.6. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf- stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes. Record Review of the facility's policy entitled Dishwashing Preparation and Dishwashing dated: year of 2012 indicated (in part): The facility will complete the dishwashing process in a sanitary manner to provide clean and sanitary dishes and utensils. Procedure:2. c. The wash period shall be at least 40 seconds with a temperature of 120 degrees Fahrenheit in the dish machine. The sanitizing rinse period shall be at least 20 seconds with minimum temperature of 120 degrees Fahrenheit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 26 residents (Resident #1) reviewed for accident hazards and supervision. The facility failed to ensure Resident #1 was provided two persons assist with transfer from sitting in wheelchair to standing position to provide toilet hygiene on 04/22/2025 which resulted in Resident #1 being lowered to floor by CNAT C and causing discoloration with abrasion to the left buttock, small avulsion fracture (a ligament or tendon pulls away a small piece of a bone) off the right distal fibula (calf bone), and a right ankle sprain. The non-compliance was identified as past non-compliance. The PNC began on 04/22/2025 and ended on 04/23/2025. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk of severe injury, hospitalization, and decline in quality of life.Record review of Resident # 1's face sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE], readmitted [DATE] with the diagnoses included: Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), displaced fracture of right tibia (two or more broken bones in the shinbone that is displaced from their original position), pathological fracture right fibula (broken calf bone, break happens due to underlying disease leaving bones weak and brittle), vitamin D deficiency, cognitive communication deficit (impairment in the ability to receive, send, process, and comprehend concepts of verbal, nonverbal communication), and dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Record review of Resident #1's quarterly MDS assessment dated [DATE], indicated other musculoskeletal fractures, a BIMS score of 7, which indicated severe cognitive impairment. She required moderate assistance (helper does less than have the effort) with toileting hygiene (ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement) and sit to stand (ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and toilet transfer (ability to get on and off a toilet or commode) was not attempted due to medical condition or safety concerns. Record review of Resident #1's Optional State Assessment (OSA) dated 04/19/2025, indicated she required two+ persons physical assist/support for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and toilet use (how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes.) Record review of Resident #1's care plan revised 08/16/2022 and Kardex dated as of 04/22/2025 indicated she needed assistance with ADLs and mobility needs with interventions of extensive assistance x 1 staff member for toileting task and extensive assistance x 2 staff members for transfer task. Record review of Resident #1's event note dated 04/22/2025 at 3:30 p.m. indicated she was being assisted with a brief change in her bathroom. Her legs gave out and she was lowered to the floor. Resident #1 sustained a 2-inch abrasion with redness discoloration to left buttocks during the fall. Resident #1 denied pain or discomfort. RP and PA notified of the incident. Record review of Resident #1's physician's order dated 04/23/2025 for x-ray to right lower extremity due to pain post fall with start date of 04/23/2025 and end date of 04/25/2025. Cleanse abrasion to left buttock with normal saline, pat dry and apply TAO LOTA daily on day shift for 5 days with start date of 04/23/2025 and end date of 04/29/2025. May wear walking boot to right foot x 1 week on day and night shift for 7 days with start date of 04/28/2025 and end date of 05/06/2025. Weight bearing as tolerated and bed rest as needed for 1 week with start date of 04/28/2025 and end date of 05/05/2025. Apply ice to right ankle/leg as needed; every 2 hours as needed for edema; pain for 1 week start date of 04/28/2025 and end date of 05/05/2025. Tramadol 50 mg give 2 tablets by mouth every 6 hours as needed for moderate pain with start date of 11/16/2024. Acetaminophen Extra Strength Tablet 500 mg give 500 mg by mouth every 6 hours as needed for mild pain with start date of 05/23/2017. Record review of Resident #1's medication administration record indicated she received Tramadol 50 mg 2 tablets by mouth every 6 hours as needed for moderate pain on 04/22/2025 at 9:31 p.m., 04/23/2025 at 5:41 p.m., 04/23/2025 at 2:30 p.m., and 04/24/2025 at 8:00 a.m. with effectiveness. She received Acetaminophen Extra Strength 500 mg 1 tablet every 6 hours as needed for mild pain on 04/23/2025 at 2:03 a.m. with effectiveness. Record review of Resident #1's nursing follow-up injury note dated 04/22/2025 at 9:30 p.m. she complained of a dull pain to her right upper and lower leg, and ankle relieved with PRN pain medication of tramadol. PA was notified of the pain and x-ray to the right upper and lower extremity was ordered. Record review of Resident #1's social service progress note dated 04/23/2025 at 8:14 a.m. indicated SW spoke with resident regarding the incident which occurred on 04/22/2025. Resident stated a CNA was changing her, and her legs went out on her and she was lowered to the ground. She said her right side was hurting and she was supposed to get an x-ray that day. Resident #1 was lying in her bed at the time and said she did not feel the CNA was intentionally trying to harm her. Resident #1 denied abuse and neglect. Record review of Resident #1's right ankle and right tibia/fibula x-ray results dated 04/23/2025 at 11:40 a.m. indicated right ankle 2 view findings: intramedullary rod with nail (internal fixation technique originally mainly used for the surgical management of long bone fractures) seen traversing a healing fracture deformity along the distal tibia (shinbone). A suspected hairline (fracture without separation of the fragments) cortical (outer layer) fracture lucency (areas that appear darker due to lower density) faintly and partially visualized along the distal fibula (lower end of the calf bone). No dislocation, or bony destructive lesions are noted. Talar dome (ankle bone) and ankle mortise (ankle joint) appear normal. The bony mineralization is unremarkable. Right ankle impressions: stable postprocedural status, internally fixed healing distal diaphyseal fracture (break of the shaft of the bone) of the right tibia (shinbone) noted. A suspected hairline (fracture without separation of the fragments) cortical (outer layer) fracture lucency (areas that appear darker due to lower density) faintly and partially visualized along the distal fibula (lower end of the calf bone), no acute osseous findings. Right tibia/fibula (lower leg bones) 2 view findings: there is an intramedullary rod transfixing (internal fixation technique originally mainly used for the surgical management of long bone fractures) distal 3rd tibial (Shinbone) fracture. No evidence of hardware failure or new fracture seen. There is a healed fracture of the distal fibula (calf one). Soft tissues are unremarkable. Right tibia/fibula impression: slightly osteopenia bone but intact normally aligned distal tibial and fibular fractures with hardware in good alignment. Record review of Resident #1's weekly skin assessment dated [DATE] at 10:17 a.m. indicated abrasion present: red abrasion noted to left upper buttocks approximately 3 inches. Record review of Resident #1's nursing progress note dated 04/23/2025 at 4:02 p.m. indicated x-ray images obtained, PA, DON and RP aware of finding. PA instructed to call orthopedic clinic and schedule a follow up appointment with Resident #1's established orthopedic to determine if findings on x-rays are new or old injuries. Orthopedic appointment scheduled regarding right leg discomfort and clarification of x-ray results for 04/28/2025 at 3:20 p.m. Record review of Resident #1's nursing note dated 04/23/2025 at 4:46 p.m. indicated an abrasion present on left buttocks cheeks and complaining of pain/discomfort in right leg and pain was being addressed. Record review of Resident #1's nursing progress note dated 04/23/2025 at 9:45 p.m. indicated a 7cm x 1cm abrasion/bruise present on left buttocks cheeks and no pain present during assessment. She was being monitored Q shift with follow up assessments. Record review of Resident #1's nursing progress note dated 04/24/2025 at 1:23 p.m. indicated a 7cm x 1cm abrasion/bruise present on left buttock. Record review of Resident #1's nursing progress note dated 04/24/2025 at 10:50 p.m. indicated a 7cm x 1cm blue/purple bruise present on left buttocks cheeks and no pain present during assessment. Record review of Resident #1's nursing progress note dated 04/25/2025 at 12:55 p.m. indicated a 7cm x 1cm blue/purple bruise present with a 2cm x 2cm abrasion in bruised area on left buttock and no dressing, s/s of infection or pain present during assessment. Record review of Resident #1's nursing note dated 04/25/2025 at 11:19 p.m. indicated a 7cm x 1cm blue/purple bruise present with a 2cm x 2cm abrasion in bruised area on left buttock and no dressing, s/s of infection or pain present during assessment. Record review of Resident #1's nursing progress note dated 04/28/2025 at 6:13 p.m. indicated resident had an appointment at orthopedic clinic and returned to the facility with no concerns or discomforts. The report stated there was a possible small avulsion fracture (a ligament or tendon pulls away a small piece of a bone) off the distal fibula and right ankle sprain and the resident may have to wear a boot for a week or two for support. Record review of Resident #1's orthopedic visit note dated 04/28/2025 at 3:20 p.m. present illness indicated [Resident #1] was an established patient with orthopedic clinic and well known to physician and underwent intramedullary nail fixation of right tibia fracture on 11/20/2024 and was doing well until a few days ago when she had an incident at facility. They got a portable x-ray there are some concerns for fracture so referred her for further evaluation with pain primarily about the right lateral ankle. The assessment/plan indicated plain films of the right tibia (shinbone)/fibula (calf bone) obtained and indicated orthopedic implants with subacute fractures (a bone break that has occurred recently, usually several weeks or months ago, and is in the healing process) of the tibia and fibula and a possible small avulsion fracture (a ligament or tendon pulls away a small piece of a bone) off the distal fibula. Status post intramedullary fixation of right tibia/fibula fracture, now with likely right ankle sprain will treat this conservatively. She can go into her boot for a week or so. She will elevate, ice and rest. Then advance her activity as tolerated, if unable to do that will need to contact clinic, otherwise follow-up as needed. Record review of Resident #1's treatment administration record dated April 2025 indicated cleanse abrasion to left buttock with normal saline, pat dry and apply TAO LOTA daily. She may wear walking boot to right foot x 1 week every day and night shift for 7 days and apply ice to right ankle/leg as needed every 2 hours for edema and pain for 1 week starting 04/29/2025. During an interview on 08/18/2025 at 11:10 a.m., Resident #1 said the day of the incident she was needing to be changed and was in her bathroom in preparation to have her brief changed. She stated CNAT C entered her bathroom, and she requested to be changed. She said CNAT C assisted her to stand up, she held onto the grab bars, when she was reapplying the new brief, her knees became weak and gave way. She said with the assistance of CNAT C, she was lowered to the floor. She said she did not have any pain at the time of the incident, but later that evening, her right lower leg started hurting and an x-ray was obtained. She said she went to the orthopedic doctor for treatment. She said she had weakness in her lower extremities and that was why she was receiving therapy. She said only one staff member was assisting her at the time of the incident, but now two staff members assist her with all transfers and toileting hygiene. She said her right lower leg and ankle hurt for 2 or 3 days after incident, and she wore a boot to help keep stable, but it was better now. During an interview on 08/18/2025 at 1:10 p.m., Resident #4 (roommate) said the day of the incident, she was in the room and heard Resident #1 say her knees were getting weak. She said the bathroom door was closed so she did not see the incident. She said only one staff was assisting Resident #1 that day and usually there was two staff. She said several staff entered the room after the incident to assist Resident #1. During an interview on 08/19/2025 at 11:43 a.m., CNAT C said she was completing her clinical rotation for her CNA certification at the facility, and on 04/22/2025 she was instructed by her trainer to answer call lights on the hall. She said Resident #1 call light alarmed, so she went to answer and found Resident #1 in her bathroom damaging to be changed immediately. She said she stood the Resident #1 up, had her hold the grab bars on the wall, and while completing the hygiene task and applying her new brief, Resident #1's knees gave away and she began to lower toward the floor. She said she attempted to but the wheelchair under her, but she slid down grazing wheelchair with her buttocks/hip, and she then assisted her by lowering her to the floor and called for assistance. She said Resident #1 said she was not injured and started cussing at her to get her off the fucking floor. She said two nurses and a CNA entered Resident #1's bathroom so she left. She said the clinical educator had informed the trainees not to perform hands on care until approval by trainer or clinical educator, but she had received training on transfers and been checked off, so thought she could assist with the requested transfer. She said she was not aware Resident #1 was a 2 person assist with transfers and had she been aware, she would not have attempted to transfer her by herself. She said as a CNA trainee she was not provided access to the Kardex, so would have to ask her trainer if the resident required 2-person transfer. She said she had provided care to other residents under the supervision or guidance of the trainer or clinical educator. CNA trainee C said she received one on one training from clinical educator, DON and administrator regarding the incident on abuse, neglect, incontinent care, safe transfers, Kardex use, and expectations and proved task a clinical trainee and trainer can/should perform. CNA C trainee said she should not have transferred Resident #1 by herself. During an interview on 08/19/2025 at 11:43 a.m., CNA D said she was the trainer for CNAT C at the time of the incident with Resident #1. She said she had told CNAT C to answer the call light and do minor task like give ice, water, or report complaints to the CN. She said she had told CNAT C several times during her clinical rotation not to provide hands on care without her as the trainer or clinical educator present. CNA D said Resident #1 could be demanding and manipulative to get her way. CNA D said she assisted the LVN to get Resident #1 back to her wheelchair after the LVN assessed her after the incident and she denied pain when facility staff ask about pain. During an interview on 08/19/2025 at 2:15 p.m., LVN E said she was one of the LVNs that assessed Resident #1 after the incident and she, another LVN and CNA D assisted her to her wheelchair after the incident. LVN E said she walked in the resident's room observed resident #1 on the bathroom floor sitting on her butt, with her right leg under her left leg and CNAT C was holding her in the upright sitting position. She said CNAT C said her knees gave out and she lowered her to the floor. She said it appeared Resident #1 was holding onto the grab bars and had to be lowered to the floor. She said Resident #1 denied hitting her head, pain, and refused any pain medications during the assessment. She said Resident #1 did have a discoloration with an abrased area to her left buttocks which was in proximate of hitting the wheelchair arm. During an interview on 08/19/2025 at 4:00 p.m., LVN G said she provided care for Resident #1 on 6 p.m. to 6 a.m. shift after the incident 04/22/2025. She said around 9:30 p.m., Resident #1 complained of pain/discomfort to right upper and lower leg, and dull pain to right ankle. She said she administered PRN pain medication of Tramadol with effectiveness. She said she notified the PA of the complaint of pain to right upper and lower leg and ankle and he ordered an x-ray. She said she send an x-ray requested to the mobile x-ray unit. She said Resident #1 had pain the evening and night of the incident and maybe the next day but after that did not recall her complaining of pain or giving her any PRN pain medications related to her right lower leg or ankle. During an interview on 08/20/2025 at 11:15 a.m., RN F said she was the clinical educator, and she does the training and oversees the CNA trainees while they are in the facility for their clinical rotation. She said the CNA trainee contacts her to be placed on the clinical rotation schedule; she verifies they have completed their 60 hours of on-line education and received a certificate. She says they are in the facility for 40 hours to be trained on different task a CNA may be responsible for completing. She said the rotation is usually five 8-hour days totaling 40 hours. She said the first 1/2 of the day usually consist of classroom training, demonstrating with mannequin certain task and then the trainee would shadow a trainer completing the task assignment. She said trainee was provided transfer training and competency check off by facility physical therapy staff. She said the trainees are told not to provide any hands-on task/care unless the trainer or herself was present. She said the trainees are not provided logins to the electronic medical records to access task or ADL care because facility staff trainer should be accessing and instructing the trainee. Unsuccessful attempts to interview orthopedic physician on 08/19/2025 at 3:11 pm and 08/20/2025 at 8:00 a.m. During an interview on 08/20/2025 at 1:25 p.m., the DON stated the CNA trainee should not have been performing task without trainer or clinical educator present. She said the facility staff have been in-serviced CNA trainer were not allowed to allow student nurses aide or CNA trainees to perform direct resident task without supervision. The DON said all facility staff should follow policy regarding transferring a resident and if the resident requires two persons assist that two staff members were to transfer the resident, no exceptions. The DON said if the transfer assist task needs to be updated then the staff should notify the CN or DON for review. The DON said facility therapist provided transfer training and competency check offs. The DON said the residents may be injured if proper assistants not provided during transfer. During an interview on 08/20/2025 at 1:45 p.m., the Administrator said she expected facility staff, CNA students and trainees to follow facility policies and CNA trainees and students were not to be allowed to provide ADL care or task until approved by clinical educator or trainer. The Administrator said not utilizing 2 staff members for a resident requires a 2-person transfer could result in a fall or injury. During an interview on 08/20/2025 at 4:15 p.m., the Orthopedic physician nurse said she clarified with the orthopedic physician and Resident #1 did have a small avulsion fracture (a ligament or tendon pulls away a small piece of a bone) of the distal fibula and right ankle sprain possibility from the incident, but he would prescribe the same treatment for both injuries, which included an immobilizer boot and elevate, ice and rest. Record review of the facility's nursing policy and procedure titled, Moving a resident, bed to chair/chair to bed. Purpose: The purposes of this procedure are to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the Procedure. Note: This procedure may require two (2) persons. f. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her on the edge of the bed/chair. Record review of the facility's policy titled, Preventive Strategies to reduce fall risk undated 10/05/2016, indicated Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Procedure: After risk is assessed, individualize nursing care plans will be implemented to prevent falls. The resident and/or family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family's, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. The facility implemented the following interventions before the survey entrance on 08/18/2025. During an interview on 08/20/2025 at 1:00 p.m., RN F, Clinical educator, said she now stressed to all CNA trainees they were not to provide any hands-on skills unless approval from her as the clinical educator. Record review of in-service training titled, Incontinent care dated 04/22/2025 for nursing staff indicated 39 staff in attendance. Summary: Provide incontinent care on all residents with lower extremity weakness, requires two-person assistance with transfers and/or utilize mechanical lift for transfers in the bed only. Record review of in-service training titled, CNA trainers dated 04/22/2025 for CNA's indicated 36 staff in attendance. CNA trainers do not allow student nurses' aides or trainees to perform direct resident task without supervision. Record review of in-service training titled, How to use Kardex to communicate resident information and needs to the CNAs. Ensure you follow all care planned interventions including how much staff is required to perform an ADL. If unable to have the proper number of staff to assist a resident, do not perform the task until the proper amount is present. Do not rush. If for any reason the amount of staff assistance needed is not listed for bathing, bed mobility, transferring, walking, incontinent care, then you should contact the charge nurse, ADON and/or DON. If more assistance is required than what is on the Kardex, report to the DON, ADON or MDS case manager immediately so Kardex can be adjusted. Charge nurse- through assessment of affected residents for injury or pain and report findings to the NP/MD dated 04/22/2025 with 38 staff in attendance. Record review of in-service training titled, Transfer training dated 04/23/2025 for all nursing staff indicated 40 staff in attendance. Summary safe, effective transfer training with demonstrations. Interviews with 36 staff members from all shifts from 08/18/2025 at 8:50 a.m. to 08/20/2025 at 2:30 p.m. the following staff LVN A, CNA B, CNAT C, CNA D, LVN E, RN F, LVN G, RN H, RN J, LVN K, LVN L, LVN M, LVN N, LVN O, LVN P, LVN Q, CNA R, CNA S, CNA T, CNA U, CNA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, CNA BB, CNA CC, COTA LL, ST MM, OT NN, SNA OO, CNAT PP, CNAT QQ, CNAT RR, CNA SS, and CNA/MA TT confirmed completion of in services/training of incontinent care, always follow the plan of care, care plan and Kardex when providing resident care, look at the Kardex for resident required assistance, transfer training, and if a trainer with the CNA trainees or student do not allow student nurses' aides or trainees to perform direct resident task without supervision. The staff, CNA trainees and students were able to verbalize understanding and information provided in the in-service/training. During an observation on 08/19/2025 at 1:30 p.m. SNA OO was observed providing one person transfer with Resident #5 using correct procedure. During an observation on 08/20/2025 at 9:35 a.m. CNA/MA TT and CNA AA were observed providing a two person transfer with Resident #6 using correct procedure. The non-compliance was identified as past non-compliance. The PNC began on 04/22/2025 and ended on 04/23/2025. The facility had corrected the non-compliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Record review of Resident #12's face sheet, dated 08/21/2024, originally admitted to the facility on [DATE] with diagnoses which included hypertensive heart disease (high blood pressure that affect the heart) without heart failure and unspecified protein-calorie malnutrition.
Record review of the quarterly MDS assessment, dated 07/23/2024, indicated Resident #12 usually made herself understood and usually understood others. Resident #12 BIMS score was 8, which indicated her cognition was moderately impaired. Resident #12 had no behaviors or refusal of care.
Record review of the comprehensive care plan, revised on 07/26/2022, indicated Resident #12 required staff assist with ADL and mobility tasks. The interventions included: limited staff assist x1 for personal hygiene, oral care task, and continent of bowel with occasional incontinent episodes of bladder.
Record review of the order summary report dated 08/21/2024 did not address the use of Preparation H.
During an observation on 08/19/2024 at 2:56 p.m., Resident #12 was sitting in her recliner. There were 2 tubes of Preparation H cream located in a 4-drawer clear storage container in Resident #12's bathroom.
During an observation and interview on 08/20/2024 at 11:08 a.m., Resident #12 was sitting in her recliner visiting family members. When asked if the state surveyor could look in her clear storage container, she stated yes. The State Surveyor asked Resident #12 what the 2 tubes that were in the storage container were used for, she stated, I use it for my bottom. Resident #12 stated a family member brought the medication to her. Resident #12 stated I don't use it often.
During an interview and observation on 08/21/2024 at 1:58 p.m., RN G stated Resident #12 had not been checked off for self-administration. RN G stated if a resident was able to self-administer an assessment must be completed and an order obtained prior to administration. RN G observed the 2 tubes of Preparation H in Resident #12's clear storage container. RN G stated it was important that medications were not left in the room because others could ingest the medication or cause toxicity.
During an interview on 08/22/2024 at beginning at 5:41 p.m., the DON stated nurses were responsible for ensuring medications were stored appropriately. The DON stated before a resident could keep medications at bedside a self-administer assessment must be completed. The DON stated the MD must be notified and orders would be obtained. The DON stated she monitored by routine checks to ensure compliance. The DON stated she has had issues in the past with medications being stored at bedside. The DON stated if there was an issue it was corrected immediately by removing the medication and educating the resident and the family. The DON stated champion rounds were done every morning by the admission Coordinator. The DON stated it was important to ensure medications were not left at bedside for resident safety and to prevent harm.
During an interview on 08/22/2024 at 6:02 p.m., the admission Coordinator stated she was responsible for champion rounds for Resident #12. The admission Coordinator stated during rounds she checked to see if the residents have any concerns, questions, or issues. The admission Coordinator stated she also looked around the room and bathroom to see if there was anything that needed to be addressed. The admission Coordinator stated, I would assume those tubes were toothpaste or polydent (denture cream). The admission Coordinator stated it was important that medications were not left in room to prevent an adverse reaction to another medication.
During an interview on 08/22/2024 at 6:26 p.m., the Administrator stated that if the resident did not have an order to self-administer, she expected medications to be stored on the medication cart. The Administrator stated the DON, the ADONs, and the charge nurses were responsible for monitoring and overseeing that medications were not left out. The Administrator stated it was important to ensure medications were not let at bedside to prevent an adverse reaction.
Record review of the facility's policy titled, Self-Administration of Drugs, revised 01/09/2006 indicated, . 1. Only medication permitted (ordered) for self-administration shall be left in residents' room .
Record review of the facility's policy from the Pharmacy Policy & Procedure Manual 2003 titled, Medication Administration Procedures, indicated, .After the medication administration process is completed, the medication cart must be completely locked, or otherwise secured .
Record review of the facility's policy from the Pharmacy Policy & Procedure Manual 2003 titled, Order Changes, indicated, .Medication orders for which changes have been made are to be completely re-written in the medication administration record as a new order. The previous order is to be discontinued. The nurse may apply a Label Change, Check Med-Sheet@, or a similar accessory label to the medication package for continued use of the medication. This will alert subsequent staff that the directions have been changed .
Record review of the Texas Administrative Code Texas Administrative Code (state.tx.us) accessed on 08/28/2024 indicated, .Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container. For example, a double lock can include a lock on the cabinet or filing cabinet and the door to the closet where medications are stored .
Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 24 residents (Resident #24 and Resident #82) and 1 of 5 medication carts (D-hall medication cart) reviewed for drugs and biologicals.
1. The facility failed to ensure LVN L secured the D-hall medication cart and keys during medication administration and while the D-hall medication cart was not in use.
2. The facility failed to ensure LVN N secured the D-hall medication cart during medication administration.
3. The facility failed to ensure the controlled medications awaiting disposal were under a double lock.
4. The facility failed to ensure Resident #82's Carbidopa-Levodopa (medication used to treat Parkinson's Disease) medication label matched her physician order.
5. The facility did not ensure Resident #12's Preparation H (medication used to temporarily relieve swelling, burning pain and itching caused by hemorrhoids) was properly safe and secured.
These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.
Findings included:
1. During an observation of medication administration on 08/20/2024 starting at 8:46 AM, LVN L gathered supplies to administer medications and went into the resident's bathroom. The D-hall medication cart was left in the hallway across from where the room was located. LVN L did not lock her medication cart and left the keys on top of the medication cart.
During an interview on 08/20/2024 at 9:27 AM, LVN L said she was supposed to lock the medication cart every time she walked away from it. LVN L said she did not realize she had left the medication cart unlocked and the keys on top of the medication cart. LVN L said leaving the medication cart unlocked and the keys to the medication cart on top of the medication cart could result in a resident or any staff getting into the medication cart.
During an observation and interview on 08/20/2024 at 4:22 PM, the D-hall medication cart was at the nurses' station unlocked. LVN L was observed down the hall on the opposite side. LVN L noticed the State Surveyor standing at the medication cart and approached it. LVN L said she forgot to lock the medication cart.
2. During an observation and interview of medication administration on 08/21/2024 starting at 8:19 AM, LVN N went into a resident's room to check a blood sugar. LVN N left the D-hall medication cart unlocked and out of her view. LVN N said she thought she had locked the medication cart. LVN N said the medication cart should be locked every time she stepped away from the medication cart. LVN N said it was important to lock the medication cart so the residents and no one could get into the medication cart. LVN N said if the medication cart was unlocked the residents could get a hold of the medications.
3. During an observation on 8/21/2024 at 3:00 p.m., the regional nurse was sitting in the DON's office alone. The DON's office door was not locked.
During an observation and interview on 08/22/2024 starting at 2:58 PM, an observation was made of where the DON kept controlled medications awaiting disposal. The DON's door to her office was open and unlocked upon entering. The DON opened the single locked file cabinet located in her office. There were approximately 10 different controlled medications awaiting disposal. The medications were not stored under two locks. The DON said she was responsible for keeping the controlled medications awaiting disposal. The DON said the controlled medications should be stored under two locks. The DON said the lock on her door was one lock and the lock on the cabinet was the second lock. The DON said she was normally in her office. The DON said it was important to store the controlled medications under a double lock to ensure nobody could go in and get them.
During an interview on 08/22/2024 at 6:47 PM, the Administrator said the controlled medications awaiting disposal should be under two locks. The Administrator said the DON was responsible for keeping the controlled medications awaiting disposal. The Administrator said it was important for them to be stored under two locks to ensure nobody could take the medications.
4. Record review of a face sheet dated 08/21/2024 indicated Resident #82 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease without dyskinesia, without mention of fluctuations (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves causes unintended or uncontrollable movements).
Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #82 was able to make herself understood and understood others. The MDS assessment indicated Resident #82 had a BIMS score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #82 required substantial/maximal assistance with toileting hygiene, set-up or clean up assistance for eating, oral hygiene, and upper body dressing, and partial to moderate assistance with showering/bathing and lower body dressing.
Record review of Resident #82's care plan dated 07/22/2024 indicated she had Parkinson's to administer medications as ordered by the physician and to monitor/document side effects and effectiveness.
Record review of the Order Summary Report dated 08/21/2024 indicated Resident #82 had an order for Carbidopa-Levodopa 25-250 MG (Carbidopa-Levodopa) Give 1 tablet by mouth three times a day with a start date of 07/19/2024.
During an observation of medication administration and interview on 08/21/2024 starting at 8:19 AM, LVN N administered medications to Resident #82. Resident #82's medication label instructions indicated Carbidopa-Levodopa 25 mg/250 mg take 1.5 tablets by mouth four times a day. LVN N said she was administering 1 tablet because that was what the order indicated. LVN N said the medication labels on the resident's medication should match their orders. LVN N said she did not regularly administer medications to Resident #82. LVN N said the nurse that noticed the discrepancy was responsible for notifying the pharmacy of the discrepancy. LVN N said a sticker should be placed on the label to alert staff the directions had changed. LVN N said it was important for the orders to match the medication label because the dosage could be wrong, and this could lead to a medication error.
During an interview on 08/22/2024 starting at 6:07 PM, the DON said the charge nurses were responsible to ensuring the resident's medication label matched the order. The DON said the hall managers were supposed to monitor the medication carts monthly to ensure the residents' medication labels matched their orders. The DON said a change of direction label should have been placed on the medication. The DON said the medication label not matching the resident's order placed the resident at risk of not getting the correct dose. The DON said this also placed the resident at risk of what they were getting treated for not getting managed properly. The DON said it was the nurses' responsibility to ensure the medication carts were locked and they kept the keys on themselves at all times. The DON said the medication carts should be locked anytime the nurses walked away from the cart. The DON said she made rounds twice a day and looked at the medication carts to make sure they were locked. The DON said in the past she had noticed medication carts not locked and she would tell the nurses to lock them.
During an interview on 08/22/2024 at 6:22 PM, ADON Q said the nurses were responsible for checking the medication labels when they were received from the pharmacy to ensure they matched the residents' orders. ADON Q said she had looked at Resident #82's Carbidopa-Levodopa during medication administration before, and she had not noticed the discrepancy between Resident #82's order and the medication label. ADON Q said she guessed she missed it. ADON Q said it was important for the residents' medication labels to match their orders to ensure they received the correct dosage. ADON Q said the medication labels not matching the residents' orders placed them at risk for being under or over medicated.
During an interview on 08/22/2024 starting at 6:43 PM, the Administrator said she expected for the nurses or whoever received the medication order to follow through and ensure the medication label matched the order. The Administrator said the ADON/hall nurse should be reviewing the medications to ensure they matched. The Administrator said it was important for the medication label to match the order to ensure the residents received the correct dose. The Administrator said she expected for the nurses to lock the medication carts when thy walked away from them. The Administrator said the DON and the hall managers were responsible for monitoring the nurses. The Administrator said if the medication carts were not locked the residents could access stuff that they should not have access to.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 24 residents (Resident #64) reviewed for grievances.
The facility did not ensure a grievance was filed for Resident #64's black bra and 1 pair of pants when they were not returned from the laundry.
This failure could place residents at risk for grievances not being addressed or resolved promptly.
Findings included:
Record review of a face sheet dated 08/22/24 indicated Resident #64 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety (deterioration of memory, language, and other thinking abilities without behaviors) and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs).
Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #64 was able to understand others and was able to make herself understood. The MDS assessment indicated Resident #64 had a BIMS score of 7, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #64 required partial/moderate assistance with dressing and personal hygiene.
Record review of the grievances for the months of February 2024 through August 2024 did not indicate a grievance for Resident #64's black bra and pants.
During an interview on 08/19/2024 at 10:22 AM, Resident #64 said she had lost a pair of aqua green pants and a black sports bra. Resident #64 said they had been sent to the laundry a couple months ago and were not returned. Resident #64 said she had told the laundry lady (was not able to provide a name) when she went by to leave her clothes. Resident #64 said the laundry lady told her she was still looking for it when Resident #64 asked her about the pants and bra.
During an interview on 08/22/2024 at 8:41 AM, Laundry Staff D said Resident #64 told her a couple months ago that she was missing a black bra, and she had looked for it and could not find it. Laundry Staff D said she was not aware of the missing pants. Laundry Staff D said when a resident reported a missing item, they first looked in the resident's closet, the clothing items with no name, and in the laundry. Laundry Staff D said if she was not able to locate the missing clothing, she would tell the residents I am so sorry, but I could not find it. Laundry Staff D said she was not aware she could file a grievance for missing clothes. Laundry Staff D said it was important for the residents clothing to be returned because it was something valuable to them.
During an interview on 08/22/2024 at 2:17 PM, Laundry Staff E said Resident #64 told her she was missing a bra and pants about three weeks ago. Laundry Staff E said she had looked for them but had not found them. Laundry Staff E said when a resident reported missing clothes, they looked for it on the laundry carts and on the carts with clothing that had no names, and other residents' closets. Laundry Staff E said if the clothing was not found she notified the Laundry Supervisor. Laundry Staff E said she had notified the Laundry Supervisor that Resident #64's clothes were missing. Laundry Staff E said it was important for the residents clothing to be returned to them because it was their belongings.
During an interview on 08/22/2024 at 2:24 PM, the Laundry Supervisor said when residents reported clothing missing, they searched the laundry, the lost and found, and the residents' rooms. The Laundry Supervisor said when clothing went missing a grievance was filed, and if the clothing was not found it was replaced. The Laundry Supervisor said the laundry staff were supposed to notify her if a resident reported missing clothes to them. The Laundry Supervisor said she was not notified of Resident #64's missing bra and pants. The Laundry Supervisor said it was important for a grievance to be filed so they knew what was missing, and so they could look for the clothes and be aware of if it happened again. The Laundry Supervisor said it was important for the residents clothing to be returned to them because it was their personal stuff and their clothing.
During an interview on 08/22/2024 at 6:37 PM, the Administrator said if the residents reported missing clothes to the laundry staff, they were supposed to notify the laundry/housekeeping supervisor, and she notified the Administrator. The Administrator said she would text the CNAs and the laundry staff would check the lost and found and conduct a room to room sweep. The Administrator said if the clothing item was not found and they had proof of the item they would repurchase the missing clothes. The Administrator said she was not aware Resident #64 was missing a bra and pants. The Administrator said a grievance was filed to track the steps and progress. The Administrator said it was important for the residents clothing to be returned to them because it was their stuff, and they had a right to have it.
Record review of an undated policy titled, Grievance Forms, indicated, Grievance Policy All residents have the right to voice grievances with respect to treatment or care without fear of discrimination or reprisal. In accordance with state and federal laws, community residents, their family members or any other interested parties have the right to file oral and/or written grievances regarding the community, staff members and other residents . EVERY complainant shall be notified of the actions taken in a timely manner .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed by the interdisciplinary team and that the resident was invited to participate in developing the care plan and making decisions about his or her care for 1 of 24 residents (Resident #64) reviewed for care plan timing and revision.
The facility failed to ensure Resident #64 was invited to participate in the development and review of her care plan.
This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being.
Findings included:
Record review of a face sheet dated 08/22/24 indicated Resident #64 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety (deterioration of memory, language, and other thinking abilities without behaviors) and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs).
Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #64 was able to understand others and was able to make herself understood. The MDS assessment indicated Resident #64 had a BIMS score of 7, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #64 required partial/moderate assistance with dressing and personal hygiene.
Record review of Resident #64's care plan last reviewed 08/14/2024, did not address inviting Resident #64 to participate in the development and review of her care plan.
During an interview on 08/19/2024 at 10:24 AM, Resident #64 said she had not been invited or attended any care plan meetings.
Record review of Resident #64's electronic health record on 08/22/2024 did not indicate any care plan meetings had been completed.
During an interview on 08/22/2024 at 10:55 AM, the Social Worker said the care plan meetings were documented in the electronic health record under the assessments as a Care Plan Conference. The Social Worker said the care plan meetings should be completed every three months. The Social Worker said Resident #64 had not had a care plan meeting yet. The Social Worker said Resident #64 should have had one already, but she was trying to catch up from COVID. The Social Worker said it was important for the care plan meetings to be completed with the IDT (IDT team consisted of the RN or hall nurse the dietary manager, MDS nurse, therapy if on therapy, and the activities director) to be able to touch base with the residents and families, to address any issues the residents were having, and to ensure they were all on the same page.
During an interview on 08/22/24 at 6:39 PM, the Administrator said the care plan meetings were offered to the resident and family, and they were completed quarterly. The Administrator said social services was responsible for the care plan meetings. The Administrator said it was important for the care plan meetings to be completed to keep everybody up to date on the plan of care.
Record review of an undated policy titled, Comprehensive Care Planning, indicated, .Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life . The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions . The facility will provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed ensure each resident receives and the facility provides food that accommodates residents' food preferences for 1 (Resident #290) of 27 residents reviewed for food preferences and the accommodation of resident's meal choices.
The facility failed to honor Resident #290's preference for meat to be chopped at table/bedside.
This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss.
Findings included:
Record review of a face sheet, dated 08/21/2024, indicated Resident #290 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life).
Record review of Resident #290's quarterly MDS assessment, dated 07/23/2024, indicated Resident #290 usually made herself understood and understood others. Resident #290 had a BIMS score of 5, which indicated her cognition was severely impaired. Resident #290 required set up or clean up assistance for eating.
Record review of the comprehensive care plan, revised 08/21/2024, indicated Resident #290 had an ADL self-care performance deficit related to dementia. The interventions included: resident was independent with eating after set up.
Record review of the order summary report did not address Resident #290's preference regarding meat to be cut at table/bedside.
Record review of the lunch meal ticket dated 08/19/2024 for Resident #290 indicated Resident #290 was on a regular diet and meat should be cut up at bedside/table.
During an observation and interview on 08/19/2024 at 12:21 p.m., Resident #290 lunch meal ticket stated, cut up meat at table/bedside. Resident #290 received a slice of meatloaf. The DON did not cut the meat after she delivered Resident #290 tray. An attempted interview with Resident #290, indicated she was non-interview able.
During an interview on 08/22/2024 beginning at 5:41 p.m., the DON stated she was responsible for checking the trays to ensure the proper diet has been served. The DON stated she was not aware that Resident #290's meat should be cut until the state surveyor intervention. The DON stated, state in the building threw all of us off. The DON stated Resident #290 had issues in the past with cutting her meat. The DON stated it was her preference for staff to assist her with cutting her meat at mealtimes. The DON stated it was important for Resident #290's food preference to be followed to prevent an injury.
During an interview on 08/22/2024 at 6:26 p.m., the Administrator stated he expected for the meal tickets and for food preferences to be followed. The Administrator stated the nurse should be checking the meal tickets for accuracy. The Administrator stated it was important for their food preferences and meal tickets to be followed because it was their right and prevent injury.
Record review of the facility's policy, titled Nursing Responsibilities at Meal Service, dated 2012, indicated, 6. Assist in preparing food after the tray has been delivered to the resident, if necessary. This includes unwrapping food, cutting meat
Record review of the facility's undated policy, titled Resident Meal Service and HS snack, indicated .3. resident preference will be honored .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of a face sheet dated 8/22/2024 indicated Resident #15 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of hypertensive heart disease (heart damage from high blood pressure over time) and dementia (memory loss disease).
Record review of the Annual MDS dated [DATE] indicated Resident #15 was understood and understands others. The MDS indicated Resident #15's BIMS score was a 6 indicating severe cognitive impairment. Section O- Special Treatment, Procedures, and Programs indicted Resident #15 received hospice services while a resident of the facility.
Record review of the comprehensive care plan revised on 12/29/2022 indicated Resident #15 had a terminal prognosis of hypertensive heart disease. The goal of the care plan was Resident #15 would be comfortable. The care plan interventions included to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met.
Record review of the consolidated physician's orders dated August 22, 2024, indicated Resident #15 was ordered on 12/29/2022 to admit to hospice care with the diagnosis of hypertensive heart disease.
Record review of the comprehensive care plan revised on 12/29/2022 indicated Resident #15 had a terminal prognosis of hypertensive heart disease. The goal of the care plan was Resident #15 would be comfortable. The care plan interventions included to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met.
Record review of the Annual MDS dated [DATE] indicated Resident #15 was understood and understands others. The MDS indicated Resident #15's BIMS score was a 6 indicating severe cognitive impairment. Section O- Special Treatment, Procedures, and Programs indicted Resident #15 received hospice services while a resident of the facility.
During an observation on 8/19/2024 at 8:52 a.m., Resident #15 was lying on her bed, awake, and oriented to herself only.
During an observation and interview on 8/19/2024 at 1:40 p.m., RN A said Resident #15 had hospice services. RN A said Resident #15's nurse visited twice weekly, and the hospice aide 3 times weekly, and was unsure of the social worker or chaplain. RN A reviewed in the miscellaneous section of the EMR and indicated the last upload hospice records was delivered on 6/25/2024 and included the signed recertification of Terminal Illness for the benefit period of 5/24/2024 - 6/23/2024. The contents of this delivery included a demographics page, a medication regimen, nurse notes dated 5/24/2024, 5/28/2024, 5/29/2024, 6/04/2024, 6/06/2024, 6/11/2024, 6/13/2024, 6/17/2024, 6/20/2024, a medical social worker hospice visit note dated 5/29/2024 and 6/11/2024, a chaplain note dated 6/04/2024 and 6/18/2024, nurse aide care plan reports dated 5/24/2024, and a missed visit note dated 5/31/2024, 6/03/2024, 6/06/2024, 6/10/2024, 6/13/2024, 6/17/2024. The hospice packet also included a Hospice Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report indicated the benefit period was 4/05/2024 - 6/03/2024 (the hospice certification was not current) and another Interdisciplinary Group Comprehensive Assessment and Plan of Care with the benefit period on 6/04/2024 - 8/02/2024. The Hospice Interdisciplinary Group Comprehensive Assessment indicated the nurse would have weekly assessments.
Record review of a Facility Document Delivery form indicated on 7/25/2024 the hospice delivered Resident #15's signed recertification of Terminal illness for benefit period 6/24/2024 to 7/23/2024. The contents of this delivered package were a patient information sheet, medication record, and nurse visit notes dated 6/25/2024, 6/27/2024, 7/02/2024, 7/10/2024, 7/11/2024, 7/18/2024, 7/19/2024, and 7/22/2024. The packet included a Medical Social Worker Hospice Visit note dated 6/26/2024 and 7/15/2024. The packet included two chaplain visits dated for 7/01/2024 and 7/18/2024. The packet included nurse aide visit reports for 6/28/2024, 7/01/2024, 7/05/2024, 7/12/2024, 7/15/2024, and 7/18/2024. The packet had a missed visit notification for the nurse on 7/05/2024 and an aide missed visit on 7/08/2024. The packet included the Hospice IDG (Interdisciplinary Group) comprehensive Assessment and Plan of Care update Report with the benefit dates of 6/04/2024 - 8/02/2024. The IDG report indicated the skilled nurse would visit 1 time weekly and prn, the chaplain would visit 2 times monthly, the aide visit plan was not documented.
During an interview on 8/20/2024 at 11:30 a.m., Medical Records said she had not requested the medical records from Resident #15's hospice provider. The Medical Records staff member said she had found in the medical records department a packet delivered on 7/25/2024 and had uploaded this in the EMR. The Medical Records said the hospice provider delivers a month at a time of hospice records. The Medical Records staff member said she would have to call the hospice and request records after 7/25/2024.
During an interview on 8/21/2024 at 3:55 p.m., the Hospice Nurse said the hospice office staff send the residents medical records over electronically per the facility's request. The Hospice Nurses said sending the hospice visit notes and certifications timely would ensure the staff would be knowledgeable of any changes and updates. The Hospice Nurse said she visits all the hospice residents 2 times weekly, the nurse aide was scheduled two times weekly, and the chaplain and social worker were once monthly. The hospice nurse said the risk to the resident was the facility staff would not be updated on the current hospice plan of care.
During an interview on 8/21/2024 at 4:14 p.m., the Hospice Administrator said the hospice sent the resident medical records to the facility monthly unless the facility requests something different. The Hospice Administrator said with the hospice plan of care not being current she could see how the facility nursing staff would not be aware of the current plan of care.
During an interview on 08/22/2024 at 5:53 PM, the DON said medical records wereas responsible for uploading the hospice records into the residents' electronic health record. The DON said she was not aware the residents' hospice records were not up to date. The DON said it was important for the hospice records to be up to date to ensure they had the most recent plan of care, and they were doing what they needed to do.
During an interview on 08/22/2024 at 6:18 PM, the Administrator said she expected for the hospice records to be current in the residents' electronic health record. The Administrator said the hospice usually scanned them to the facility towards the end of the month. The Administrator said they received the hospice records monthly. The Administrator said she expected for the nurses to know they had the hospice records available to them, and LVN K probably did not know because she was new. The Administrator said the DON and the ADONs checked the hospice records to ensure they were kept up to date.
Record review of the Hospice Services policy dated 2/13/2007 indicated as an end-of-life measure, the resident or responsible family member may choose to use hospice services within the facility. Goals: 1. The resident and/or responsible party will verbalize wishes for end-of-life measures. 2. The resident and/or responsible party will receive comfort care. 3. The family will verbalize feelings about end-of-life measures Procedures .11. The DON or designee will be responsible for ensuring that documentation is a part of the current clinical record Hospice Plan of Care. 12. The nursing facility and hospice provider must ensure that a coordinated plan of care reflects the participation of the hospice, nursing facility, the recipient, and legal representative to the extent possible. 13. The plan of care must include directives for managing pain and other uncomfortable symptoms. The plan must be revised and updated as necessary to reflect the resident's current status.
Record review of the Amendment to Nursing Facility Hospice Services Agreement effective July 26, 2019, indicated, .Review and Revision of Plan of Care. The IDT, in consultation with Nursing Facility representatives and the Nursing Facility Attending Physician, shall review and revise the individualized Plan of Care as frequently as the Resident Patient's condition requires, but no less frequently than every fifteen (15) calendar days .2.7 Patient Care Information Provided. Hospice shall provide the Nursing Facility Designee with the following: (a) A copy of the most recent Plan of Care specific to each Resident Patient; (b) A copy of the Hospice election form and any advance directives specific to each Resident Patient; (c) A copy of the physician certification and recertification of the terminal illness specific to each Resident Patient; (d) Names and contact information for Hospice personnel involved in the hospice care of each Resident Patient; (e) Instructions on how to access the Hospice's twenty-four (24) hour on-call system; (f) A copy of Hospice medication information specific to each Resident Patient; and (g) A copy of Hospice physician and Attending Physician (if any) orders specific to each Resident .
Based on observation, interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 3 residents (Resident #11, Resident #15, and Resident #35) reviewed for hospice services.
The facility did not ensure Resident #11 and Resident #35 had the most current hospice plan of care.
The facility failed to obtain Resident #15's most current hospice certification and plan of care, nurse visit notes, and aide visit notes.
These deficient practices could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.
Findings included:
1. Record review of Resident #11's face sheet dated 08/21/2024 indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system).
Record review of Resident #11's Quarterly MDS assessment dated [DATE] indicated she sometimes was able to make herself understood and sometimes understood others. The MDS assessment indicated Resident #11 had a BIMS score of 7, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #11 received hospice care while a resident at the facility.
Record review of Resident #11's care plan last reviewed 07/25/2024 indicated she had a terminal prognosis and was receiving hospice services, and if receiving hospice services, to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs were met.
Record review of the Order Summary Report dated 08/21/2024 indicated Resident #11 had an order to admit to hospice for diagnosis of chronic obstructive pulmonary disease with a start date of 01/23/2024.
Record review of Resident #11's hospice Facility Document delivery indicated hospice documents were delivered 06/25/2024, and the last hospice Plan of Care in the documents was dated 06/18/2024. There were no plans of care for the month of July 2024 and August 2024.
2. Record review of a face sheet dated 08/21/2024 indicated Resident #35 was an 87- year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions).
Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #35 was understood by others and was able to understand others. The MDS assessment indicated Resident #35 had a BIMS score of 08, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #35 received hospice care while a resident at the facility.
Record review of Resident #35's care plan last reviewed 07/10/2024 indicated he had a terminal prognosis and was receiving hospice services, and if receiving hospice services, to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met.
Record review of the Order Summary Report dated 08/21/2024 indicated Resident #35 had an order to admit to hospice for diagnosis of Alzheimer's disease with a start date of 06/17/2024.
Record review of Resident #35's hospice Facility Document delivery indicated hospice documents were delivered 07/25/2024, and the last hospice Plan of Care in the documents was dated 07/23/2024. There were no plans of care for the month of August 2024.
During an interview on 08/21/2024 at 4:26 PM, the hospice nurse said the facility had requested for the hospice documents to be sent to them electronically. The hospice nurse said the hospice office was responsible for sending the residents hospice documents to the facility, and they were sent monthly. The hospice nurse said it was important for the facility to have the hospice documents for the facility to be up to date on the hospice plan of care.
During an interview on 08/22/2024 at 3:53 PM, LVN K said Resident #11 and Resident #35 received hospice services from the same company. LVN K said she was not able to view any of the hospice records. LVN K said she was able to communicate with the hospice nurse almost daily regarding the residents' care. LVN K said it was important for the facility to have access to the hospice records so they could give the correct medications and for continuation of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.
The facility did not ensure:
1. Food items were labeled and dated.
2. Hair restraints were worn.
3. The prepared green beans were not stored beside dirty dishes.
4. Volunteer XX wore a hair net and performed hand hygiene while assisting with preparing the appetizers prior to the lunch meal on 08/19/2024.
These failures could place residents at risk for foodborne illness.
Findings included:
During the initial tour observation and interview with the Dietary Manager on 08/19/2024 beginning at 8:28 a.m., the following was revealed:
1. The Dietary Manager, [NAME] R, Dietary Aide S hairnets were not covering their entire head. There was loose hair sticking out for all 3 of them.
2. The Dietary Dishwasher was in the kitchen without wearing a hair restraint.
3. Plastic storage bag that was identified by the Dietary Manager as bacon undated and unlabeled.
4. Plastic bag that was identified by the Dietary Manager as cherries unlabeled.
5. Plastic bag that was identified by the Dietary Manager as shrimp undated and unlabeled.
6. A bag of okra undated and unlabeled.
7. A bag of cherry pies unlabeled.
8. A bag of guacamole unlabeled.
9. A bag of Italian breaded zucchini sticks undated.
10. 2 bags of macaroni elbow pasta undated.
11. 1 bag of spaghetti undated.
12. A large pan of frozen green beans were stored on the prepping table by dirty dishes.
During an interview on 08/22/2024 at 2:50 p.m., Dietary Aide S stated all kitchen staff were responsible for labeling and dating food products. Dietary Aide S stated hairnets should always be worn while in the kitchen and hairnets were supposed to cover the entire head without loose hair sticking out. Dietary Aide S stated the cook was responsible for ensuring the food was stored correctly. Dietary Aide S stated these failures could put residents at risk for food borne illness and contamination.
During an interview on 08/22/2024 at 3:15 p.m., [NAME] U stated all kitchen staff were responsible for labeling and dating food products. [NAME] U stated hairnets should always be worn while in the kitchen and hairnets were supposed to cover the entire head without loose hair sticking out. [NAME] U stated the green beans should have been placed on the stove after prepping them. [NAME] U stated these failures could put residents at risk for food borne illness and contamination.
During an interview on 08/22/2024 at 3:40 p.m., the Dietary Manager stated cleanliness was important in the kitchen, so her staff were not spreading germs or contaminating anything. The Dietary Manager stated she was responsible for making sure the kitchen was cleaned appropriately. The Dietary Manager stated all food should be labeled and dated with the date received and the date it was opened. The Dietary Manager stated hairnets should be worn while in the kitchen and covering the entire head without loose hair sticking out. The Dietary Manager stated the cook should have placed the green beans on the stove after she prepped them. The Dietary Manager stated she was responsible for monitoring and overseeing by daily walk throughs and when there was an issue staff were verbally in serviced immediately. The Dietary Manager stated she had to address these issues in the past. The Dietary Manager stated these failures could potentially put residents at risk for cross contamination and food borne illness.
During an interview on 08/22/2024 at 6:26 p.m., the Administrator stated she expected all food to be labeled and dated. The Administrator stated she expected hairnets to always be worn and covering the entire head. The Administrator stated after the cook prepped the green beans, she should have placed them on the stove. The Administrator stated the Dietary Manager was responsible for monitoring and overseeing the kitchen. The Dietary Manager stated these failures could potentially put residents at risk for cross contamination.
4. During an observation on 08/19/24 beginning at 11:39 a.m., Volunteer XX was helping to prepare the appetizer in the main dining room. Volunteer XX was pouring ranch dressing into cups. Volunteer XX had no hair net and applied gloves without washing her hands or using alcohol-based hand sanitizer. Volunteer XX pulled the appetizer out of the oven and then placed more in the oven. Volunteer XX took her gloves off and did not perform hand hygiene.
During an observation on 08/19/2024 beginning at 11:46 a.m., Volunteer XX applied gloves without performing hand hygiene. Volunteer XX was holding her cell phone with gloved hands. Volunteer XX put the cell phone on the table with her gloved hands then took food out of the oven.
During an interview on 08/22/2024 beginning at 5:00 p.m., Volunteer XX stated she had been volunteering at the facility since 2015. Volunteer XX stated she was instructed by the facility to perform hand hygiene prior to applying gloves and applying a hair net prior to handling food. Volunteer XX stated she knew better she just did not do better. Volunteer XX stated she had taken food handler classes several times per year. Volunteer XX stated when she was asked to help, she just jumped in without thinking. Volunteer XX stated it was important to ensure hand hygiene was performed prior to putting on gloves or taking off gloves and putting on a hair net prior to handling the food to maintain food sanitation. Volunteer XX stated not wearing a hair net or washing hands was unsanitary.
During an interview on 08/22/2024 beginning at 5:59 p.m., the DON stated she expected the facility staff and volunteers to ensure a hair net was used when handling food and hand hygiene was performed prior to applying gloves. The DON stated activity and dietary staff were responsible for monitoring to ensure hair nets were used and hand hygiene was performed prior to handling food. The DON stated it was important to ensure a hair net was worn and hand hygiene was performed to prevent food contamination and maintain sanitation of the food.
During an interview on 08/22/2024 beginning at 6:51 p.m. the Administrator stated she expected volunteers to ensure hair nets were worn and hand hygiene was performed while preparing food. The Administrator stated the staff member in the dining room was responsible for monitoring to ensure a hair net was used and hand hygiene was performed. The Administrator stated it was important to ensure a hair net was worn and hand hygiene was performed to prevent cross-contamination and maintain food sanitation practices.
Record review of the facility's policy titled, Food Safety, dated 2012 indicated, .2. Opened food shall be labeled, dated, and stored properly .
Record review of the facility's policy titled, Infection Control, dated 2012 indicated, .1b. Clean hair is required. It is to be covered with an effective hair restraint .
Record review of the Texas Food establishment Rules, dated August 2021 indicated .TFER 228.43 states that food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. It does not apply to food employees such as counter staff who only serve TEXAS DEPARTMENT OF STATE HEALTH SERVICES DIVISION FOR REGULATORY SERVICES ENVIRONMENTAL AND CONSUMER SAFETY SECTION POLICY, STANDARDS, AND QUALITY ASSURANCE UNIT PUBLIC SANITATION AND RETAIL FOOD SAFETY GROUP PSRFSGRC - No.19 Hair Restraints April 1, 2016 (Revised February 21, 2017) Page 2 Public Sanitation and Retail Food Safety Group ? PO Box 149347, Mail Code 1987 ? [NAME], Texas 78714-9347 (512) [PHONE NUMBER] ? Facsimile: (512) [PHONE NUMBER] ? http://www.dshs.texas.gov/foodestablishments/ Pub #23 -14843 Rev. 02/21/2017 beverages and wrapped or packaged foods, hostesses, and wait staff if they present a minimal risk of contaminating exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles
Record review of the Texas Food establishment Rules, dated August 2021 indicated the container of ready-to-eat food shall be marked to indicate the date by which food shall be consumed on the premises, sold or discarded. The ready-to-eat food if held at 41°F can only be held for a maximum of 7 days, with day of preparation being day 1.
Record review of FDA 2-402.11, dated 2022, revealed FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE SERVICE and SINGLE-USE ARTICLES. The FDA further revealed in 5-501.17, Based on a predictive growth curve modeling program for Listeria monocytogenes, ready-to-eat, time/temperature control for safety food may be kept at 5oC (41oF) a total of 7 days. Food which is prepared and held, or prepared, frozen, and thawed must be controlled by date marking to ensure its safety based on the total amount of time it was held at refrigeration temperature, and the opportunity for Listeria monocytogenes to multiply, before freezing and after thawing. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 24 residents (Resident #40) and 2 of 2 staff (CNA NN and CNA YY) reviewed for infection control practices and transmission-based precautions.
1. The facility did not ensure Resident #40 was provided proper incontinent care.
2. The facility did not ensure EBP were put in place for Resident #40
These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the resident's quality of life.
Findings included:
Record review of Resident #40's face sheet, dated 08/21/2024, originally admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life).
Record review of the order summary report dated 08/21/2024 indicated Macrobid 100 mg give 1 capsule by mouth two times a day for UTI for 10 days with a start date 08/18/2024.
Record review of the quarterly MDS assessment, dated 08/06/2024, indicated Resident #40 made herself understood and usually understood others. Resident #40's BIMS score was 0, which indicated her cognition was severely impaired. Resident #40 was always incontinent of urine and bowel. Resident #40 required substantial/maximal assistance with toileting and partial/moderate assistance with personal hygiene.
Record review of the comprehensive care plan, revised on 08/20/2024, indicated Resident #40 had a urinary tract infection. The interventions included: encourage adequate fluid intake, and give antibiotic therapy as ordered.
Record review of the urine culture dated 08/12/2024 indicated Resident #40 was positive for a UTI with the organism Klebsiella pneumoniae (urinary tract bacteria).
During an observation on 08/19/2024 at 10:16 a.m., revealed Resident #40 had no enhanced barrier precautions in place outside of her room.
During an observation on 08/19/2024 at 3:10 p.m., revealed Resident #40 had no enhanced barrier precautions in place outside of her room.
During an observation on 08/20/2024 at 07:30 a.m., revealed Resident #40 had no enhanced barrier precautions in place outside of her room.
During an observation and interview on 08/19/2024 at 3:15 p.m., CNA NN provided incontinent care to Resident #40 without donning any PPE. CNA NN did not provide hand hygiene or apply hand sanitizer prior to donning (put on) gloves. CNA NN donned gloves and wiped Resident #40 peri area once without separating the inner labia (peri area). CNA NN continued providing incontinent care. CNA NN stated she should have performed hand hygiene before donning her gloves. CNA NN stated she should have wiped Resident #40's peri area once and got another wipe and wiped her again. CNA NN stated, I get nervous when someone watches me. CNA NN stated this failure put Resident #40 at risk for a UTI. When asked if PPE should be worn while providing care, CNA NN stated, no ma'am.
During an observation on 08/20/2024 at 9:45 a.m., CNA YY was getting Resident #40 out of the bed to give her a shower without donning any PPE.
During an interview on 08/21/2024 at 2:17 p.m. CNA YY stated she had performed incontinent care and given Resident #40 a shower. CNA YY stated she was not aware gown and gloves should be worn while providing care to Resident #40. CNA YY stated she was not informed that PPE should be worn. CNA YY this failure put residents at risk for spread of infection.
During an interview on 08/22/2024 at 2:58 p.m., ADON Y stated she was the Infection Control Preventionist for the facility. ADON Y stated she expected CNAs to perform hand hygiene prior to donning gloves. ADON Y stated she expected her to open her peri area and wiped front to back with a clean wipe each time until clear of soilage. ADON Y stated she monitored by monthly in-services, performance of skill check offs, and random checks while performing incontinent care on a resident. ADON Y stated she never had an issue with CNA NN providing incontinent care in the past. ADON Y stated this failure put Resident #40 at risk for a UTI. ADON Y stated Resident #40 should have had EBP in place when her labs showed positive for MDROs. ADON Y stated she was responsible for ensuring infection control measures were put in place for all residents. ADON Y stated she reviewed the lab results every morning to determine if they need to be on EBP precautions. ADON Y stated, I overlook the page that contained the MDROs positives. ADON Y stated this failure could place the residents at risk for an infection.
During an interview on 08/22/2024 at 6:26 p.m., the Administrator stated she expected staff to perform hand hygiene prior to donning gloves to prevent the spread of germs. The Administrator stated she expected staff to clean the peri area correctly. The Administrator stated ADON Y was responsible for monitoring and overseeing infection control practices.
Record review of a CNA Proficiency Audit dated 4/11/2024 indicated CNA NN was assessed in the area of hand washing, perineal care; female, and infection control awareness scoring a satisfactory in skill level.
Record review of the facility's policy titled, Perineal Care Female, revised 12/08/2009 indicated, .H. Wash hands and put on clean gloves for perineal care .Ib. separate inner labia (peri area) and using a different surface, wash down the center and over the urethral area, wiping downward from front toward back . c. continue to wash the rest of the perineal area Change the wash cloth or pre-moistened cleaning wipe surface or use a new washcloth or pre-moistened cleaning wipe with each wipe .
Record review of the facility's policy titled, Enhanced Barrier Precautions, effective 04/01/2024 indicated, .EBP is used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good hygiene for 1 of 3 residents (Resident #32) reviewed for ADLs.
The facility did not ensure Resident #32's fingernails were cleaned.
This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.
The findings included:
Record review of the face sheet, dated 08/22/2024, revealed Resident #32 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and dementia (group of symptoms affecting memory, thinking and social abilities that interfere with their daily lives).
Record review of the quarterly MDS assessment, dated 07/23/2024, revealed Resident #32 had clear speech and was usually understood by others. The MDS revealed Resident #32 was usually able to understand others. The MDS revealed Resident #32 had a BIMS score of 7, which indicated severe cognitive impairment. The MDS revealed Resident #32 had no behaviors or refusal of care. The MDS revealed Resident #32 required substantial/maximal assistance (helper does more than half the effort) with personal hygiene and shower/bathing.
Record review of the comprehensive care plan, revised 04/25/2024, revealed Resident #32 required assistance with ADLs and mobility needs. The interventions included: extensive assistance x 1 staff member for bathing and personal hygiene tasks.
Record review of the task documentation schedule for August 2024, revealed Resident #32 received bathing assistance on 08/20/2024.
During an interview and observation on 08/19/2024 beginning at 3:36 PM, Resident #32 had a thick black gooey substance under his fingernails. Resident #32 said he received a shower regularly by the facility staff. Resident #32 stated the staff would have completed his nail care tomorrow (08/20/2024) with his shower.
During an interview and observation on 08/20/2024 beginning at 9:02 AM, Resident #32 had a thick black gooey substance under his fingernails. Resident #32 said the facility staff had not performed nail care yet.
During an interview and observation on 08/21/2024 beginning at 8:04 AM, Resident #32 had a thick black gooey substance under his fingernails. Resident #32 said he received his bed bath yesterday (08/20/2024), but the staff could have forgotten to clean his nails.
During an interview on 08/22/2024 beginning at 2:45 PM, CNA RR stated she assisted Resident #32 with his bed bath on 08/20/2024. CNA RR stated she was helping out on the floor because the facility was short-staffed. CNA RR stated normally nailcare was completed with a bed bath or showers, but she forgot to go back and clean Resident #32's nails because she got busy. CNA RR stated it was important to make sure nail care was performed so the residents did not put their hands in their mouth which could spread or cause infection. CNA RR stated dirty fingernails were unsanitary.
During an interview on 08/22/2024 beginning at 5:59 AM, the DON stated CNAs were responsible for cleaning fingernails. The DON stated some residents go to pretty nails (an activity where nails were clean, painted, and trimmed) but most of the time nail care was performed during showers. The DON stated all staff were responsible for monitoring to ensure nail care was completed. The DON said unit managers perform daily champion rounds in which the staff looked for things like that specifically. The DON stated she was unsure who was responsible for completing champion rounds on Resident #32. The DON stated it was mostly administrative staff. The DON said it was important to ensure Resident #32's nails were kept clean to prevent infections from spreading and ensure sanitation.
During an interview on 08/22/2024 beginning at 6:14 AM, the Admissions Coordinator UU stated she performed champion rounds on Resident #32. The Admissions Coordinator stated Resident #32's hands were under the covers when she went into his room, so she did not notice his dirty fingernails. The Admissions Coordinator stated nail care was something that was looked at during champion rounds, but she did not ask Resident #32 to look at his fingernails.
During an interview on 08/22/24 beginning at 6:51 AM, the Administrator stated she expected nail care to have been completed by the facility staff. The Administrator stated nail care was performed during showers and as needed. The Administrator stated all staff were responsible for monitoring to ensure nails were cleaned. The Administrator stated performing nail care was important for infection control.
Record review of the Nail Care policy, undated, revealed Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury form scratching by fingernails or pressure of shoes on toenails .It includes cleansing, trimming, smoothing, and cuticle and is usually done during the bath .When performed at bath time, the nail care can be done following the procedure or as a separate procedure when needed at the convenience of the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for 4 of 6 residents (Residents #33, #40, #290, and #1) and prevent coffee burns for 1 of 2 residents (Resident #2) reviewed for accident hazards and supervision.
1.
The facility failed to prevent Resident #33 from eloping from the facility on 04/14/2024, 06/20/2024 and 06/21/2024.
2.
The facility failed to prevent Resident #40 from eloping from the facility on 08/09/2024.
3.
The facility failed to prevent Resident #290 from eloping from the facility on 06/13/2024.
4.
The facility failed to prevent Resident #1 from eloping from the facility on 07/13/2024.
5.
The facility failed to ensure Resident #2's coffee lid was placed properly which resulted in her spilling it on herself on 04/04/2024.
6.
The facility failed to ensure Resident #2 was served coffee in a cup with a lid on it, which resulted in her spilling it on herself on 06/09/2024.
An Immediate Jeopardy (IJ) situation was identified on 08/20/2024 at 4:15 p.m. While the IJ was removed on 08/21/2024, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.
These failures could place residents at risk of serious injury or harm.
The findings included:
1. Record review of Resident #33's face sheet, dated 08/21/2024, originally admitted to the facility on [DATE] with a diagnosis which included Alzheimer's (progressive disease that destroys memory and other important mental functions).
Record review of the quarterly MDS assessment, dated 08/12/2024, indicated Resident #33 made herself understood and understood others. Resident #33's BIMS score was 7, which indicated her cognition was severely impaired. Resident #33 had no behaviors or refusal of care.
Record review of the comprehensive care plan, revised on 12/26/2023, indicated Resident #33 was at risk for wandering and elopement. The interventions included: distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, redirect away from entrances and exits, monitor the location frequently and document the wandering behavior and attempted diversional interventions.
Record review of Resident # 33's Elopement assessment, dated 04/14/2024, 06/20/2024, and 06/21/2024, reflected Resident #33 was at risk for elopement.
Record review of the event nurse's note dated 04/14/2024 at 11:00 a.m., reflected Resident #33 followed another resident outside through the front door. Resident #33 was observed by a staff propelling in the front parking lot of the facility.
Record review of the event nurse's note dated 06/20/2024 at 2:10 p.m., reflected Resident #33 was found outside in the front parking lot. Resident #33 stated she really did not know where she was.
Record review of the event nurse's note dated 06/21/2024 at 9:00 p.m., reflected Resident #33 was found by a family member outside by vehicles approximately 50 feet from the entrance door.
2. Record review of Resident #40's face sheet, dated 08/21/2024, originally admitted to the facility on [DATE] with a diagnosis which included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life).
Record review of the quarterly MDS assessment, dated 08/06/2024, indicated Resident #40 made herself understood and usually understood others. Resident #40's BIMS score was 0, which indicated her cognition was severely impaired. Resident #40 had no behaviors or refusal of care.
Record review of the comprehensive care plan, revised on 08/09/2024, indicated Resident #40 attempted to elope and was found in the parking lot to the back of building. The interventions included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, supervise closely and make regular compliance rounds whenever residents in the room.
Record review of Resident # 40's Elopement assessment, dated 08/09/2024, reflected Resident #40 was at risk for elopement.
Record review of the event nurse's note dated 08/09/2024 at 8:41 a.m., reflected Resident #40 was observed rolling in her wheelchair outside in the parking lot around the building. Resident #40 stated she was going to see a friend at the hospital.
3. Record review of the face sheet, dated 08/20/2024, revealed Resident #290 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of Traumatic brain injury (head injury causing damage to the brain by external force or mechanism), unspecified dementia with agitation (group of symptoms affecting memory, thinking, and social abilities with excessive verbal or physical aggression that causes emotional distress and excess disability), schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and bipolar disorder with psychotic features (serious mental illness characterized by extreme mood swings).
Record review of the quarterly MDS assessment, dated 07/23/2024, revealed Resident #290 had clear speech and was usually understood by others. The MDS revealed Resident #290 was able to understand others. The MDS revealed Resident #290 had a BIMS score of 5, which indicated severely impaired cognition. The MDS revealed Resident #290 had disorganized thinking, which fluctuated. The MDS revealed Resident #290 had delusions, but no behaviors, wandering, or refusal of care. The MDS revealed Resident #290 used a manual wheelchair.
Record review of the comprehensive care plan, revised on 04/18/2023, revealed Resident #290 was at risk for elopement and wandering because of impaired safety awareness. The goals included: The resident will not leave facility unattended through . and The resident's safety will be maintained . The interventions included: Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes; Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate; and Monitor location frequently. Document wandering behaviors and attempted diversional interventions.
Record review of the elopement risk assessment dated [DATE], 06/12/2024, and 06/13/2024, revealed Resident #290 was at risk for elopement.
Record review of the event nurses' note, dated 06/13/2024, revealed Resident #290 exited out the front door of the building and was witnessed in the parking lot by vehicles. Resident #290 told staff she was going to work.
4. Record review of the face sheet, dated 08/20/2024, revealed Resident #1 was a [AGE] year-old male who initially admitted to the facility on [DATE] with a diagnosis of intracranial injury (head injury causing damage to the brain by external force or mechanism).
Record review of the quarterly MDS assessment, dated 07/29/2024, revealed Resident #1 had unclear speech and was usually understood by others. The MDS revealed Resident #1 was usually able to understand others. The MDS revealed Resident #1 had a BIMS score of 0, which indicated severe cognitive impairment. The MDS revealed Resident #1 had disorganized thinking, that fluctuated. The MDS revealed Resident #1 had no behaviors, wandering, or refusal of care. The MDS revealed Resident #1 used a wheelchair.
Record review of the comprehensive care plan, revised 07/15/2024, revealed Resident #1 was at risk for elopement and wandering. The goals included: The resident will not leave facility unattended . and The resident's safety will be maintained . The interventions included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate.; If the resident is exit-seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc.; Provide structed activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes.; . Resident redirected back into facility, educated on the dangers of being in parking lot and ongoing monitoring in place.
Record review of the elopement risk assessments dated 12/28/2023, 03/29/2024, 06/29/2024, and 07/13/2024 revealed Resident #1 was at risk for elopement.
Record review of the event nurses' note, dated 07/13/2024, revealed Resident #1 exited out the front door and was found, by a family member, sitting in his wheelchair behind an employee vehicle. Resident #1 stated he was enjoying the sunshine.
Record review of the facility's policy titled, Elopement Prevention, revised 10/27/2010 indicated, .every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement .2. All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team . Physical Plant .1. All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts .2. All others exit not considered fire exits will be locked when not occupied by staff members .3. All exit devices will be maintained by the manufacture's recommendations and function of each door device will be verified weekly and a log maintained .
During an observation on 08/19/2024 at 8:15 a.m., the front door had an automatic sliding door and no alarm had sounded upon entrance to the building. The facility was located on a busy highway.
During an interview on 08/19/2024 at 4:12 PM, LVN K said if a resident was a high risk for elopement, they redirected them. LVN K said interventions for residents at risk for elopement were redirecting them, and they had the two double doors before the door to exit that acted as an intervention to stop them. The double doors were not locked. LVN K said the door to the exit had a button you had to push for it to open, but it was not locked either. LVN K said it would be hard for a resident to reach the button in a wheelchair. LVN K said the door to the exit did not have an alarm. LVN K said they did not have a wander guard system or anything like it to put on the residents that wandered. LVN K said elopement risk assessments were completed on admission, every three months, and if a resident had an elopement attempt. LVN K said if a resident attempted to elope 1-2 times they would be moved to the secure unit.
During an observation on 08/20/2024 at 7:15 a.m., the front door had an automatic sliding door and no alarm had sounded upon entrance to the building. No staff members were observed in the lobby.
During an observation on 08/20/2024 beginning at 7:21 a.m., Resident #33 was wheeling herself down the B-Hall during breakfast time. The only staff member on the hallway was a housekeeper, who was in another resident's room cleaning. Resident #33 started from the nurses' station and slowly wheeled herself down to the therapy gym. Resident #33 wheeled herself around the therapy gym, then sat in the doorway wheeling herself back and forth.
During an interview on 08/20/2024 beginning at 9:38 a.m., the DON stated residents at risk for elopement, not on the secured unit, had no special monitoring. The DON stated the direct care staff were made aware of the residents at risk for elopement and were instructed to keep a close eye on them. The DON stated there were no set timeframes for monitoring the residents, they should have been monitored according to their judgment. The DON stated the facility did not use a wander guard system or alarms. The DON stated the facility tried to keep the double doors leading into the lobby closed and a staff member in lobby to slow residents who were at risk for eloping down. The DON stated if residents actually eloped, then the residents were redirected into the building. The DON stated if residents were not easily redirected, they were placed on the secured unit. The DON stated labs were ordered on a case-by-case basis to determine if an acute illness was causing wandering behaviors or if placement on the secured unit was necessary. The DON stated residents were placed on the secured unit pending labs. The DON stated after an elopement, residents were placed on 72-hour monitoring. The DON stated the IDT usually met after an elopement to discuss and update the care plan. The DON stated Resident #40 started wandering during the evening times. The DON stated Resident #40 was able to go outside without staff supervision as long as a staff member was sitting in the lobby. The DON stated Resident #40 was easily redirected into the building and 72-hour monitoring was performed. The DON stated she did not believe Resident #40 had been evaluated for the secured unit. The DON stated Resident #290 and Resident #33 had been on the secured unit previously but had to be taken out of the secured unit because they were having combative behaviors with other residents. The DON said there was no special monitoring in place for Resident #290 or Resident #33. The DON stated Resident #33 wandered constantly around the building and have instructed staff to ensure she was watched. The DON stated after Resident #290 and Resident #33 eloped they were placed on 72-hour monitoring. The DON was unsure if labs had been completed. The DON stated Resident #1 was able to wheel himself around the facility. The DON stated Resident #1 was probably at risk for elopement related to past attempts. The DON stated Resident #1 was placed on 72-hour monitoring and reeducated on the dangers of wandering outside. The DON stated the risk for residents eloping would depend on the time of the day, but they were at an increased risk for injury or elopement.
During an interview on 08/20/2024 beginning at 2:03 p.m., The Administrator stated the preventative measures put in place currently for residents at risk for elopement who do not reside on the secured unit included: staff monitoring and closing the double doors in the front lobby to slow the residents down. The Administrator stated she had been asking corporate to get the facility a locked keypad for the front door and it was supposed to have been a work in progress. The Administrator stated the facility did not have a wander guard system or alarms for the front door. The Administrator stated if a resident eloped the facility implemented 72-hour monitoring. The Administrator stated incident and accidents were reviewed regularly but she was unsure if any trends had been identified. The Administrator stated she asked for the door keypad around the time the resident elopements had started.
Record review of a printed screen shot, provided on 08/20/2024 with a time of 2:31 p.m., revealed the Administrator had asked the corporate office for a keypad entry and exit for the front door on 05/07/2024.
Record review of a printed copy, provided on 08/20/2024, revealed a submitted proposal on 05/23/2024 for a keypad entry and exit for the front door. The owner had not signed.
5. Record review of a face sheet dated 08/20/2024 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety (deterioration of memory, language, and other thinking abilities without behaviors), cerebral infarction (stroke), and glaucoma (eye disease that can cause vision loss or blindness).
Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 usually understood others and was usually able to make herself understood. Record review of the MDS assessment indicated Resident #2 had a BIMS score of 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #2 required supervision or touching assistance with eating, substantial/maximal assistance with toileting hygiene, and was dependent for showering/bathing and personal hygiene.
Record review of Resident #2's care plan last reviewed 07/25/2024 indicated Resident #2 was at risk of burns due to hot liquids with interventions which included coffee and other hot liquids should not be served if over 140 degrees, educational in-service was given to staff about making sure cup lid was on properly to prevent spillage, if hot liquid was spilled on self, staff should pour room temperature or lower temp liquid on the affected area of the resident, resident to use spill proof cup with lid for coffee, should be seated in upright position with table or overbed table when hot liquids were being consumed, and staff to provide observation and verbal assistance when resident had hot liquids.
Record review of the Order Summary Report dated 08/21/2024, indicated Resident #2 had an order for a fortified/enhanced diet, mechanical ground texture, regular consistency, and liquids by straw.
Record review of an Event Nurses' Note - Burn dated 04/04/2024 indicated Resident #2 was in the dining room and had a burn caused by coffee, tea, or other hot liquid to the left abdomen and left lower breast. Details of injury indicated she had an 8x9 cm red area, no blistering, slight pain to touch. Nursing Description of the event indicated, CNA stated she was bringing another resident to the dining room and resident was saying help me, when CNA went to her, she noted that her shirt was wet and the resident stated she spilled her coffee. Resident had her personal cup with lid. Unknown who fixed coffee for resident as she is not able. Resident Statement indicated, Resident stated that she did not know who got her coffee but the lid was not on it like it was supposed to be and she spilled it. Initial treatment/new orders indicated, No treatment at this time, will monitor and offered pain med and was refused. Interventions initiated by nurse indicated, Lid on cup/mug/glass. Signed by Treatment Nurse H.
Record review of an Injury Nurses' Note 12 hr dated 04/05/2024 12:09 AM, indicated Resident #2 had no injury.
Record review of an Event Nurses' Note - Burn dated 06/09/2024 indicated Resident #2 was in the dining room and had a burn caused by coffee, tea, or other hot liquid to the left breast and under left breast. Details of injury indicated she had a burn injury slightly red, approximately 4 cmx2 cm to under left breast and 6 cmx5 cm to left breast. Nursing Description of the event indicated, CNA observed residents blouse being wet, and when she checked she seen the redness underneath. Resident Statement indicated, Resident stated leave me alone. Initial treatment/new orders indicated Zinc oxide (ointment used for skin) BID x 3 days. Interventions initiated by nurse indicated, Lid on cup/mug/glass. Signed by LVN P.
Record review of an Injury Nurses' Note 12 hr dated 06/10/2024 12:43 PM, indicated Resident #2's redness related to the burn was gone.
During an observation on 08/20/2024 at 7:20 AM, Resident #2 was observed sitting in the dining room drinking coffee from a covered cup with a straw.
During an interview on 08/20/2024 at 7:44 AM, the Food Service Supervisor said Resident #2 was the only one who had spilled coffee on herself that she could think of, and she believed it was only once. The Food Service Supervisor said there had not been any further incidents after June 2024. The Food Service Supervisor said if the residents needed therapy ordered a spill proof cup, and Resident #2 required a spill proof cup for her coffee. The Food Service Supervisor said Resident #2 had to be served her coffee, but the residents that were able to, served themselves coffee. The Food Service Supervisor said they checked the coffee temperature daily and ensured it was at 140 degrees to prevent burns. The Food Service Supervisor said she monitored coffee was available during the day while kitchen staff were present.
During an interview on 08/20/2024 at 9:32 AM, LVN L said residents had access to coffee in the dining room all day. LVN L said residents were allowed to get coffee on their own. LVN L said Resident #2 required a special cup because she had spilled coffee on herself a couple of times, and the cup was needed to prevent future burns. LVN L said if she noticed a resident was having issues holding a cup, she would let the nurse manager know and they would get with therapy to get the devices the residents needed.
During an interview on 08/20/2024 at 9:56 AM, CNA O said the residents usually had coffee available to them all day. CNA O said the residents were able to get it themselves. CNA O said Resident #2 had a special cup for coffee that had a lid on it, and she was the only one that she knew of. CNA O said Resident #2 required the cup because her grip was not good, and to prevent her from spilling the coffee on herself and getting burned.
During an interview on 08/20/2024 at 10:01 AM, the DON said on 04/04/2024 when Resident #2 spilled coffee on herself Resident #2 said the lid was not on tight enough. The DON said Resident #2 was supposed to be using the cup with the lid on it at that point. The DON said she educated the staff to make sure the lid was properly secured to prevent spillage. The DON said she provided an in-service. The DON said they were unable to determine what degree burn she had gotten from the spilled coffee but there was redness, no blister, and had resolved by the next day. The DON said on 06/09/2024 when Resident #2 spilled coffee on herself Resident #2 did not have the coffee cup with the lid on it. The DON said Resident #2 was unable to get coffee herself that somebody had given it to her. The DON said the staff was reeducated again on ensuring Resident #2 had her special cup. The DON said the education was provided verbally and she did not have documentation of it. The DON said they were doing the coffee logs to ensure the coffee was at safe temperatures. The DON said there was not anything implemented to see if any of the other residents were at risk for burning themselves with hot liquids. The DON said they did not complete hot liquid assessments.
During an attempted phone interview on 08/20/2024 at 10:31 AM, LVN P did not answer the phone.
During an interview on 08/20/2024 at 2:04 PM, the Director of Rehab said they did not have a particular screen to assess residents for their abilities to handle hot liquids. The Director of Rehab said if they noticed or were told by the staff a resident was having issues feeding themselves or required adaptive equipment therapy would evaluate and address the need. The Director of Rehab said she believed when Resident #2 was burned she was already receiving occupational therapy and they ordered a cup with a lid for her.
During an interview on 08/20/2024 at 2:14 PM, the DON said the nurses should be assessing the residents needs for their abilities to feed themselves and on admission therapy screened the residents for any special needs.
During an interview on 08/22/2024 at 6:48 PM, the Administrator said Resident #2 did not want to sit still with her coffee, and they discussed getting her a cup that would assist with spills. The Administrator said residents were assessed by the nurses on a resident-by-resident case for their abilities to handle hot liquids. The Administrator said anytime there was a change of status the residents were supposed to be assessed. The Administrator said there was always a risk for an accident to happen.
Record review of the Coffee Temperature log for February 2024, March 2024, April 2024, June 2024, indicated the coffee temperature was 140° daily.
Record review of a Record of Inservice Education dated 04/04/2024 with a subject of Coffee cup for Resident #2 indicated, Resident #2 has a cup for coffee with a lid to help prevent spills. It is very important that you make sure lid is on correctly why you make her coffee.
Record review of the undated Guidelines on Serving Coffee in the Nursing Facility indicated, .3. Any residents who have risk factors for coffee burns, such as significant cognitive impairment or extreme shaking may be evaluated for additional safety precautions using a hot beverage risk assessment. Safety precautions may include but are not limited to additional supervision when consuming coffee, insulated or non-insulated coffee mugs with sippy lids, coffee service at lower temperatures, or restricted coffee availability .
This was determined to be an Immediate Jeopardy (IJ) on 08/20/2024 at 4:15 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 08/20/2024 at 4:19 p.m.
During an observation on 08/20/2024 at 5:00 p.m., the speed limit sign in front of the facility changes from 45 to 55 miles per hour.
During an observation on 08/21/2024 at 7:15 a.m., the front door had an automatic sliding door and no alarm had sounded upon entrance to the building.
During an interview and observation on 08/21/2024 beginning at 9:18 a.m., the Administrator was standing at the front door with a technician. The Administrator stated she had not realized the alarm system had not been functioning. The Administrator stated the technician had disabled the alarm system the last time he worked on it. The Administrator stated the technician was working on the system and adding another contact alarm that would alarm when the front door was opened. The doors had automatically slid open and the alarm had sounded. Beeping was heard at the nurse's station.
The following plan of removal submitted by the facility was accepted on 08/21/2024 at 4:27 p.m. and included the following:
Interventions:
1. On 8/20/24, Residents #33, Resident #1 and Resident #290 will be transferred to a sister facility for appropriate supervision. All 3 residents will be placed on 1:1 supervision until transferred. Both residents have been screened and do not meet the criteria to be placed on the secure unit. Other interventions such as alarms, increased staff, wander guards have been reviewed. All doors and alarms have been tested and are functioning properly. All doors with existing alarms were tested and in operation 8/20/24. Front door had an alarm installed the morning of 8/21/24 and will be monitored every shift.
2. On 8/20/24, Resident #40 will be transferred to the secure unit inside the facility.
3. Elopement risk assessments for all residents in the facility were completed and reviewed by the DON/ADON/Designee on 8/20/24. No additional concerns were identified.
4. All elopement risk care plan interventions were reviewed on 8/20/24 by the Regional Compliance Nurse, DON, and ADON. All interventions are in place and care planned.
5. The Administrator, DON, and ADON were in-serviced 1:1 by the ADO and Regional Compliance Nurse on 8/20/24 on the following:
A.
Elopement Prevention Policy- This in-service includes implementing interventions for residents at risk for elopement. - Completing the elopement risk assessment to determine at risk residents. This in-service also includes reporting to the Charge Nurse, Administrator, or DON any resident who is attempting to elope. The policy includes interventions to assist in preventing elopements, environmental modifications, and staff training.
B.
Elopement Response Policy- Nursing personnel must report and investigate all residents who attempt to elope. This includes when a resident is observed leaving the premises. A response plan will be implemented immediately. The resident's care plan will be modified to include interventions to prevent further elopement attempts.
C.
Abuse and Neglect- Neglect includes the failure to prevent, supervise, monitor, and/or intervene when a resident has eloped from the facility.
Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement.
o The Elopement Risk Assessment will be completed upon admission by the charge nurse. The assessment will be completed by reviewing the resident's medical history and social history. Information may be obtained by reviewing current medical records, if available, interview with resident/family, or conference with the interdisciplinary team member. The Elopement Risk Assessment is to be completed at least quarterly, after an elopement attempt, upon new exit seeking behavior, and upon change of condition. The Elopement Risk Assessment will be completed by the charge nurse or designee. The DON will be responsible for ensuring the completion and review of the assessment. This will begin 8/20/24.
o All residents who are at risk for elopement will be assessed by the interdisciplinary team. This will begin 8/20/24.
o The resident's care plan will be modified by the DON, MDS Coordinator, or designee to indicate the resident is at risk for elopement with appropriate interventions to prevent elopement attempts. This will begin 8/20/24.
6. Medical Director notified of the immediate jeopardy on 8/20/24.
7. An ADHOC QAPI meeting was conducted on 8/20/24 to discuss the immediate jeopardy citation and subsequent plan of correction.
In-services:
The Regional Compliance Nurse, Administrator, DON, and ADON will in-service all staff on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming scheduled shift.
A.
All staff were in-serviced on the Elopement Response Policy by the Compliance Nurse, Administrator and DON on 8/20/24. Nursing personnel must report and investigate all residents who attempt to elope. This includes when a resident is observed leaving the premises. A response plan will be implemented immediately. The resident's care plan will be modified to include interventions to prevent further elopement attempts.
B.
All staff were in-serviced on Elopement Prevention by Compliance Nurse, Administrator and DON on 8/20/24. This in-service includes implementing interventions for residents at risk for elopement. - Completing the elopement risk assessment to determine at risk residents. This in-service also includes reporting to the Charge Nurse, Administrator, or DON any resident who is attempting to elope. The policy includes interventions to assist in preventing elopements, environmental modifications, and staff training.
C.
All staff were in-serviced on Abuse and Neglect by the Compliance Nurse, Adm[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 1 resident (Resident #40) reviewed for incontinent care.
The facility failed to ensure Resident #40 was provided proper incontinent care.
These failures could place residents at risk for urinary tract infections and a decreased quality of life.
Findings included:
Record review of Resident #40's face sheet, dated 08/21/2024, originally admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life.
Record review of the quarterly MDS assessment, dated 08/06/2024, indicated Resident #40 made herself understood and usually understood others. Resident #40's BIMS score was 0, which indicated her cognition was severely impaired. Resident #40 was always incontinent of urine and bowel. Resident #40 required substantial/maximal assistance with toileting and partial/moderate assistance with personal hygiene.
Record review of the comprehensive care plan, revised on 08/20/2024, indicated Resident #40 had a urinary tract infection. The interventions included: encourage adequate fluid intake, and give antibiotic therapy as ordered.
Record review of the order summary report dated 08/21/2024 indicated Macrobid 100 mg give 1 capsule by mouth two times a day for UTI for 10 days with a start date 08/18/2024.
During an observation and interview on 08/19/2024 at 3:15 p.m., CNA NN provided incontinent care to Resident #40. CNA NN did not provide hand hygiene or apply hand sanitizer prior to donning (put on) gloves. CNA NN donned gloves and wiped Resident #40 peri area once without separating the inner labia (peri area). CNA NN continued providing incontinent care. CNA NN stated she should have performed hand hygiene before donning her gloves. CNA NN stated she should have wiped Resident #40's peri area once and got another wipe and wipe her again. CNA NN stated, I get nervous when someone watches me. CNA NN stated this failure put Resident #40 at risk for a UTI.
During an interview on 08/22/2024 at 2:58 p.m., ADON Y stated she was the Infection Control Preventionist for the facility. ADON Y stated she expected CNAs to perform hand hygiene prior to donning gloves. ADON Y stated she expected her to open her peri area and wipe front to back with a clean wipe each time until clear of soilage. ADON Y stated she monitored by monthly in-services, performance of skill check offs, and random checks while performing incontinent care on a resident. ADON Y stated she never had an issue with CNA NN providing incontinent care in the past. ADON Y stated this failure put Resident #40 at risk for a UTI.
During an interview on 08/22/2024 at 6:26 p.m., the Administrator stated she expected staff to perform hand hygiene prior to donning gloves to prevent the spread of germs. The Administrator stated she expected staff to clean the peri area correctly. The Administrator stated ADON Y was responsible for monitoring and overseeing appropriate peri care.
Record review of a CNA Proficiency Audit dated 4/11/2024 indicated CNA NN was assessed in the area of hand washing, perineal care; female, and infection control awareness scoring a satisfactory in skill level.
Record review of the facility's policy titled, Perineal Care Female, revised 12/08/2009 indicated, .H. Wash hands and put on clean gloves for perineal care .Ib. separate inner labia (peri area) and using a different surface, wash down the center and over the urethral area, wiping downward from front toward back . c. continue to wash the rest of the perineal area Change the washcloth or pre-moistened cleaning wipe surface or use a new washcloth or pre-moistened cleaning wipe with each wipe .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 2 residents (Resident # 5) reviewed for respiratory care.
The facility did not ensure Resident #5's oxygen concentrator was set at 2-4 liters per nasal cannula as ordered by the physician.
These failures could place residents requiring respiratory care at risk for shortness of breath, respiratory distress, or complications.
Findings included:
Record review of a face sheet dated 08/20/2024 indicated Resident #5 was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system).
Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #5 understood others and was able to make herself understood. The MDS assessment indicated Resident #5 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #5 required substantial/maximal assistance with toileting, dressing, and personal hygiene. The MDS assessment indicated Resident #5 received oxygen therapy while a resident at the facility.
Record review of Resident #5's care plan last reviewed on 05/26/2024 indicated she had chronic obstructive pulmonary disease with recurrent exacerbation and increase shortness of breath and coughing to give oxygen therapy as ordered by the physician.
Record review of the Order Summary Report dated 08/20/2024 indicated Resident #5 had an order for oxygen at 2-4 liters per nasal cannula every day and night shift with a start date of 11/25/2022.
During an observation and interview beginning on 08/19/2024 at 3:35 PM, Resident #5 was sitting in the dining room wearing oxygen via nasal cannula with her oxygen concentrator at her side. Resident #5 said she wore the oxygen all the time and it was supposed to be at 2 liters. Resident #5's oxygen concentrator was set at 1 liter. Resident #5 did not appear to be in respiratory distress. Resident #5 said CNA M had put the oxygen on her. The State Surveyor asked LVN K to check Resident #5's oxygen settings. LVN K said Resident #5's oxygen should be set at 2-4 liters. LVN K checked Resident #5's oxygen concentrator and said it was set incorrectly at 1 liter. LVN K adjusted the settings. LVN K said she did not know who had put the oxygen on Resident #5. LVN K said a nurse should put the oxygen on and set it correctly. LVN K said if the oxygen was not set per the physician's order Resident #5's oxygen level could get too low, or she could get short of breath.
During an interview on 08/19/2024 at 4:04 PM, CNA M said she had not applied the oxygen on Resident #5. CNA M said she had brought the oxygen concentrator to the dining room and Resident #5 had put it on herself. CNA M said the CNAs were allowed to help them put it on, but they could not adjust the settings. CNA M said she should have gotten the nurse to check the settings to ensure they were set properly. CNA M said it was her mistake, but she was in a rush. CNA M said Resident #5's oxygen being set below what was ordered could make it harder for Resident #5 to breathe.
During an interview on 08/22/2024 at 6:05 PM, the DON said the nurses were responsible for ensuring the residents oxygen was set per the physician's order. The DON said the CNA should have let the nurse know that Resident #5 needed oxygen so the nurse could have made sure that the settings were correct. The DON said Resident #5's oxygen being set lower than prescribed placed her at risk for not getting enough oxygen and suffocating.
During an interview on 08/22/2024 at 6:41 PM, the Administrator said she expected for the nurses to set the oxygen properly. The Administrator said CNA M had pushed the oxygen concentrator down to Resident #5 and had bumped it and had forgotten to tell the nurse to check the settings. The Administrator said the CNA should have told the nurse. The Administrator said the physician ordered the oxygen to be set at a specific level for a reason, so it needed to be set at the appropriate level.
Record review of the policy titled, Oxygen Administration, revised 03/21/2023, indicated, Oxygen therapy includes the administration of oxygen (O2) in liters/minute (I/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission for 3 of 26 residents (Resident's #29, #37, and #64) reviewed for physician services.
The facility failed to ensure Resident's #29, #37, and #64 were seen by a physician within the first 30 days of their skilled admission to the facility.
This failure could place the residents at risk for medical conditions not being identified, care needs not being met, and a decline in health status.
The findings included:
1. Record review of the face sheet, dated 08/22/2024, revealed Resident #29 was a [AGE] year-old male who admitted to the facility for skilled services on 05/26/2024 with a diagnosis of pneumonitis due to inhalation of food and vomit (aspiration pneumonia or lung infection). The face further revealed the Medical Director was Resident #29's primary physician and his primary payor was Medicare A.
Record review of the quarterly MDS assessment, dated 08/04/2024, revealed Resident #29's start date for the most recent Medicare stay was 05/26/2024 with no end date documented. The MDS revealed Resident #29 had clear speech and was understood by others. The MDS revealed Resident #29 was able to understand others. The MDS revealed Resident #29 had a BIMS score of 09, which indicated moderately impaired cognition.
Record review of the progress notes, dated between 05/26/2024 and 08/22/2024, revealed no progress note from the Medical Director had been completed for Resident #29.
Record review of the PA notes, dated between 05/26/2024 and 08/22/2024, revealed the PA completed visits for Resident #29 on 05/27/2024, 05/29/2024, 06/03/2024, 06/05/2024, 06/10/2024, 06/12/2024, 06/25/2024, 07/01/2024, 07/09/2024, 07/15/2024, 07/22/2024, 07/27/2024, 07/29/2024, 07/31/2024, 08/05/2024, 08/12/2024, and 08/19/2024.
During an interview on 08/22/2024 beginning at 10:53 AM, Resident #29 stated he was unsure if he had seen the Medical Director or the physician since he had admitted to the facility. Resident #29 stated he knew he had seen the PA.
2. Record review of the face sheet, dated 08/22/2024, revealed Resident #37 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of peritoneal abscess (infection of peritoneal cavity (inner wall of the abdomen)). The face sheet further revealed the Medical Director was her primary care physician and her primary payor source was Medicare A.
Record review of the quarterly MDS assessment, dated 07/09/2024, revealed Resident #37' start date of her most recent Medicare stay was 07/05/2024 with no end date documented. The MDS revealed Resident #37 had clear speech and was understood by others. The MDS revealed Resident #37 was able to understand others. The MDS revealed Resident #37 had a BIMS score of 09, which indicated moderately impaired cognition.
Record review of the progress notes, dated between 07/05/2024 and 08/22/2024, revealed no progress note from the Medical Director had been completed for Resident #37.
Record review of the PA notes, dated between 07/05/2024 and 08/22/2024, revealed the PA completed visits for Resident #37 on 07/09/2024, 07/11/2024, 07/15/2024, 07/17/2024, 07/22/2024, 07/24/2024, 07/29/2024, 07/31/2024, 08/05/2024, 08/12/2024, and 08/19/2024.
During an interview on 08/22/2024 at 2:33 PM, Resident #37 stated she did not remember if the Medical Director had made a visit.
3. Record review of the face sheet, dated 08/22/2024, revealed Resident #64 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of gastrointestinal bleed (bleeding inside the gastrointestinal tract). The face sheet further revealed the Medical Director was her primary care physician and her primary payor source was Medicare A.
Record review of the quarterly MDS assessment, dated 07/04/2024, revealed Resident #64's most recent Medicare stay started on 07/02/2024 and no end date was documented. The MDS revealed Resident #64 had clear speech and was understood by others. The MDS revealed Resident #64 was able to understand others. The MDS revealed Resident #64 had a BIMS score of 7, which indicated severely impaired cognition.
Record review of the progress notes, dated between 07/04/2024 and 08/22/2024, revealed no progress note from the Medical Director had been completed for Resident #64.
Record review of the PA notes, dated between 07/05/2024 and 08/22/2024, revealed the PA completed visits for Resident #64 on 07/09/2024, 07/15/2024, 07/22/2024, 07/29/2024, 08/05/2024, 08/12/2024, and 08/19/2024.
During an attempted interview on 08/21/2024 at 5:23 PM, the Medical Director did not answer the telephone. A brief message was left with a call back number.
During an interview on 08/22/2024 at 9:27 AM, the PA stated he completed all the visits for patients at the facility. The PA stated the Medical Director only saw patients if she was requested directly.
During an attempted interview on 08/22/2024 at 10:31 AM, the Medical Director did not answer the telephone. A brief message was left with a call back number. No return call upon exit of the facility.
During an interview on 08/22/2024 at 11:10 AM, LVN F stated the PA primarily handled the direct care of all the residents. LVN F stated the Medical Director only handled residents on hospice or if residents directly requested to see her. LVN F stated the Medical Director did not answer the phone well but if you sent her a text message, she would have responded timely.
During an interview on 08/22/2024 at 11:53 AM, the DON stated Medical Records were responsible for monitoring to ensure the Medical Director was performing the initial visits for skilled patients. The DON stated the physician visit notes would have been documented under the progress notes tab in the electronic medical records. The DON stated it was important to ensure the physician completed the initial visits for skilled residents, so the Medical Director knew what was going on with the residents and was involved with their care.
During an interview on 08/22/2024 beginning at 6:51 PM, the Administrator stated the Medical Director should have completed the initial assessment for skilled residents and then as requested. The Administrated stated the Medical Director left all other care to her PA. The Administrator stated she was unaware the PA was completing the initial visit and assessment for skilled residents. The Administrator stated Medical Records usually alerted staff if the initial visit was not being completed by the Medical Director. The Administrator stated the Medical Records were responsible for monitoring to ensure the Medical Director completed the initial visit for skilled patients. The Administrator stated it was important to ensure the physician was completing the initial visit on skilled patients to ensure she was kept in the loop and included in the care of her patients.
Record review of the Physician Services Guidelines, undated, revealed Frequency: A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 24 residents (Residents #24) and 1 of 1 facility reviewed for pharmacy services.
1. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation.
2. The facility failed to ensure Resident #24 medications were administered during the scheduled time.
These failures could place the residents at risk of not having medications available for use, drug diversion, not receiving their medications as ordered, and exacerbation of their disease processes.
Findings included:
1. During an observation and interview on 08/22/2024 starting at 2:58 PM, an observation was made of the controlled medications awaiting disposal. The controlled medications awaiting disposal were in a locked file cabinet in the DON's office. There were approximately 10 different controlled medications awaiting disposal in the DON's locked file cabinet in her office. The DON said controlled medications that needed to be disposed of were brought to her. The DON said when a controlled medication that needed to be disposed was brought to her, she made a copy of the narcotic count sheet and gave it to the Administrator. The DON said she was not keeping a log of the controlled medications awaiting disposal as they were brought to her. The DON said it was important to keep accurate reconciliation of the controlled medications awaiting disposal because they could get stolen or something.
During an interview on 08/22/2024 at 6:42 PM, the Administrator said the DON was responsible for ensuring the controlled medications awaiting disposal were reconciliated periodically. The Administrator said it was important to reconcile the controlled medications to ensure they were disposed of properly.
2. Record review of Resident #24's face sheet, dated 08/21/2024, originally admitted to the facility on [DATE] with a diagnosis which included hypothyroidism (thyroid gland does not produce enough thyroid hormone), hypertensive heart disease (high blood pressure that affect the heart) without heart failure, and unspecified protein-calorie malnutrition.
Record review of the order summary report dated 08/21/2024 indicated Resident #24 was ordered:
Pantoprazole 20 mg 1 tablet by mouth QD at 7:00 a.m.
Levothyroxine 100 mcg 1 tablet by mouth QD at 7:00 a.m.
Hydrochlorothiazide 12.5 mg 1 tablet by mouth QD at 8:00 a.m.
Refresh Tears Ophthalmic Solution Instill 2 drops in both eyes TID at 8:00 a.m.
Aspirin EC 81 mg 1 tablet by mouth QD at 8:00 a.m.
Multivitamin 1 tablet by mouth QD at 8:00 a.m.
Vitamin B12 1000 mcg 1 tablet by mouth QD at 8:00 a.m.
Lisinopril 20 mg 1 tablet QD at 8:00 a.m.
Metoprolol Succinate ER 24-hour 25 mg 1 tablet by QD at 8:00 a.m.
Procardia XL ER 24-hour 30 mg 1 tablet by mouth QD at 8:00 a.m.
MiraLAX Powder 3350 17 grams by mouth QD every 3 days at 8:00 a.m.
Record review of the Medication Administration Audit Report dated 08/21/2024 indicated Resident #24 received her medications on 08/18/2024 by LVN B as listed:
Pantoprazole 20 mg 1 tablet at 9:48 a.m.
Levothyroxine 100 mcg 1 tablet at 9:48 a.m.
Hydrochlorothiazide 12.5 mg 1 tablet at 9:48 a.m.
Refresh Tears Ophthalmic Solution at 9:48 a.m.
Aspirin EC 81 mg 1 tablet at 9:48 a.m.
Multivitamin 1 tablet at 9:48 a.m.
Vitamin B12 1000 mcg 1 tablet at 9:48 a.m.
Lisinopril 20 mg 1 tablet at 10:08 a.m.
Metoprolol Succinate ER 24-hour 25 mg 1 tablet at 10:08 a.m.
Procardia XL ER 24-hour 30 mg 1 tablet at 10:09 a.m.
Record review of the Medication Administration Audit Report dated 08/21/2024 indicated Resident #24 received her medications on 08/19/2024 by RN C as listed:
Pantoprazole 20 mg 1 tablet at 9:41 a.m.
Levothyroxine 100 mcg 1 tablet at 9:41 a.m.
Hydrochlorothiazide 12.5 mg 1 tablet at 9:41 a.m.
Refresh Tears Ophthalmic Solution at 9:42 a.m.
Aspirin EC 81 mg 1 tablet at 9:41 a.m.
Multivitamin 1 tablet at 9:42 a.m.
Vitamin B12 1000 mcg 1 tablet at 9:42 a.m.
Lisinopril 20 mg 1 tablet at 9:41 a.m.
Metoprolol Succinate ER 24-hour 25 mg 1 tablet at 9:41 a.m.
Procardia XL ER 24-hour 30 mg 1 tablet at 9:42 a.m.
MiraLAX Powder 3350 17 grams by mouth at 9:42 a.m.
During an interview on 08/20/2024 at 11:08 a.m., Resident #24 stated her medications were not always given on time. Resident #24 stated she preferred her medications to be given before or during breakfast. Resident #24 stated she noticed it only occurred with certain nurses but could not recall the names.
During an interview on 08/22/2024 at 10:04 a.m., LVN B stated medications that were scheduled at 7:00 a.m. should have been given between 6:00 a.m.-8:00 a.m. and the medications scheduled at 8:00 a.m. should have been given between 7:00 a.m.-9:00 a.m. LVN B stated, it's impossible to administer medications to 35 residents in a timely manner. LVN B stated this failure could potentially cause an accumulation of medications or adverse effect.
During a telephone interview on 08/22/2024 at 11:03 a.m., RN C stated medications that were scheduled at 7:00 a.m. should have been given between 6:00 a.m.-8:00 a.m. and the medications scheduled at 8:00 a.m. should have been given between 7:00 a.m.-9:00 a.m. When asked why the medications were not administered on time, RN C stated, I can't tell you, don't know if I got sidetrack or I charted late. RN C stated this failure could potentially cause an adverse effect.
During an interview on 08/22/2024 beginning at 5:41 p.m., the DON stated she expected medications to be administered one hour before or one hour after the scheduled time. The DON stated when a medication was given late the MD should have been notified. The DON stated was unaware of the medication administration audit report until the state surveyor intervention. The DON stated her and LVN F reviewed the dashboard on PCC daily to see if there was a green dot which indicated medications were administered or missed. The DON stated the dashboard did not indicate if the medications were administered late. The DON stated the failure of not administering medications on time were not following the physician's order and could cause interactions with other medications.
During an interview on 08/22/2024 at 6:26 p.m., the Administrator stated she expected the medications to be administered according to the schedule. The Administrator stated the DON, the ADONs, and the charge nurses were responsible for overseeing and monitoring. The Administrator stated this failure could potentially cause an adverse effect.
Record review of the facility's policy titled, Medication Administration Procedures, revised 10/25/2017 indicated, . 9. Defining the schedules for administering medications to maximize the effectiveness of the medication, prevent potential significant medication interactions such as medication-medication 20. The 10 rights of medication should always be adhered to . right time
Record review of the facility's policy from the Pharmacy Policy & Procedure Manual 2003 titled, Storage of Controlled Substance, did not address the storage, logging, or reconciliation of controlled substances awaiting disposal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the services provided or arranged by the facility, as outlined by the comprehensive care plan were provided by qualified persons in accordance with each resident's written plan of care for 1 of 21 residents sampled (Resident #33).
The facility NA applied a medication cream to bilateral buttocks of Resident #33 without qualifications to do so.
This failure could place residents at risk for not receiving appropriate care and treatment outlined in their comprehensive care plan.
Findings included:
Record review of Resident #33's face Sheet dated 07/05/23 indicated that resident was an 89year old female who originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses Dementia (decline in cognitive abilities), Heart failure (impaired heart blood pumping), chronic obstructive pulmonary disease (a lung disease that blocks the air flow making it difficult to breathe, and depression.
Record review of Resident #33's MDS dated [DATE] indicated that resident had a BIMS score of 8 (which indicated she had moderately impaired cognition). The MDS also indicated that Resident #33 required extensive assist of two staff for bed mobility, transfers, dressing, toileting, and total assist with bathing.
Record review of Resident #33's Care Plan revised on 02/24/23 indicated that resident required assistance with toileting due to resident had a foley catheter related to neurogenic bladder and bowel incontinence that required incontinent care. It also indicated that Resident #33 had actual impairment to skin integrity and facility was to administer medications per physician orders.
During an observation of incontinent care on 06/27/23 at 03:47 PM CNA L and NA K provided incontinent care for Resident #33. NA K applied a cream to Resident #33's left inner thigh and buttocks. When asked to see the cream that was applied, it was Clotrimazole & Betamethasone Dipropionate 1/0.05% cream.
During an interview with NA K on 06/28/23 at 02:25 PM she said she thought the cream that she applied to Resident #33's buttocks and inner thigh was a type of barrier cream that she had been placing on the resident for the last week to 2 weeks and it was given to her by the charge nurse. NA K said the charge nurse kept the medication and gave it to the nurse aides to use on Resident #33 when they provided incontinent care. NA K said she requested the barrier cream from the charge nurse and that's what the nurse gave her to apply on resident. NA K said her applying the cream not knowing what it was could cause problems, but when the nurse gave her something to apply on a resident, that was what she applied.
During an interview on 06/28/23 at 02:36 PM LVN M said a CNA or NA could basically apply non medicated or over the counter medications like barrier cream to residents. He said he gave Clotrimazole & Betamethasone Dipropionate 1/0.05% cream to the NA to apply to the Resident #33 on 06/27/23. LVN M said he should have been present when the NA applied the medication on the resident. LVN M said the biggest issue of allowing the NA to apply the medication to Resident #33 was the resident could have had an allergic reaction. LVN M said it was out of the NA's scope of practice to apply the prescription cream to the resident.
During an interview on 06/28/23 at 02:51 PM ADON D said a CNA or NA could only apply barrier cream and body lotion to residents. She said that a CNA or NA should not have been applying prescription medications to residents. ADON D said applying prescription medications was out of a CNA's or NA's scope of practice. She said the NA or CNA applying the medications could have placed Resident #33 at risk for adverse side effects, adverse reactions, and allergic reactions that may have occurred when the medication was applied.
During an interview on 06/28/23 at 03:00 PM the DON said the CNAs and NAs were only allowed to apply barrier cream to residents. The nurse should have applied the medication to the resident because that was out of a NA or CNA scope of practice. The DON said nurse knew better and all nurses were responsible for ensuring CNA or NA provide proper care. The DON said the nurse allowing a NA or CNA to apply prescription medication issue could have caused the NA to give too much medication or it could have caused an adverse reaction.
During an interview on 06/28/23 at 03:25 PM the Administrator said a CNA or NA should have only been allowed to apply over the counter barrier cream to residents. She said NA or CNA could not apply prescription medications to residents because they were not licensed. She said the failure could have caused the NA or CNA to apply medications to the incorrect areas or even could have caused Resident #33 to have an allergic or adverse reaction.
Record review of the Medication Administration Procedures revised 10/25/2017 indicated 1. All medications are administered by licensed medical or nursing personnel

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of living received services to maintain grooming and personal hygiene for 1 of 2 residents reviewed for ADLs (Resident #10).
The facility did not ensure Resident #10's contracted hands were free from odor and her fingernails trimmed.
These failures could place residents at risk for not receiving services/care and decreased quality of life.
Findings included:
Record review of a face sheet dated 07/28/2023 indicated Resident #10 was a [AGE] year-old female who originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of seizures (burst of uncontrolled electrical activity between the brain cells that causes temporary abnormalities with the muscle tone or movement) and dementia (a group of thinking and social symptoms that interferes with daily functioning) and contracture of left hand (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).
Record review of a comprehensive care plan dated 02/03/2017 with a revision date of 01/05/2023 indicated Resident #10 had an ADL self-care deficit. The care plan goal was to have Resident #10's ADL needs met with the interventions of total personal hygiene and bathing care provided by 1 staff member. The comprehensive care plan included an alteration in musculoskeletal status related to a left- and right-hand contracture. The care plan goal was to be free of any complications related to the contractures of both hands. The intervention included to keep Resident #10's fingernails short.
Record review of the Significant Change MDS dated [DATE] indicated Resident #10 usually was understood and usually understands others. The MDS indicated Resident #10's cognition was severely impaired. The MDS indicated Resident #10 had not refused care. The MDS indicated Resident #10 required extensive care of one staff with personal hygiene, and total dependence of one staff with bathing. The MDS indicated Resident #10 had an impairment on one upper extremity.
Record review of the nursing electronic medical record dated June 2023 did not indicate nursing provided Resident #10 with care to the bilateral hand contractures. The record only was marked with an X.
Record review of the ADL documentation record dated June 28, 2023, indicated Resident #10 received personal hygiene daily and was totally dependent.
During an observation on 06/26/2023 at 9:39 a.m., Resident #10 was sitting up in her chair in her room. Resident #10's fingernails on both hands were ½ inch long, the palm of her left hand had a brownish colored material and there was a foul odor coming from the hand.
During an observation and interview on 06/27/2023 at 8:33 a.m., Resident #10 hand contractures to her right and left hands. Resident #10's fingernails to both hands were ½ inches long and her hands had a foul odor. LVN E assisted Resident #10 with opening of her hands. LVN E said the nurse aides were responsible for ensuring Resident #10's hands were cleansed, and nails trimmed daily. LVN E said the nurses were responsible for monitoring for nail care while making their rounds.
During an interview on 06/28/2023 at 2:52 p.m., CNA N said she was responsible for ensuring Resident #10's fingernails were trimmed and her hands free of odors. CNA N said she needed the assistance of another staff member to complete the task. CNA N said she needed someone to help hold Resident #10's hand open was a reason she had not completed the personal hygiene task. CNA N said not cleaning Resident #10's hand could cause an infection and the long nails could make a sore in her hand.
During an interview on 06/28/2023 at 3:19 p.m., the Administrator said she expected the resident's nails to be trimmed. The Administrator said the hands should be cleansed to prevent infection and sores. The Administrator said the DON, and nurses were responsible for monitoring.
During an interview on 06/28/2023 at 3:34 p.m., the DON said nails should be trimmed ideally on shower days. The DON said the nurses were responsible for ensuring the nurse aides complete the personal hygiene tasks. The DON said she was unsure why Resident #10's personal hygiene to her hands was not completed. The DON said maceration, fungal infections, odors, and dignity issues could arise from not receiving personal ADL care.
Record review of a Nail Care policy dated 2003 indicated nail management was the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath .Goals 1. Nail care will be performed regularly and safely. 2. The residents will be free from abnormal nail conditions. 3. The resident will be free from infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs and as prescribed by the physician for 1 of 21 residents (Resident #77) reviewed for therapeutic diets.
The facility failed to ensure Resident #77 received finger foods as ordered by the physician.
This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity.
Findings included:
Record review of Resident #77's face sheet dated 06/28/2023 indicated she was a [AGE] year-old female with an original admission date of 01/27/2023 with the diagnosis of seizures (burst of uncontrolled electrical activity between the brain cells that causes temporary abnormalities with the muscle tone or movement) and dementia (a group of thinking and social symptoms that interferes with daily functioning).
Record review of the consolidated physician orders dated 02/17/2023 indicated Resident #77 was ordered a regular diet, with regular texture, regular consistency, finger foods for assisted dining.
Record review of the comprehensive care plan dated 01/30/2023 and a revision date of 02/17/2023 indicated Resident #77 had a potential risk for malnutrition and was provided a regular diet with finger foods. The goal was Resident #77 would maintain a stable weight and nutritional parameters with the intervention of offer diet as ordered by the physician. The care plan also indicated Resident #77 had an ADL self-care deficit. The intervention included to be provided limited assistance by one staff for meals.
Record review of an admission MDS dated [DATE] indicated Resident #77 was understood by others and was usually able to understand others. The MDS indicated Resident #77's cognition was severely impaired. The MDS indicated Resident #77 required limited assistance of one staff for eating.
During an observation, interview, and record review on 06/27/2023 at 7:48 a.m., Resident #77 was grabbing her oatmeal with her hands. The oatmeal was running down Resident #77's chain and onto her clothing. Resident #77's tray tag indicated she was to be served regular finger foods. The items listed on the tray tag were 1 hardboiled egg, toast, finger food cereal, and breakfast sausage. CNA H said they have spoken to dietary about receiving finger foods.
During an interview on 06/28/2023 at 1:38 p.m., the DM said Resident #77 was supposed to receive finger foods with her meals. The DM said Resident #77 should have received a boiled egg and dry cereal. The DM said oatmeal and scrambled eggs were not finger foods as they were served.
During an interview on 06/28/2023 at 1:45 p.m., the cook said she missed reading the tray tag and sent Resident #77 scrambled eggs and oatmeal instead of finger foods.
During an interview on 06/28/2023 at 2:00 p.m., ADON D said to her knowledge the assisted dining trays were not checked by a nurse. The ADON said not receiving finger foods could make Resident #77 feel embarrassed by eating eggs and oatmeal with her fingers.
During an interview on 06/28/2023 at 3:08 p.m., the DON said the cook should follow the tray ticket. The DON said Resident #77 could be bothered by eating oatmeal and scrambled eggs with her fingers instead of finger foods.
During an interview on 06/28/2023 at 3:15 p.m., the ADM said the nursing staff should be checking the trays for accuracy. The ADM said the DON was responsible for ensuring nursing monitored the trays for accuracy.
Record review of a Dietary Services Policy and Procedure dated 2012 indicated the policy was to ensure correct understanding and interpretation of therapeutic diets, all diets were ordered as stated in the Diet Manual. The physician will prescribe diets in accordance with the approved Diet Manual. A written order must appear on the medial record before the resident may be served. 5. Physicians will be asked to order only those diets appearing on the daily spreadsheet. If another diet is requested, the registered dietician will be contacted. The following list of commonly used diets included the regular diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3). Record review of a face sheet dated 6/28/2023 indicated Resident #12 was a [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of a stroke, and absence of the right toes (surgically removed).
Record review of the consolidated physician's orders dated June 28, 2023, indicated Resident #12 to cleanse arterial wound to left 2nd digit, great toe, and 5th digit with normal saline, pat dry and apply skin prep leave open to air.
Record review of the admission MDS dated [DATE] indicated Resident #12 could make himself understood and he understood others. Resident #12's cognition was moderately impaired. The MDS indicated Resident #12 required extensive assistance of one staff with bed mobility and toilet use, transferred and completed personal hygiene with limited assistance of one staff. The MDS indicated he was at risk for pressure injuries.
Record review of the comprehensive care plan dated 6/16/2023 indicated Resident #12 had a DTI to his left heel. The goal of the care plan was the pressure injury would heel and remain free of infection with the intervention of administer treatments as ordered.
During an observation and interview on 6/27/2023 at 9:08 a.m., the treatment nurse entered Resident #12's room and washed her hands. The treatment nurse with gloved hands removed the heel protector from Resident #12's left foot and then his sock. The treatment nurse then cleansed Resident #12''s DTI wound to his left heel with normal saline, then she removed her gloves and used hand sanitizer. The treatment nurse applied clean gloves and applied the skin prep to the DTI to the left heel. The treatment nurse then removed her gloves and exited the room. The treatment nurse did not use hand sanitizer or wash her hands prior to exiting the room. The treatment nurse returned to the room, washed her hands, applied gloves, and applied the kerlix to Resident #12's left foot. The treatment nurse said she should have sanitized her hands prior to exiting Resident #12's room to obtain the kerlix. The treatment nurse said not washing your hands or using hand gel could spread infection.
Record review of a hand hygiene check off dated 1/12/2023 indicated the treatment nurse was checked off on hand hygiene which included: (washing hands) wet hands with water, lather hands by rubbing them together with soap, scrub your hands for 20 seconds, rinse your hands well under clean running water, dry your hands using lean towel, turn the faucet off with dry paper towel. Hand hygiene (hand washing with hand sanitizer): apply product to the palm of the hand, rub hands together covering all surfaces until hands were dry, include areas around and under the fingernails. The form indicated she passed the check off. The check off was signed by the infection preventionist.
During an interview on 6/28/2023 at 3:15 p.m., the Administrator said she expected the treatment nurse to wash her hands or use hand sanitizer prior to exiting Resident #12's room. The Administrator said the infection preventionist was responsible for evaluating staff and infection control practices. The Administrator said the DON was responsible for the annual nursing check offs including wound care and hand hygiene. The Administrator said infection could spread when hands were not washed after resident care.
During an interview on 6/28/2023 at 3:33 p.m., the DON said not cleansing hands prior to exiting a resident room was a big thing. She said the treatment nurse should sanitizer her hands and change her gloves as much as possible. The DON said she was responsible for annual check offs of the nursing staff for hand hygiene practices. The DON said the infection preventions was responsible for the monitoring for more education related to hand hygiene practices.
2.Record review of the undated face sheet indicated Resident #2 was admitted on [DATE].
Record review of the physician's orders dated June 2023 indicated Resident #21 was an [AGE] year-old male with diagnoses that included: Dementia (progressive loss of intellectual functioning), and Cerebral Infarction (a disrupted blood supply and restricted oxygen to the brain).
Record review of the Care Plan dated 12/28/22 indicated Resident #21 required the assistance of 1 staff for bed mobility and transfer. The Care Plan indicated he was incontinent of bowel and bladder and wore briefs. Resident #21 had Dementia and a Cerebral Infarction.
Record review of the quarterly MDS dated [DATE] indicated Resident #21 had clear speech, usually understood others, and was usually understood by others. The MDS indicated he had severe cognitive impairment and required the extensive assistance of one staff for bed mobility and transfer. Resident #21 was always incontinent of bowel and bladder.
During an observation on 6/27/23 at 2:17 p.m., CNA B and CNA A performed incontinent care on Resident #21. CNA B began incontinent care with clean gloves and a basin with warm clean water that had clean washcloths in it. She grabbed a washcloth and wiped Resident #21's front perineal area, then discarded the dirty washcloth. She did not change her gloves, then reached into the clean water basin, grabbed a washcloth and rung water out of it over the basin. She wiped his front area again and discarded the washcloth. CNA B did this two more times without changing her gloves. She then got a dry washcloth and dried his front perineal area without changing her gloves. She then assisted Resident #21 to roll on his side by placing her dirty gloves on his right hip and upper right back. She removed and discarded her dirty gloves, washed her hands, and donned clean gloves. CNA B grabbed a washcloth out of the same basin, rung the water out over the basin, then wiped Resident #21's backside, folded the washcloth, wiped again and discarded the washcloth. She put her dirty gloves back into the water basin and grabbed a washcloth, rung it out and cleaned Resident #21's backside again. She repeated this three times. She then grabbed a dry washcloth and dried Resident #21's backside. At that time, she discarded her dirty gloves, washed her hands, and donned clean gloves. CNA B's gloves were not visibly soiled at any time during peri care.
During an interview on 6/27/23 at 2:29 p.m., CNA B said she did not change her dirty gloves before putting them in the clean water basin. She said when she did that, she contaminated the clean water. She said doing that could cause a risk of infection. She said she had also put her dirty gloves on Resident #21 to turn him and should have changed her gloves and washed her hands prior to touching him. She said she did not remember when her last incontinent care in-service was, but it had been in the last year. She said putting dirty gloves in a clean water basin and on a resident could cause spread of infection. She said she knew she was not supposed to put dirty gloves in a clean water basin or on a resident.
During an interview on 6/27/23 at 2:32 p.m., CNA A said she did not realize CNA B did not change her gloves before she put her dirty gloves in the clean water basin with the washcloths. She said she did not realize CNA B touched Resident #21 with dirty gloves. She said CNA B should have changed her gloves and washed her hands before touching the resident and before putting her hands in the clean water basin. She said what CNA B did was contamination and that presented a danger of infection control.
During an interview on 6/28/23 at 7:31 a.m., LVN C said she expected CNA's to change their gloves during peri care after any contact with feces, urine, or bodily fluids. She said gloves would be considered dirty after touching any of those things. She said if staff put dirty gloves, whether visibly soiled or not in a water basin with clean washcloths and water, it would contaminate the water basin and that could cause major issues with infection. LVN C said if you touched a resident with dirty gloves that would also have been potential for the spread of infection.
During an interview on 6/28/23 at 7:33 a.m., ADON D said she expected CNA's to change their gloves when they were soiled meaning they had touched something dirty, not necessarily visibly soiled. She said if a CNA had dirty gloves on and she put those gloves in a clean water basin with washcloths, she would have contaminated the water basin and washcloths. ADON D said if a CNA touched a resident with dirty/contaminated gloves that would also cause major infection control issues.
During a record review and interview on 6/28/23 at 9:27 a.m., the DON showed this surveyor the CNA Proficiency Audit for CNA B on 7/19/22. She said she was proficient with peri care and there were no problems with her competency. She said she had signed off that CNA B was proficient. The CNA Proficiency Audit included: Perineal care, Infection Control awareness including proper handwashing, preventing cross-contamination and Universal Precautions.
During an interview on 6/28/23 at 9:43 a.m., LVN E said she expected CNA's to change their gloves when they were contaminated or had touched something dirty. She said gloves did not have to be visibly soiled to need to change them. LVN E said if a CNA put dirty gloves in a clean water basin with wash cloths, she had contaminated the water basin and the washcloths. She said a CNA should not touch a resident with dirty gloves. LVN E said those things would cause a risk of infection, spread of infection, and could cause UTI's.
During an interview on 6/28/23 at 10:10 a.m., CNA F said she would change her gloves anytime they were contaminated, meaning touching anything considered dirty. She said gloves must be changed and hands washed when going from dirty to clean. CNA F said if the gloves were not changed you would contaminate whatever surface you touched. She said putting dirty gloves into a clean water basin or a resident would be risking the spread of infection.
During an interview on 6/28/23 at 10:16 a.m., CNA G said she had worked at the facility for one year. She said she was taught to change her gloves during peri care after wiping the resident's peri area. She said she would change her gloves before putting her hands in a clean water basin to get a clean washcloth and before touching a resident after wiping that resident. She said not changing gloves when going from dirty to clean could cause a risk of infection and spread of infection. She said she had her last skills check off less than a year ago, but she did not remember the date.
During an interview on 6/28/23 at 12:30 p.m., the DON said she expected CNA's to change their gloves during peri care when they were contaminated or when they had touched something, dirty whether or not gloves were visibly soiled. She said putting a dirty glove in a clean water basin would contaminate the clean water and the washcloths. She said CNA's should not touch residents with dirty gloves. She said dirty gloves can spread infection and contaminate what they came in contact with.
During an interview on 6/28/23 at 12:36 p.m., the Administrator said she expected CNA's to change their gloves anytime they were contaminated. She said if dirty gloves touched a resident or were put in a water basin it would be cross-contamination. She said that could cause an infection control problem.
During a record review and interview on 6/28/23 at 1:53 p.m., ADON D said CNA's learn when to change their gloves when they learn their skills and get their CNA certification. She showed this surveyor a Hand Hygiene Checkoff dated 2/10/22 for CNA B indicating she had met all expectations of hand washing. The Hand Hygiene Checkoff did not indicate when to change gloves. She said she had misdated the checkoff and it should have been 2/10/23.
Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 4 residents (Resident #33, Resident #21, Resident #12 and Resident #280) reviewed for infection control.
NA K did not change gloves and perform hand hygiene appropriately while performing the perineal care of Resident #33.
CNA B failed to change gloves and perform hand hygiene during incontinent care for Resident #21.
The treatment nurse failed to perform hand hygiene prior to exiting Resident #12's room.
The treatment nurse failed to perform hand hygiene while providing wound care to Resident #280.
These failures could affect all residents and place them at risk for infection.
The findings were:
1.Record review of Resident #33's face Sheet dated 07/05/23 indicated that resident was an 89year old female who originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses of Dementia (decline in cognitive abilities), Heart failure (impaired heart blood pumping), chronic obstructive pulmonary disease (a lung disease that blocks the air flow making it difficult to breathe, and depression.
Record review of Resident #33's MDS dated [DATE] indicated that resident had a BIMS score of 8 (which indicated she had moderately impaired cognition). The MDS also indicated that Resident #33 required extensive assist of two staff for bed mobility, transfers, dressing, toileting, and total assist with bathing.
Record review of Resident #33's Care Plan revised on 02/24/23 indicated that resident required assistance with toileting due to resident had a foley catheter related to neurogenic bladder and bowel incontinence that required incontinent care. It also indicated that Resident #33 had actual impairment to skin integrity and facility was to administer medications per physician orders.
During an observation and interview on 06/27/23 at 03:47PM NA K and CNA L entered Resident #33's room with hands already gloved. NA K and CNA L said they washed their hands prior to donning gloves. Both Aides talked to Resident #33 throughout the process. CNA L was on the left of Resident #33 and NA K was on the right side of Resident #33. NA K rolled Resident #33 to her left side to remove the dirty draw sheet from under resident. NA K then placed a clean draw sheet from under the resident. NA K placed wipes on the bed beside the resident to use. NA K removed a wet wipe from the wipe container and cleaned the left peri area and threw it in the trash at foot of Resident #33's bed. NA K then grabbed another wipe from the box using the same gloves and wiped the right inner peri area. She then threw the wipe in the trash. NA K pulled another wipe from the box using the same gloves and cleaned the middle peri area from front to back and threw the wipe in the trash. NA K then unstrapped the catheter from Resident #33's left thigh, pulled a wipe from the box with same gloves and wiped the catheter tubing from the resident away and threw the wipe in the trash. CNA L placed Resident #33's catheter back into the strap. NA K and CNA L rolled Resident #33 to left side and NA K pulled a wipe from the box and cleaned resident's buttocks. They rolled resident back on her back. NA K grabbed a box with cream with same gloves on and opened the tube. NA K then squeezed an unmeasured amount of cream into the gloved hand that she was using and applied the cream to Resident #33's left inner thigh. CNA L assisted NA K to turn resident to left side. NA K squeezed more cream into cream covered gloves and applied to Resident #33's buttocks. NA grabbed the clean brief and placed it on the bed. NA K then grabbed the cream, pulled a wipe out of box, cleaned the cream container with the wipe, placed it back in the box, and threw the wipe in the trash. NA K removed gloves for the first time during the entire process, walked out of the room, and retrieved clean gloves. NA K walked back into the room donning new gloves without hand hygiene. She then placed a new gown on Resident #33 and covered her up. CNA L and NA K removed all wipes and dirty linen, removed gloves, washed hands, and exited the room.
During an interview on 06/27/23 at 04:10PM CNA L said she thought she provided the proper peri care. She said she may have missed some steps or hand hygiene. CNA was asked if she should change her gloves when going from a dirty area of the body to a clean area and she said yes. CNA L said she was taught to change her gloves and use hand sanitizer when the gloves became visibly dirty. She said the failure in using proper hand hygiene and glove changes could place the resident at risk for infection.
During an interview on 06/27/23 at 04:15PM NA K said that she felt she did not do a good job. She said she should have gathered her supplies, extra gloves, extra bags, and pulled the wipes from the container and placed in a bag like she learned in school. NA K said she was checked off in school for peri care but had never been checked off at the facility. She said she knew the correct way to provide care but was in a hurry and had been doing what other CNAs she worked with had been doing. NA K said improper peri care could cause infection control issues.
During an interview on 06/28/23 at 02:54PM ADON D said CNAs and NAs should wash their hands before and after they glove, change gloves when they are torn or contaminated, and before touching a clean brief they should hand sanitize and place new gloves on to continue care. ADON D said the CNA and NA not providing proper hand hygiene could place all residents at risk for infection. She said she was responsible for ensuring the CNAs and NAs were providing the proper care. She said she normally provided proficiency checks annually. She said she taught the CNAs and NAs the proper way to provide care, but their forms do not go into detail.
During an interview on 06/28/23 at 03:04 PM the DON said CNAs and NAs should change gloves and sanitize between clean and dirty and apply new gloves. The DON said ADON D was responsible CNA and NA proficiency check offs. She said it was performed annually and ADON D does handwashing check off and peri care check offs often. The DON said the failure places Resident #33 and other residents at risk for infection and or worsening infection.
During an interview on 06/28/23 at 03:30PM the Administrator said she expected the CNAs and NAs to follow the infection control policy. She said they should not have touched anything with dirty gloves or gloves that had touched residents. The Administrator said ADON D was responsible for ensuring the NAs and CNAs provided care with proper handwashing and infection control. She said the failure could cause an increase in infections.
4.) Record review of Resident #280's face sheet dated 06/27/23, indicated she was an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #280's diagnoses included herpes zoster eye disease (commonly known as shingles, a viral infection of the nerve that supplies sensation to the eye surface, eyelids, forehead, and nose), delusional disorder (a type of serious mental illness called psychotic disorder), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar, dementia (a group of thinking and social symptoms that interfere with daily functioning).
Record review of Resident #280's quarterly MDS assessment dated [DATE], indicated she was sometimes understood and sometimes understood others. The MDS indicated Resident #280's had a BIMS score of 6, indicating she had severe cognitive impairment. Resident #280 required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene and was totally dependent on staff with bathing. The MDS indicated Resident #280 was at risk for pressure ulcers/injury. The MDS indicated Resident #280 had no unhealed pressure ulcers or injuries.
Record review of Resident #280's comprehensive care plan dated 06/21/23, indicated she had a stage 2 (sore that has broken through the top layer of the skin and part of the layer below) to right buttock with the goal for resident to be free of infection by/through the review date. The care plan interventions included to administer treatments as ordered and monitor for effectiveness.
Record review of Resident #280's order summary report dated 06/27/23, indicated she had an order to cleanse stage 2 to right buttock with normal saline, pat dry, apply collagen powder, cover with non-stick bandage, and secure with tape daily for wound healing with an order date of 06/26/23.
During an observation and interview on 06/26/23 at 01:46 PM, the Treatment Nurse entered Resident #280's room to provide treatment to her right buttock wound. During the procedure the Treatment Nurse did not perform hand hygiene after she cleansed Resident #280's wound and removed her gloves. The Treatment Nurse donned clean gloves and completed the treatment. The Treatment Nurse said she was responsible for providing proper wound care as well as performing hand hygiene. The Treatment nurse said failure to perform hand hygiene in between glove changes placed Resident #280 at risk for cross contamination and infection. The Treatment Nurse said she was nervous as to why she failed to perform hand hygiene in between glove changes. The Treatment Nurse said she had been checked off on wound care administration.
Record review of the Treatment Nurse's wound care skill competency evaluation indicated she had completed it on 07/13/22.
Record review of the Treatment Nurse's hand hygiene checkoff dated 01/12/23, indicated she had passed the skill evaluation.
During an interview on 06/28/23 at 01:57 PM, ADON O said she expected wound care to be performed as ordered and hand hygiene be performed after removing gloves and before donning clean gloves. The ADON said failure to perform proper hand hygiene could place Resident #280 at risk for cross contamination and infection. The ADON the person who was performing the wound care was responsible for ensuring proper hand hygiene was performed.
During an interview on 06/28/23 at 02:06 PM, the DON said she expected wound care to be done as ordered and proper hand hygiene performed to prevent infection. The DON said the Treatment Nurse should have performed hand hygiene after removing her gloves and prior to donning clean gloves. The DON said failure to perform hand hygiene before donning clean gloves placed Resident #280 at risk for wound infection.
During an interview on 06/28/23 at 02:20 PM, the Administrator said the Treatment Nurse should have performed hand hygiene in between glove changes and by not doing so placed Resident #280 at risk for infection. The Administrator said the Treatment Nurse was responsible for ensuring she performed proper wound care and hand hygiene.
Record review of a policy titled Nursing: Personal Care, Perineal Care dated 4/27/22 provided by the DON indicated:
Doffing and discarding of gloves are required if visibly soiled.
The policy did not indicate when to change gloves.
Record review of an Infection Control Plan Overview policy dated 3/2023 provided by the DON indicated:
The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice .
The intent of this policy is to assure that the facility develops, implements, and maintains an Infection Prevention and Control Program in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility .
Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination.
Implement PPE usage practices consistent with accepted standards of practice to reduce the spread of infections and prevent cross-contamination.
Record review of a Fundamentals of Infection Control Precautions, undated, provided by the DON indicated:
Hand Hygiene
Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene:
When hands are visibly soiled (hand washing with soap and water); Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) .
After contact with a resident's mucous membranes and body fluids or excretions
Before and after changing a dressing
After removing gloves .
After handling soiled or used linens, dressings, bedpans, catheters, and urinals .
Consistent use by staff of proper hygiene practices and techniques is critical to preventing the spread of infections .
The policy did not address when to change gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 21 residents (Residents #52) reviewed for reasonable accommodations.
The facility failed to ensure Resident #52's call light was accessible.
This failure could place residents at risk of injuries, health complications and decreased quality of life.
Findings included:
Record review of Resident #52's face sheet dated 06/27/23, indicated an [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #52''s diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).
Record review of Resident #52's care plan revised on 01/10/23, indicated he was at risk for falls due to confusion and unaware of safety needs. The care plan interventions included call light in easy reach, remind resident to call for staff assist when needed and answer call light promptly.
Record review of Resident #52's quarterly MDS assessment dated [DATE], indicated he rarely/never understood and rarely/never understood others. The MDS indicated Resident #52's BIMS score of 0, which indicated he had severe cognitive impairment. The MDS indicated Resident #52 required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Resident #52 was totally dependent on staff on locomotion and bathing.
During an observation on 06/26/23 at 02:19 PM, Resident #52 was lying in bed asleep. Resident #52's call light was hung on the wall and out of reach. Resident #52 was not interviewable.
During an observation on 06/27/23 at 02:12 PM, Resident #52 was lying in bed asleep. Resident #52's call light was hung on the wall and out of reach.
During an interview on 06/28/23 at 09:30 AM, the DON said the facility did not have a call light policy.
During an interview on 06/27/23 at 02:14 PM, NA K said the call lights should be close to the resident in case they need assistance. NA K said everyone was responsible for ensuring the call lights were within reach of the resident. NA K said Resident#52 was not mobile but he could move his hands. NA K said by not having his call light next to him he could be at risk for falls or be in pain. NA K did not know why Resident 52's call light was not within reach.
During an interview on 06/28/23 at 01:15 PM, LVN C said she expected the call lights to be within reach of the resident. LVN C said all staff were responsible for ensuring the residents had their call lights within reach. LVN C said by not having their call light within reach the resident could be choking, in pain, or have fallen and not be able to call for help.
During an interview on 06/28/23 at 01:57 PM, ADON O said she expected the residents to always have the call lights within reach. The ADON said everyone who entered the resident's room was responsible for ensuring the resident had their call light within reach. The ADON said not by having the call light within reach, the resident could have fallen or be in trouble and not be able to notify staff.
During an interview on 06/28/23 at 02:06 PM, the DON said she expected the call lights to be within reach of the resident. The DON said all staff was responsible for ensuring the call light were within reach of the resident. The DON said not having their call light within reach the resident could have fallen, fractured something, they might have an accident or needing to go to the bathroom.
During an interview on 06/28/23 at 02:20 PM, the Administrator said she expected the call lights to be answered timely and within reach. The Administrator said the CNAs and hall supervisor (ADONs) were responsible for ensuring the call lights were within reach of the resident when doing their rounds. The Administrator said not having their call light within reach the resident could not be able to call for help and not receive the attention they need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property and establish policies and procedures to report and investigate such allegations, for 1 of 20 residents reviewed for abuse. (Resident #77)
The facility failed to follow their policy when they did not report Resident #77's allegation of sexual assault on 4/10/2023 at 3:06 p.m. to HHSC.
This failure could cause residents to have continued abuse, sexual abuse, and neglect.
Findings included:
Record review of the facility's abuse policy dated 03/29/2018 indicated the resident has a right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. 4. Sexual abuse: non-consensual sexual contact of any type with a resident. Reporting: 3. Facility employees must report all allegation of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/2019.
a.
If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation.
b.
If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.
Record review of Resident #77's face sheet dated 06/28/2023 indicated she was a [AGE] year-old female with an original admission date of 01/27/2023 with the diagnosis of seizures (burst of uncontrolled electrical activity between the brain cells that causes temporary abnormalities with the muscle tone or movement) and dementia (a group of thinking and social symptoms that interferes with daily functioning).
Record review of the admission MDS dated [DATE] indicated Resident #77 was able to make herself understood, and she was usually understood others. The MDS indicated Resident #77 had severe cognitive impairment. The MDS in the section of Delirium indicated she had disorganized thinking. The MDS indicated Resident #77 had not demonstrated any physical, verbal, or other behavioral symptoms.
Record review of the comprehensive care plan dated 01/30/2023 indicated Resident #77 had a communication problem the intervention was to validate Resident #77's message by repeating aloud, use communication techniques to enhance interaction by allow Resident #77 adequate time to respond, do not rush, request feedback and clarification. The comprehensive care plan did not address any history of physical of sexual abuse by others in Resident #77's past. The comprehensive care plan did not address Resident #77's behaviors, delusions, or hallucinations.
Record review of a social history note dated 01/27/2023 was left blank in the areas of emotional and mental health, behavioral problems, history of mental illness, verbal or physically aggressive behaviors, sexually inappropriate behaviors, and socially inappropriate behaviors. The social history notes in the area of Trauma Informed Care indicated Resident #77 had no previously documented diagnosis, no Post-Traumatic Stress Disorder, she had not been in a situation that was extremely frightening, she had not witnessed any extremely frightening situation, or she had not had a close relationship with someone who experienced any extremely frightening situations.
Record review of a progress note dated 04/10/2023 at 3:06 p.m., the SW documented she was made aware Resident #77 had made a statement about men coming into her room and sexually assaulting her . The SW documented Resident #77 was confused as evidenced by her rambling semi-incoherently. The note indicated Resident #77 was asked if any men or women had been in to see her and she stated no. The note indicated the SW asked Resident #77 if she had said men came into her room and done something bad and Resident #77 said yes. The SW note indicated she asked Resident #77 what happened, and she stated paper over and over. Then the note indicated Resident #77 said brother and sister. The SW documented Resident #77 was not making statements. The note also indicated the SW asked Resident #77 if this occurred recently, or it had been a while and Resident #77 stated 3 years. The SW note indicated due to her BIMS (cognitive ability) score and her altered mental status, she will be evaluated by her nurse to ensure she is physically healthy.
Record review of the incident reports for the January 2023 to June 2023 there was not an incident report for Resident #77.
Record review of a progress note dated 04/10/2023 at 3:10 p.m., indicated LVN E assessed Resident #77. LVN E documented there were no further statements of an attack mentioned. LVN E documented she completed a head-to-toe assessment and there were no unusual marks noted, no complaints of pain, or distress.
During an interview on 06/27/2023 at 10:23 a.m., the SW indicated the Administrator notified her of Resident #77's allegation of sexual abuse. The SW said she interviewed Resident #77 concerning the allegation of men sexually assaulting her. The SW said Resident #77 was very confused, but denied anyone being in her room, but she said she could not get a clear answer if the allegation occurred in the past. The SW said she was a mandatory reporter, but she was unaware if this allegation was reported to HHSC. The SW said without reporting and investigating the abuse could continue to occur.
During an interview on 06/27/2023 at 10:29 a.m., the Administrator said she did not report Resident #77's allegation of sexual abuse to HHSC. The Administrator said she felt the sexual abuse occurred in the past. The Administrator said she did not feel Resident #77's statement was a current allegation. The Administrator said with any allegation of suspected abuse she would complete an investigation and report any suspected allegation of abuse. The Administrator said she had not notified the local police of Resident #77's allegation.
During an interview on 06/27/2023 at 2:57 p.m., LVN E said she was aware Resident #77 made an allegation to a NA . LVN E said she never heard the allegation directly from Resident #77, but she reported the NA's report of an allegation. LVN E said the NA no longer worked at the facility. An attempt was made to interview the NA but the provided phone number was disconnected
During an interview on 06/27/2023 at 3:29 p.m., the DON said she was aware of Resident #77's statement to the NA who reported to the Administrator the abuse coordinator. The DON said Resident #77 did not say anyone hurt her. The DON said Resident #77 was not offered any psychological therapy. The DON said not reporting abuse could cause depression, feel endangered, and could be harmful if abuse was continuing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 20 residents (Resident #77) reviewed for abuse and neglect.
The facility failed to report Resident #77's allegation of sexual assault on 4/10/2023 at 3:06 p.m. to HHSC.
This failure could cause residents to have continued abuse, sexual abuse, and neglect.
Findings included:
Record review of Resident #77's face sheet dated 06/28/2023 indicated she was a [AGE] year-old female with an original admission date of 01/27/2023 with the diagnosis of seizures (burst of uncontrolled electrical activity between the brain cells that causes temporary abnormalities with the muscle tone or movement) and dementia (a group of thinking and social symptoms that interferes with daily functioning).
Record review of the admission MDS dated [DATE] indicated Resident #77 was able to make herself understood, and she was usually understood others. The MDS indicated Resident #77 had severe cognitive impairment. The MDS in the section of Delirium indicated she had disorganized thinking. The MDS indicated Resident #77 had not demonstrated any physical, verbal, or other behavioral symptoms.
Record review of the comprehensive care plan dated 01/30/2023 indicated Resident #77 had a communication problem the intervention was to validate Resident #77's message by repeating aloud, use communication techniques to enhance interaction by allow Resident #77 adequate time to respond, do not rush, request feedback and clarification. The comprehensive care plan did not address any history of physical of sexual abuse by others in Resident #77's past. The comprehensive care plan did not address Resident #77's behaviors, delusions, or hallucinations.
Record review of a social history note dated 01/27/2023 was left blank in the areas of emotional and mental health, behavioral problems, history of mental illness, verbal or physically aggressive behaviors, sexually inappropriate behaviors, and socially inappropriate behaviors. The social history notes in the area of Trauma Informed Care indicated Resident #77 had no previously documented diagnosis, no Post-Traumatic Stress Disorder, she had not been in a situation that was extremely frightening, she had not witnessed any extremely frightening situation, or she had not had a close relationship with someone who experienced any extremely frightening situations.
Record review of a progress note dated 04/10/2023 at 3:06 p.m., the SW documented she was made aware Resident #77 had made a statement about men coming into her room and sexually assaulting her . The SW documented Resident #77 was confused as evidenced by her rambling semi-incoherently. The note indicated Resident #77 was asked if any men or women had been in to see her and she stated no. The note indicated the SW asked Resident #77 if she had said men came into her room and done something bad and Resident #77 said yes. The SW note indicated she asked Resident #77 what happened, and she stated paper over and over. Then the note indicated Resident #77 said brother and sister. The SW documented Resident #77 was not making statements. The note also indicated the SW asked Resident #77 if this occurred recently, or it had been a while and Resident #77 stated 3 years. The SW note indicated due to her BIMS (cognitive ability) score and her altered mental status, she will be evaluated by her nurse to ensure she is physically healthy.
Record review of the incident reports for the January 2023 to June 2023 there was not an incident report for Resident #77.
Record review of a progress note dated 04/10/2023 at 3:10 p.m., indicated LVN E assessed Resident #77. LVN E documented there were no further statements of an attack mentioned. LVN E documented she completed a head-to-toe assessment and there were no unusual marks noted, no complaints of pain, or distress.
During an interview on 06/27/2023 at 10:23 a.m., the SW indicated the Administrator notified her of Resident #77's allegation of sexual abuse. The SW said she interviewed Resident #77 concerning the allegation of men sexually assaulting her. The SW said Resident #77 was very confused, but denied anyone being in her room, but she said she could not get a clear answer if the allegation occurred in the past. The SW said she was a mandatory reporter, but she was unaware if this allegation was reported to HHSC. The SW said without reporting and investigating the abuse could continue to occur.
During an interview on 06/27/2023 at 10:29 a.m., the Administrator said she did not report Resident #77's allegation of sexual abuse to HHSC. The Administrator said she felt the sexual abuse occurred in the past. The Administrator said she did not feel Resident #77's statement was a current allegation. The Administrator said with any allegation of suspected abuse she would complete an investigation and report any suspected allegation of abuse. The Administrator said she had not notified the local police of Resident #77's allegation.
During an interview on 06/27/2023 at 2:57 p.m., LVN E said she was aware Resident #77 made an allegation to a NA . LVN E said she never heard the allegation directly from Resident #77, but she reported the NA's report of an allegation. LVN E said the NA no longer worked at the facility. An attempt was made to interview the NA but the provided phone number was disconnected
During an interview on 06/27/2023 at 3:29 p.m., the DON said she was aware of Resident #77's statement to the NA who reported to the Administrator the abuse coordinator. The DON said Resident #77 did not say anyone hurt her. The DON said Resident #77 was not offered any psychological therapy. The DON said not reporting abuse could cause depression, feel endangered, and could be harmful if abuse was continuing.
Record review of the facility's abuse policy dated 03/29/2018 indicated the resident has a right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. 4. Sexual abuse: non-consensual sexual contact of any type with a resident. Reporting: 3. Facility employees must report all allegation of : abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/2019.
a.
If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation.
b.
If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all alleged violations involving abuse or mistreatment were reported to the to the administrator of the facility and other State Survey Agency immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for 1 of 10 (Resident #1) residents reviewed for abuse and neglect.
NA A did not report immediately to the Administrator allegations of verbal abuse. NA A alleged she witnessed CNA E yell and scream at Resident #1 on 05/08/23 between 5:00 p.m. and 6:00 p.m. She did not report the verbal abuse to the facility until 05/09/23.
This failure could place residents at risk of emotional, physical, and mental abuse.
Findings included:
Record review of a face sheet dated 05/11/23 indicated Resident #1 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included COPD (group of diseases that cause airflow blockage and breathing-related problems), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) affecting right dominant side , anxiety (a feeling of fear, dread, and uneasiness), depression (serious mood disorder), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
Record review of an MDS dated [DATE] indicated Resident #1 had a BIMS score of 6 (severe cognitive impairment). Resident #1 required extensive assist of 1 staff for dressing and eating.
Record review of a care plan dated 04/14/23 indicated Resident #1 had ADL Self-Care deficit. Interventions included resident required extensive assist for personal hygiene and dressing. She required limited assist for eating.
Record review of a skin assessment dated [DATE], completed by LVN H indicated Resident #1's cheek had 3 dark spots brown in color.
During an interview on 05/10/23 at 12:30 p.m., the Administrator said NA A did not report CNA E yelled at or verbally abused Resident #1 on 05/08/23. She said when she became aware of the incident on 05/09/23, CNA E was not working but was suspended pending the facility investigation. She said NA A was also suspended but had told the SW she quit before the completion of the investigation. She said NA A should have reported the verbal abuse immediately in order to protect the residents.
During an interview on 05/10/23 at 1:50 p.m., Resident #1's family member said on 05/08/23 NA A let her know CNA E was in Resident #1's face yelling at her. She said the door to the room was open because Resident #1 preferred the door open. She said NA A went from across the hall just as CNA E was leaving Resident #1's room. She said the next day on 05/09/23, HA C asked NA A how Resident #1 got bruises on her face and asked if she had fallen. She said HA C reported the bruises to the hospice agency. She said the facility was not aware of the incident on 05/08/23. She said another family member was at the facility on 05/08/23 and there were no bruises. She said LVN G and LVN H looked at Resident #1 and said there were no bruises.
During an interview on 05/10/23 at 2:30 p.m., HA C said she arrived in Resident #1's room after 2:00 p.m. on 05/09/23 to give her a bath. She said she noticed what looked like bruises on Resident #1's face. She said NA A had gone into Resident #1's room. She said she asked NA A if Resident #1 had fallen. NA A said there was something else going on and showed her the picture of Resident #1 being naked with a red dress hanging off her right shoulder. She said she recognized it as the dress she had put on Resident #1 after her bath on 05/08/23. She said Resident #1 had no bruises on 05/08/23. She said she reported the bruises to LVN G and to her direct supervisor. She said her supervisor told her to report to the state. She said she reported to the state (there was no intake #) She said the hospice nurse came out and assessed Resident #1 and there were no bruises. She said the facility nurse and the hospice nurse said the bruises were age spots.
During an interview on 05/10/23 at 3:00 p.m., the Administrator said she became aware of the allegations of verbal and physical abuse at 4:30 p.m. on 05/09/23. She said she received a call from Resident #1's hospice agency. She said she reported the allegation of abuse to the state on 05/09/23 at 6:59 p.m. She said CNA E was off work and not in the building at the time she was made aware of the allegations. She said CNA E was immediately suspended pending the investigation. She said NA A quit prior to the completion of the investigation. She said CNA E reported Resident #1 hollered out due to spilling ice cream. She said CNA I and NA A were in a room with another resident when NA A left the room to see what was going on and CNA E was in the hallway. She said CNA I did not confirm NA A's allegation. She said there had been no complaints about CNA E. CNA E denied the allegations. She said HA C did not report the allegation of the bruises to her (the Administrator) as she should have but she did report to the charge nurse.
During observation and interview on 05/10/23 at 3:18 p.m., Resident #1 was sitting on her bed in a hospital gown. She had age spots on her face. There were no bruises on her face. She said she was fine when asked how she was doing. Her speech was not clear and concise. She did not respond to questions with appropriate answers.
During an interview on 05/11/23 at 9:52 a.m., NA A said on 05/08/23 between 5:00 p.m. and 6:00 p.m., she was assisting CNA I to transfer another resident across the hall from Resident #1. She said she heard CNA E yelling you are going to have to wait a minute and you have it all over you. She said she went out of the room across the hall from Resident #1's room and CNA E slammed Resident #1's door. She said CNA E said she could not deal with Resident #1 because she had spilled melted chocolate ice cream all over the place. NA A said she went into Resident #1's room and found her distraught, half-clothed, and crying. She said that was when she took the picture of Resident #1 half-clothed. She said CNA J knew she (NA A) was mad about how CNA E treated Resident #1. She said CNA J said CNA E was something else. She said she was off work on 05/09/23 but went to the facility to pick up her check. She said after she got her check, she went to visit with Resident #1. She said HA C asked her (NA A) about the bruises on Resident #1's face and if she had fallen. She said she started taking more pictures of Resident #1's face. She said HA C said she was going to report the bruises to the facility nurses and her supervisor. She said she left the facility. She said she did not report the verbal abuse or that she took pictures while she was at the facility. She said she called the facility on 05/09/23 to speak with the DON but the DON was busy. She said she talked to the SW and told her about the pictures. She said the SW sent her an email and she sent a return email with the pictures and her statement. She said CNA E was loud with the residents all the time and had a bad attitude. She said everyone said that was just how she (CNA E) is. She said she was trained on abuse, neglect, and reporting. She said she was trained on resident rights and privacy. She said she should have reported CNA E was screaming in Resident #1's face immediately to the charge nurse and the administrator. She said she did not report immediately because she was gathering evidence. She said she felt she had to gather evidence because she reported staff for not doing their job previously and felt she was treated poorly by the facility.
Record review of NA A statement sent to the SW on 05/09/23 at 7:03 p.m. indicated the following: CNA I and I (NA A) were in (another resident's room) getting ready to transfer when we heard a scream. I pulled the privacy curtain back and could see CNA E yelling in Resident #1's face. I leave CNA I with the other resident to see what's going on and when I am walking across the hall CNA E came out slamming the door saying how she can't deal with Resident #1. Resident #1 had spilled her ice cream on herself. She (CNA E) always talks about how hard Resident #1 is to deal with. When I walked in the room Resident #1 was half naked, crying, and distraught. I started cleaning her up and CNA E came back with a completely different attitude. She started helping me change Resident #1 and talking sweet to her. It was past 6 pm already and my shift had ended. The next day I go to pick up my check and walk in to see how Resident #1 is doing and her hospice nurse (HA C) was asking her (Resident #1) where she got the bruises on her face from. I asked her (HA C) where she saw them and she pointed them as I took the pictures. The hospice nurse (HA C) was there the day before giving Resident #1 a bed bath and there were no bruises then. Before I left I heard CNA E say I and (another resident) are gonna fight tonight. I have attach pictures from when her hospice nurse (HA C) was pointing out the bruises. There are bruises on each cheek and on her nose.
During an interview on 05/11/23 at 10:40 a.m. CNA I said she had started doing a transfer of another resident with NA A across the hall from Resident #1. She said CNA E was in the hallway. She said CNA E came in and took over the transfer and NA A left the room. She said she never heard CNA E yelling and did not hear any door slam. She said she left the room across from Resident #1's room and saw both NA A and CNA E in Resident #1's room. She said it looked like they were changing the bed. She said Resident #1 had covers around her. She said no one reported any yelling or bruises. She said staff are not supposed to take pictures of the residents. She said all allegations of abuse should be reported to the charge nurse or the administrator immediately.
During an interview on 05/11/23 at 11:12 a.m. SW B said she talked to NA A on 05/09/23 because the DON was busy. She said she told NA A the facility was reporting bruising on Resident #1 and that was when NA A told her (SW) about what occurred on 05/08/23. She said NA A called CNA E a nut job. She said NA A said she was in the resident's room across the hall from Resident #1 and heard yelling. She said she left that room and went to Resident #1's room and pulled the privacy curtain aside and saw CNA E yelling and screaming in Resident #1's face because Resident #1 had spilled ice cream on herself. She said when CNA E saw her (NA A), CNA E said I am done. I can't. I can't. and left Resident #1's room. The SW said she asked NA A what she did next, and NA A said she took a picture of Resident #1 and a picture of the wipes on the floor. She said NA A said she got some wipes and continued to clean Resident #1. She said NA A told her CNA E returned and her attitude had changed, like she knew she did something wrong. She said NA A said CNA E said, I can do this and they both cleaned up Resident #1. She said NA A said it was close to 6:00 p.m. and she left the facility as it was the end of her shift. She said NA A went to the facility on [DATE] around 2:00 p.m. to pick up her check. She said NA A said she went down to visit with Resident #1 and HA C asked where the bruises on Resident #'s face came from. She said NA A told HA C what had happened the previous evening on 05/08/23. The SW said she texted NA A on 05/09/23 and asked for the pictures. She said NA A sent her the pictures via email on 05/09/23. The SW said she told NA A she should have reported immediately. She said NA A said, she was gathering evidence.
During an interview on 05/11/23 at 11:40 a.m., the DON said she was notified by hospice on 05/09/23 that HA C said Resident #1 had bruises on her face. She said HA C reported to the nurses the bruises were not there the day before (05/08/23). She said the nurses assessed Resident #1, and she assessed Resident #1 and there were no bruises on her face or body. She said LVN G reported HA C said there was bruises and she (LVN G) assessed Resident #1 and there were no bruises. She said hospice reported a disgruntled employee at the facility was telling HA C that staff would fight with Resident #1.
During an interview on 05/11/23 at 11:59 a.m., CNA E said she was collecting the dinner trays on 05/08/23 between 5:00 p.m. and 6:00 p.m. She said Resident #1 had spilled her chocolate ice cream. She said Resident #1 was upset and hollering. She said she asked Resident #1 what was going on. She said Resident #1 appeared to not hear very well and she had to speak loud and clear. She said she was not screaming in Resident #1's face. She said Resident #1 would get upset if there was a mess. She said staff had to stay calm when Resident #1 got upset. She said Resident #1 kept repeating it was a mess. She said she gathered the tray and left the room. She said NA A had come in the room and she (CNA E) said she was going to get some wash clothes. She said NA A made the statement I'll do it and grabbed the wipes because the wipes were closer. She said NA A had a look on her face but she did not know what the issue was. She said NA A was new and did not take criticism or suggestions. She said she did not see any bruises on Resident #1. She said she was trained on abuse and neglect. She said she would report immediately to the charge nurse or administrator. She said staff were not supposed to take pictures of residents with their cell phones.
During an observation and interview on 05/11/23 at 12:30 p.m., Resident #1 was sitting in her bed. She laughed and made a face when asked if staff were mean or yelled at her. She called her mattress a horse. There were no suspicious bruises on her face.
During an interview on 05/11/23 at 1:20 p.m., LVN G said HA C came to the nurse station on 05/09/23 and reported Resident #1 had bruises on her face. She said she assessed Resident #1 and said there were age spots but there were no bruises. She said she immediately reported HA C's concerns of bruises on Resident #1's face to the DON.
Record review of the facility's Abuse/Neglect policy dated 03/29/18 indicated The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .Reporting: 1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse or neglect must report this to the DON, administrator, state, and/or adult protective services. 2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee must make an immediate report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were treated with dignity and respect for 1 of 10 (Resident #1) reviewed for resident rights.
NA A took a photograph of Resident #1 sitting on her bed in a state of undress, with breast area, abdomen, and legs exposed.
This failure could place all residents at risk of not being treated with dignity and respect.
Findings included:
Record review of a face sheet dated 05/11/23 indicated Resident #1 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included COPD (group of diseases that cause airflow blockage and breathing-related problems), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) affecting right dominant side , anxiety (a feeling of fear, dread, and uneasiness), depression (serious mood disorder), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
Record review of an MDS dated [DATE] indicated Resident #1 had a BIMS score of 6 (severe cognitive impairment). Resident #1 required extensive assist of 1 staff for dressing and eating.
Record review of a care plan dated 04/14/23 indicated Resident #1 had ADL Self-Care deficit. Interventions included resident required extensive assist for personal hygiene and dressing. She required limited assist for eating.
During an interview on 05/10/23 at 12:30 p.m., the Administrator said she became aware of the pictures after she received a call from Resident #1's hospice agency on 05/09/23. She said NA A should not have taken the pictures of Resident #1.
During an interview and record review on 05/10/23 at 1:50 p.m., Resident #1's family member said NA A took pictures and provided them as evidence of how CNA C treated Resident #1. The family member said NA A discovered Resident #1 naked on 05/08/23 and took pictures. Record review of a photo provided by a family member of Resident #1, taken by NA A, revealed Resident #1 was sitting on her bed. She was holding an empty chocolate ice cream cup and spoon in her left hand. Her red robe was hanging off her right shoulder and she was pointing at the empty ice cream cup. Her breast area, abdomen, and legs were exposed. She had no other clothes or pants on and appeared naked except for an incontinent brief. She appeared upset. She was not smiling.
During an interview on 05/10/23 at 2:30 p.m., HA C said she arrived in Resident #1's room after 2:00 p.m. on 05/09/23 to give her a bath. She said NA A had come into Resident #1's room. She said NA A showed her the picture of Resident #1 being naked with a red dress hanging off her right shoulder. She said she recognized it as the dress she had put on Resident #1 after her bath on 05/08/23.
During observation and interview on 05/10/23 at 3:18 p.m., Resident #1 was sitting on her bed in a hospital gown. She said she was fine when asked how she was doing. Her speech was not clear and concise. She did not respond to questions with appropriate answers.
During an interview on 05/11/23 at 9:52 a.m., NA A said she was close to the family of Resident #1 and had sent them the pictures she had taken. She said on 05/08/23 between 5:00 p.m. and 6:00 p.m., she was assisting CNA E to transfer another resident across the hall from Resident #1. She said she heard CNA E yelling you are going to have to wait a minute and you have it all over you. She said she came out of the room across the hall from Resident #1's room and CNA E slammed Resident #1's door. She said CNA E said she could not deal with Resident #1 because she had spilled melted chocolate ice cream all over the place. NA A said she went into Resident #1's room and found her distraught, half-clothed, and crying. She said that was when she took the picture of Resident #1 half-clothed. She said she called the facility on 05/09/23 to speak with the DON but the DON was busy. She said she talked to the SW and told her about the pictures. She said the SW sent her an email and then she sent a return email with the pictures and her statement.
During an interview on 05/11/23 at 11:12 a.m. SW B said she talked to NA A on 05/09/23 because the DON was busy. She said NA A told her (SW) about what occurred on 05/08/23. She said NA A called CNA E a nut job. She said NA A said she was in the resident's room across the hall from Resident #1 and heard yelling. She said she left that room and went to Resident #1's room and pulled the privacy curtain aside and saw CNA E yelling and screaming in Resident #1's face because Resident #1 had spilled ice cream on herself. She said when CNA E saw her (NA A), CNA E said I am done. I can't. I can't. and left Resident #1's room. The SW said she asked NA A what she did next and NA A said she took a picture of Resident #1 and a picture of the wipes on the floor. She said NA A said it was close to 6:00 p.m. and she left the facility as it was the end of her shift. She said she texted NA A on 05/09/23 and asked for the pictures. She said NA A sent her the pictures via email on 05/09/23.
During an interview on 05/11/23 at 11:59 a.m., CNA E said she was collecting the dinner trays on 05/08/23 between 5:00 p.m. and 6:00 p.m. She said Resident #1 had spilled her chocolate ice cream. She said Resident #1 was upset and hollering. She said she asked Resident #1 what was going on. She said Resident #1 would get upset if there was a mess. She said staff have to stay calm when Resident #1 gets upset. She said Resident #1 kept repeating it was a mess. She said she gathered the tray and left the room. She said NA A had come in the room and she (CNA E) said she was going to get some wash clothes. She said NA A made the statement I'll do it and grabbed the wipes because the wipes were closer. She said staff were not supposed to take pictures of residents with their cell phones.
Record review of the facility's Resident Rights policy signed and dated by NA A on 03/21/23 indicated . Respect and Dignity-the resident has the right to be treated with respect and dignity, .Privacy and Confidentiality-The resident has a right to personal privacy .
Record review of the facility's Employee Handbook Acknowledgment form dated and signed by NA A on 03/29/23 and the Employee Handbook revised 09/20/19 indicated Personal Communication Devices-Use of personal communication devices during scheduled work hours is not permitted at the facility. These devices include but are not limited to cell phones . The facility prohibits the use of any type of cell phone camera, digital camera, video camera, or other form of image-recording device without the express permission of the facility and of each person whose image is recorded. the phone may not be used in the resident area or used in an unprofessional manner.
Reviewed Resident Right's policy dated 11/2021 reflected: The Resident has a right to be treated with dignity, courtesy, consideration, and respect.
Record review of the facility's Videotaping, Photographing, and other imaging of Residents policy dated 2001 (revised 04/17) indicated Residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities. Policy Interpretation and Implementation-1. For the purpose of this policy, resident image means the likeness of a resident though photography, videotaping, digital imaging, scans, audio recordings, etc. 2. Staff may not take or release images or recordings of any residents without the explicit written consent. Written consent must be obtained from the resident or representative prior to obtaining images or recordings of the resident for any purposes other than investigation of abuse, neglect, or emergencies, and photography obtained for personal/family use at the verbal request of the resident or family.