ROSE TRAIL NURSING AND REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care within 48 hours of the residents' admission for 2 of 2 residents (Resident #1, Resident #2). The facility failed to ensure Resident #1, and Resident #2 had a baseline care plan.This failure could place residents at risk for not communicating appropriate treatment and services to meet their needs.Findings included: A Review of the physician's orders and face sheet dated [DATE] indicated Resident #1was a 58 -year-old female who admitted on [DATE] with diagnoses including acute respiratory failure, unspecified lack of coordination, scabies, urinary tract infection bacteremia muscle weakness, schizophrenia, borderline intellectual functioning, anemia, atrial fibrillation, mood disorder, pressure ulcer, rhabdomyolysis, acute kidney failure, Systemic inflammatory response syndrome, hyperkalemia, hyperlipidemia and hypertension. A review of Resident #1 quarterly MDS section C dated [DATE], revealed a BIM score of 05 (Brief Interview for Mental Status) score of 5 indicates severe cognitive impairment. Record review of Resident #1's care plans, there were none initiated since admission on [DATE] did not document, develop or implement any current diagnosis, care level, any measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a phone interview on 10/14/2025 at 10:20 AM with a daughter of resident #1, she said she has not had a care plan meeting with the facility. During an observation and interview on 10/14/2025 at 11:00 AM, Resident #1 was resting in her bed. Sher was awake with some noticeable confusion, she was totally dependent on staff for ADL's, room was clean without any odors noted she said she was going to be going back to her hometown to another facility which was closer to her family. She said she knew that the social worker was contacting the other facility to help get her transferred. During an interview on 10/14/2025 at 12:18PM, the administrator and the Social Worker both said they were not aware of issues of residents #1 & #2's care plans, and the MDS nurses were responsible for these, and the DON should have overseen that the care plans were completed appropriately and timely. Both admitted the care plans were an issue due to transition of interim DON and new MDS Nurse who was out sick and only been with the facility for a couple of weeks. The administrator said they were addressing this issue in the daily morning meetings to be informed of changes to be care planned but did not know what happened. During an interview on 10/14/2025 at 2:00 PM, the ADON said the care plans were the responsibility of the MDS Nurse (RN) she was an LVN, and it is the responsibility of the RN. A Review of the physician's orders and face sheet dated [DATE] indicated Resident #2 was a 63 -year-old male who admitted on [DATE] and re-admitted on [DATE] with hypertension, Dementia, severity with other Behavioral Disturbance, lack of Coordination, abnormal posture difficulty in walking, not elsewhere classified, unsteadiness on feet, muscle weakness, cerebral infarction, type 2 diabetes with diabetic neuropathy, anxiety disorder, altered mental status, shortness of breath, constipation, hemiplegia and hemiparesis, skin changes, pressure ulcer of sacral region, stage 3, disorders of ear, bilateral, candidiasis, dry eye syndrome. A review of Resident #2 quarterly MDS section C revealed a BIM score of 10 (Brief Interview for Mental Status) score of indicates moderately cognitive impairment. Record review of Resident #2's care plans, there were none initiated since admission on [DATE] did not document, develop or implement any current diagnosis, care level any measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During an interview on 10/13/2025 at 12:30 PM resident #2 was observed up in his specialized wheelchair, with hydraulics up high in air, he did not response to verbal stimuli with first attempt, after much encouragement he responded and stated he had no current issues with the facility. During an interview on 10/14/2025 at 12:18PM, the administrator and the Social Worker both said they were not aware of issues of residents #1 & #2's care plans, and the MDS nurses were responsible for these, and the DON should have overseen that the care plans were completed appropriately and timely. Both admitted the care plans were an issue due to transition of interim DON and new MDS Nurse who was out sick and only been with the facility for a couple of weeks. The administrator said they were addressing this issue in the daily morning meetings to be informed of changes to be care planned but did not know what happened. During an interview on 10/14/2025 at 2:00 PM, the ADON said the care plans were the responsibility of the MDS Nurse (RN) she was an LVN, and it is the responsibility of the RN. Record review of an undated care planning policy dated March 2022 indicated the care planning/interdisciplinary team shall develop a comprehensive care plan for each resident. The policy indicated a comprehensive care plan included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs which shall be developed for each resident. The policy indicated implementation included the resident's comprehensive care plan was to be developed within 7 days of the completion of the resident's comprehensive MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

**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, are reported immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 2 of 7 (Resident #1 and Resident #2) residents reviewed for abuse and neglect.<BR/>The facility did not report the allegations of verbal and physical abuse of Resident #1 and Resident #2 by CNA B to the state agency.<BR/>This failure could place residents at risk of injuries, abuse, and/or neglect.<BR/>Findings Include:<BR/>1. Record review of the face sheet orders dated 8/08/23 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including dementia, abnormalities of gait and mobility, amputation of right and left leg below the knee, muscle weakness, lack of coordination, and anxiety.<BR/>Record review of the MDS dated [DATE] indicated Resident # 1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 12 and was moderately cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility. The MDS did not indicate Resident #1 used limb prosthesis (artificial device that replaces a missing body part) for mobility.<BR/>Record review of the care plan last updated 7/14/23 indicated Resident #1 had an ADL self-care deficit with interventions including resident requires 1 staff member to assist with transfers and resident requires 1-2 staff members to assist with bed mobility. <BR/>Record review of a complaint intake worksheet in TULIP dated 8/07/23 indicated the complainant had witnessed abuse and neglect at the facility.<BR/>Record review in TULIP on 8/08/23 indicated there was not a facility report regarding abuse for Resident #1.<BR/>During an interview on 8/08/23 at 11:17 a.m. RN A said she started at the facility in 2023. RN A said the weekend of August 4-6th she had witnessed abuse to Resident #1. RN A said the CNA B had asked her to help get Resident #1 up about 7:00 a.m. RN A said Resident #1 was a double amputee and needed assistance with his prosthetics. RN A said Resident #1 could not hold his legs up at the same time as he was a large man. RN A said she got one prosthetic on and CNA B was trying to put on the other prosthetic and Resident #1 could not lift his leg. RN A said the CNA B slapped the Resident #1's leg, cursed at him, and referred to him as an idiot. RN A said she asked CN B to leave the room and she finished putting the other prosthetic on for Resident #1. RN A said she reported the incident to the DON and was informed to call the Administrator. RN A said she called the Administrator and left a message regarding the alleged abuse and had to leave him a message. RN A said she called the Administrator back on Monday and left another message. RN A said she had not heard back from the Administrator and reported the incident to the state agency.<BR/>During an interview on 8/08/23 at 11:24 a.m. Resident #1 said there might have been an issue over assisting him with putting his prosthetic legs on over the weekend. Resident #1 said if someone had cussed him he would not have heard it because he chooses not to hear those words and said he does not know those type of words. Resident #1 said the surveyor would have to ask the staff about what happened and he was not saying anything.<BR/>During an interview on 8/08/23 at 12:53 p.m. the DON said CNA B had been suspended on 8/08/23 pending investigation of abuse allegation. The DON said the abuse allegation was involving Resident #1 and happened over the weekend of August 4-6, 2023. The DON said she had been notified by RN A on 8/05/23 of the alleged abuse by CNA B to Resident #1. DON said she advised the RN A to contact the Administrator who was the Abuse Coordinator. The DON said she never told the Administrator of the alleged abuse because she was under the impression RN A had reported to him.<BR/>During an interview on 8/08/23 at 12:54 p.m. the Administrator said CNA B had been suspended on 8/08/23 pending investigation of alleged abuse of Resident #1. The Administrator said he had spoken to RN A on 8/08/23 regarding the allegation of abuse. The Administrator said RN A had called and left him messages stating she need to speak with him. The Administrator said he was not aware she needed to speak with him regarding an abuse allegation. <BR/>Record review on 8/11/23 in TULIP indicated the allegation of abuse of Resident #1 by CNA B had not been reported to the state agency by the facility.<BR/>2. Record review of the face sheet dated 8/11/23 indicated Resident #2 was a [AGE] year-old woman admitted to the facility on [DATE] with diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis), muscle weakness, lack of coordination, and glaucoma (an eye condition where the nerve connecting the eye to the brain is damaged, usually due to high eye pressure, and can cause blindness)<BR/>Record review of the MDS dated [DATE] indicated Resident #2 usually understood others and was usually understood by others. The MDS indicated Resident #2 had a BIMS of 13 and was cognitively intact. The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene.<BR/>Record review of the care plan dated 6/12/23 indicated Resident #2 had a potential for an activities of daily living self-care performance deficit. <BR/>Record review of a grievance dated 7/13/23 indicated the Social Worker form Resident #2's dialysis center reported to the facility that Resident #2 informed the dialysis center that CNA B had cursed her and pulled her leg causing pain. The grievance indicated the facility's resolutions were to have Resident #2 be a two-person transfer, not have CNA B provide care to Resident #2, and refer to psych services to ensure she is psychosocially and emotionally stable. <BR/>During an interview on 8/11/23 at 3:06 p.m. the DON said she was aware of the allegation of abuse made by the dialysis center's Social Work against CNA B. The DON said CNA B was working the date of 7/13/23 and completed her entire shift. The DON said since Resident #2 was at dialysis CNA B was not a threat to her pending investigation. The DON said CNA B's shift had ended and she was not at the facility when Resident #2 returned from dialysis. The DON said CNA B was permitted to return to work the next day (7/14/23) as it was determined no abuse occurred during the investigation.<BR/>During an interview on 8/11/23 at 3:17 p.m. Resident #2 said the incident on 7/13/23 had been taken care of by the facility. Resident #2 said CNA B no longer provided care for her. Resident #2 said she needed assistance with sitting up and transferring. Resident #2 said CNA B would drop her legs and let them fall to the floor via gravity and not provide her support for sitting upright when transferring her. Resident #2 said CNA B called her a heifer. <BR/>During an interview on 8/11/23 at 3:26 p.m. the Administrator said the grievance filed on 7/13/23 regarding CNA B and Resident #2 would be considered an allegation of abuse. The Administrator said Resident #2 was interviewed upon her return to the facility from dialysis and Resident #2 relayed a different story than what the Dialysis Social Worker reported. The Administrator said CNA B was not suspended following the allegation of abuse on 7/13/23 and the allegation was not reported to the state agency. <BR/>Record review of the facility's Abuse Investigation and Reporting policy dated 7/2022 indicated, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property . Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies within specific time frames: a. Immediately, but no later than 2 hours after the allegation is made, if the event that cause the allegation involve abuse or result in seriously bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in seriously bodily injury.

**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 had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and pain for 1 of 7 (Resident #2) residents reviewed for urinary catheters. <BR/>The facility did not ensure Resident #2's urinary catheter (a tube inserted into the bladder to drain urine) bag was not lying in the floor .<BR/>This failure could place residents at risk for urinary catheter bags busting by being stepped on or wheeled over by a wheelchair allowing bacteria into the catheter tubing, pain, and infection.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 4/3/24 indicated Resident #2 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including muscle weakness, dementia, overactive bladder, chronic kidney disease, hypertension (elevated blood pressure), and lack of coordination.<BR/>Record review of the MDS dated [DATE] indicated Resident #2 was understood others and was usually understood by others. The MDS indicated Resident #2 had a BIMS of 15 and was cognitively intact. The MDS indicated Resident #2 had an indwelling catheter (urinary catheter that is left in place) and was always incontinent of urine. <BR/>Record review of the care plan revised on 2/7/24 indicated Resident #2 had impaired cognitive function/dementia or impaired thought processes related to dementia.<BR/>During an observation on 4/2/24 at 1:36 p.m. Resident #2's urinary catheter bag was lying on floor. <BR/>During an observation and interview on 4/3/24 at 9:34 a.m. Resident #2's urinary catheter drain bag was lying in the floor. Resident #2 said she did not put the catheter drain bag in the floor. Resident #2 said she could not reach the catheter drain bag to hang it on the bed where she liked it. Resident #2 said a staff member stepped on her catheter drain bag yesterday when it was in the floor and busted it. Resident #2 said staff replace the busted catheter drain bag and mopped the urine out of the floor. <BR/>During an interview on 4/3/24 at 12:33 p.m. the ADON said a foley catheter drain bag should be positioned below the abdomen unless otherwise requested by the resident. The ADON said a foley catheter drain bag should not ever be in the floor. The ADON said the importance of ensuring a foley catheter drain bag was not in the floor was for infection control. The ADON said there were approximately 3 residents in the facility she thought would put their foley catheter drain bag in the floor. The ADON said one of those residents was Resident #2.<BR/>During an interview on 4/3/24 at 1:00 p.m. CNA G said she usually worked the 200 hall. CNA G said urinary catheter drain bags should be below the waist of the resident with the tubing straight without kinks. CNA G said urinary catheter drain bags should not be in the floor. CNA G said the importance of catheter drain bags not being in the floor was for sanitary purposes and to ensure they do not get busted by being stepped on or rolled over with a wheelchair. CNA G said she was not aware of any residents who would place their foley catheter drain bag in the floor.<BR/>During an interview on 4/3/24 at 1:31 p.m. the DON said she expected a urinary catheter drain bag to be positioned below the level of the bladder. The DON said a urinary catheter drain bag should not be in the floor. The DON said the importance of a foley catheter drain bag not being in the floor was infection control.<BR/>During an interview on 4/3/24 at 1:33 p.m. the Administrator said she expected a foley catheter drain bag to be covered, anchored, and not in the floor. The Administrator said the importance of a foley catheter drain bag not being in the floor was infection control. <BR/>Record review of the facility's Indwelling Catheter Use and Removal policy dated 7/2020 indicated, It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice .Additional care practices include .c. Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter; and d. Securement of the catheter facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the bladder .<BR/>Record review of the facility's Infection Prevention and Control Program policy dated 3/2022 indicated, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy (an opening through the neck into the trachea to provide and airway) care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #2) reviewed for tracheostomy care. The facility failed to ensure Resident #2 had replacement tracheostomy supplies (tracheostomy tubes (a curved tube inserted into the tracheostomy to keep the airway open)) in the facility or at the bedside. This failure could place residents at risk of respiratory distress and prolong emergency care being provided.Findings included:1. Record review of the face sheet dated 8/14/25 indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including anoxic brain damage (brain damage that occurs when the brain does not receive enough oxygen), epilepsy (seizure disorder), hypertension (elevated blood pressure), and heart failure (the hearts inability to pump blood around the body properly). Record review of the MDS dated [DATE] indicated Resident #2 rarely/never understood others. The MDS indicated Resident #2 was rarely/never understood by others. The MDS indicated Resident #2 had a BIMS of 02 and was severely cognitively impaired. The MDS indicated Resident #2 required special treatments of oxygen therapy, suctioning, and tracheostomy care. Record review of the care plan revised on 8/8/25 indicated Resident #2 had a tracheostomy and was at risk for increased secretions, congestion, respiratory infections and infections to tracheostomy site. Record review of the physician orders dated 8/14/25 indicated Resident #2 had an order for emergency tracheostomy supplies are to be kept at bedside to include oxygen source, suction machine, additional tracheostomy tubes, and Ambu bag (a handheld device used to provide positive pressure ventilation to individual experiencing respiratory distress). During an observation and interview on 8/14/25 at 10:49 a.m. there was one size smaller replacement tracheostomy tube in the emergency kit at bedside that had been opened, and no replacement tracheostomy tube the same size as Resident #2's in the emergency tracheostomy kit. RN D showed the surveyor the tracheostomy tube size (number printed on the tracheostomy tube itself) on Resident #2's tracheostomy tube and verified to the surveyor Resident #2's tracheostomy tube size was an 8. RN D said the tracheostomy tube one size smaller could not be used due to the fact it was already opened and no longer sterile, RN D said there was not a usable replacement tracheostomy tube at bedside. RN D said in the event of respiratory distress, cardiac arrest, or decannulation (removal of the tracheostomy tube) the facility would be in trouble, and it could hamper efforts to provide emergency care to Resident #2 by not having a usable emergency tracheostomy tube replacement at bedside. During an observation and interview on 8/14/25 at 12:00 p.m. the facility had Silicone (specific type of tracheostomy tube without an inner cannula) replacement tracheostomy tubes in size 6 and 7. The facility did not have any Silicone replacement tracheostomy tubes in size 8 (the same size trach as Resident #2 currently had in place). RN D said the facility did not carry Silicone tracheostomy tubes in size 8. RN D said the DON stocked the tracheostomy emergency kits that were at bedside. During an interview on 8/14/25 at 12:01 p.m. the DON said she was responsible for stocking the emergency tracheostomy kits at bedside. The DON said she had checked the emergency tracheostomy kits on 8/8/25 and all kits had the proper, unopened supplies. The DON said she usually checked the emergency kits 1-2 times a week. The DON said the facility had not had any Silicone size 8 tracheostomy tubes since mid-July 2025. The DON said she had ordered the Silicone size 8 tracheostomy tubes in mid-July 2025. The DON said not having the proper supplies in the tracheostomy emergency bedside kits would prolong care and make the situation worse in the event of an emergency such as respiratory distress, cardiac arrest, or decannulation. During an interview on 8/14/25 at 2:56 p.m. the Physician said he did not know about tracheostomies and did not want to give his medical opinion as he is not familiar with facility policy. The Physician said the nurses should call emergency medical services in the event of an emergency and should be able to care for Resident #2 in the event of an emergency. The Physician said the surveyor should talk to a respiratory therapist regarding the importance of having necessary supplies in the facility for tracheostomy treatment as he was not sure of the facility policy. During an interview on 8/15/25 at 9:45 a.m. the RT said the facility should have in the emergency tracheostomy kit at bedside a tracheostomy tubes the same size and one size smaller than what the resident has inserted, an ambu bag, and a suction catheter. The RT said most of the time in the event of decannulation a tracheostomy tubes the same size was not able to be re-inserted and a tracheostomy tube one size smaller was required. The RT said in the event of a life-or-death emergency a tracheostomy tube one size smaller that the sterile packaging had been opened on could be used. The RT said most tracheostomy patients were able to breath without the tracheostomy unless it was a brand-new tracheostomy. Record review of the facility's Tracheostomy Care policy dated 2001 indicated, The purpose of this procedure is to guide tracheostomy care ant the cleaning of reusable tracheostomy cannulas.A replacement tracheostomy tube must be available at the bedside at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 12 residents (Resident #1, Resident #2, and Resident #4) reviewed for infection control. <BR/>1. The facility failed to ensure a resident COVID-19 outbreak that included one hospitalization, Resident #4, was reported to state regulatory authority.<BR/>2. The facility failed to ensure the OTA G, CNA D, and PT R maintained proper donning of facemasks for source control in the hallway and within 3 feet of Resident #1 and Resident #2 during a COVID-19 outbreak.<BR/>These failures could place residents at risk for development and spread of infection.<BR/>Findings include:<BR/>1. Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old female with an initial admission date of 12/05/2022. Resident #4 had diagnoses which included atrial fibrillation (irregular heartbeat), iron deficiency anemia secondary to blood loss (chronic) (decreased iron in the body due to excess bleeding), COVID-19, acute kidney failure, and chronic kidney disease, stage 4 (severe).<BR/>Record review of Resident #4's annual MDS, dated [DATE], reflected she had a BIMS score of 12, which indicated moderate cognitive impairment.<BR/>Record review of Resident #4's Care Plan, revised 01/02/2024, reflected she was at risk for signs and symptoms of COVID-19 and tested positive on 01/02/2024 with interventions to include: following facility protocol for COVID-19 screening/precautions and educate staff of COVID-19 signs and symptoms and precautions<BR/>Record review of the COVID-19 Log, dated 1/9/2024, and undated, Floorplan reflected Resident #4 tested positive for COVID-19 on 01/02/2024. The COVID-19 Log reflected 40 total COVID-19 positive residents and 5 positive staff since 12/30/2023. <BR/>Record review of Resident #4's Progress Notes, dated from 12/16/2023 through 01/07/2023, reflected multiple COVID-19 positive staff worked with Resident #4 to include LVN B, ADON, and LVN C. Progress Notes reflected Resident #4 was sent to the hospital on [DATE] per physician's orders following a change in condition to include labored breathing, fever, and altered mental status.<BR/>Record review of Resident #4's hospital records, dated 01/09/2024, reflected resident was being discharged from the hospital on [DATE] to return to nursing facility and had a hospital diagnosis which included .acute hypoxic respiratory failure (not enough oxygen in blood) secondary to pneumonia and COVID.<BR/>During an observation and interview on 01/09/2024 at 9:12 a.m., signage was posted at the entry notifying visitors there were COVID-19 positive residents in the facility.<BR/>During an interview on 01/09/2024 at 9:15 a.m., the Administrator and DON stated the facility had a COVID-19 outbreak and the ADON and DON was the IP and the ADON was not at work at the time of the survey. The DON stated 3 staff and 30 residents were currently positive for COVID-19 at the facility. The DON stated the facility did not have a designated COVID-19 unit; however, the majority of positives were located Hall S, and the outbreak initiated from LVN B who tested positive during routine testing on 12/29/2023 at another nursing facility, she was employed. The DON said facemasks were required for all staff in the building and physical therapy services were provided in the room for COVID-19 positive residents. The DON stated there was one COVID-19 positive resident who was hospitalized , Resident #4, who remained in the hospital. The Administrator said he did not report positive COVID-19 residents to HHSC, Program Manager, or any other regulatory agency because it was the first time he had COVID-19 in a facility and could not access the computer reporting system. The Administrator said it was important to notify regulatory agencies of COVID-19 positive residents upon first COVID-19 positive resident per COVID-19 policy and he anticipated to submit a self-report of COVID-19 outbreak to HHSC by the end of the day.<BR/>Record review of the facility policy, titled COVID-19 Prevention, Response, and Reporting, dated 06/22, reflected the following:<BR/>Policy: <BR/>It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections, COVID-19 information will be reported through the proper channels as per federal, state, and/or local health authority guidance.<BR/>Policy Explanation and Compliance Guidelines:<BR/>1. <BR/>The Infection Preventionist will assess facility risk associated with COVID-19 through surveillance activities of COVID-19 infection in the community and illnesses present in the facility .<BR/>b. Threat detected - the facility will respond promptly and implement emergency and/or outbreak procedures.<BR/>2. Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: heart failure, dementia (cognitive disorder), cancer, vitamin D deficiency, hallucinations, cognitive communication deficit (difficulty with thinking and using language), schizoaffective disorder (mental health condition with symptoms of both schizophrenia and mood disorders), neurocognitive disorder, chronic kidney disease stage 3, epilepsy (seizure disorder), and metabolic encephalopathy (brain dysfunction).<BR/>Record review of Resident #1's, undated, Care Plan reflected he had diabetes mellitus, was unaware of safety needs, and had an ADL self-care performance deficit requiring 1-2 staff assistance and had a skin infection with interventions to include: follow facility policy and procedures for line listing, summarizing, and reporting infections <BR/>Record review of Resident #1's quarterly MDS, dated [DATE], reflected he had a BIMS score of 12, which indicated moderate cognitive impairment.<BR/>During an observation and interview on 01/09/2024 at 10:00 a.m., the OTA G was providing physical therapy services and talking within 3 feet of Resident #1 who sat in his wheelchair in the physical therapy room. The OTA G had a facemask on that did not cover his nose and mouth and the resident was not wearing a facemask. The OTA G said he should be wearing a facemask while in the building within proximity to residents. The DOR, she said she oversaw proper PPE donning of facemasks and she did not know why the PT did not have his facemask donned properly while he was in close proximity with residents, and it may be due to the resident not being able to understand him and the DOR said she would address the concern. The DOR said the facility provided training on PPE donning and doffing during the current COVID-19 outbreak and it was important to properly don PPE to prevent the spread of infection for all residents at the facility. The DOR said her staff had not tested positive for COVID-19 and that therapy is provided in rooms for COVID-19 positive residents.<BR/>During an observation and interview on 01/09/2024 at 10:16 a.m., CNA D walked out of the shower room into the hallway directly across from the COVID-19 positive resident room with their door open and grabbed linen from the hallway storage rack. The CNA had no facemask donned in the hallway and said she was taking care of a positive COVID-19 resident today and indicated the room with isolation precaution signage and the PPE container directly across from the shower room where she had exited. The CNA said she was required to wear a facemask in the building and did not know why she did not have one on and facemasks were available at the nurse's station. The CNA said she received training on infection control and proper donning/doffing and said it was important to wear a facemask to prevent the spread of infection for all residents. The CNA D returned to the shower room with no facemask donned and donned a facemask at the nursing station to cover her nose and mouth. <BR/>During an interview on 01/09/2024 at 10:23 a.m., LVN A said CNA D was required to wear a facemask in the hallway and when showering residents and she had not noticed any staff not wearing their facemask. LVN A said she received training on PPE donning/doffing and said she would stop and remind staff to wear their facemask if she saw staff in the hallway without a facemask. LVN A said all charge nurses, the ADON, and the DON were responsible for ensuring facemasks were donned properly. LVN A said all residents were at risk for the spread of COVID-19 if facemasks were not properly donned, and it was important for staff to wear their facemasks to prevent the spread of infection. LVN A said she worked on Hall S that had the majority of COVID-19 positive residents on 01/07/2024 and that she had approximately 7 positive residents. <BR/>Record review of Resident #2's, undated, face sheet, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: asthma (lung disease), family history of HIV (Human Immunodeficiency Virus) (virus that attacks the body's immune system), disorder invol<BR/>ving the immune mechanism, and type 2 diabetes mellitus with diabetic neuropathy (nerve damage).<BR/>Record review of Resident #2's, undated, Care Plan reflected he was at risk for signs and symptoms of COVID-19 and he was unable to wear a mask due to needing his mouth to navigate his wheelchair with interventions to include: educate staff, resident, family, and visitors of COVID-19 signs and symptoms and precautions, and follow facility protocol for COVID-19 screening/precautions.<BR/>Record review of Resident #2's MDS section in electronic health record, revealed admission MDS had not been completed since his recent admission on [DATE].<BR/>During an observation and interview on 01/09/2024 at 11:00 a.m., the PT R was ambulating in the hallway with Resident #2. The PT was wearing a facemask that did not cover his nose and mouth while talking and ambulating in the hallway within 3 feet of Resident #2. Resident #2 did not have a facemask donned and they ambulated from Hall S, with the majority of reported COVID-19 positive residents. The PT R said he was supposed to wear his facemask when interacting with residents. The PT R said he was not sure if he was supposed to wear a face mask at all times in the facility and they provided training on infection control donning and doffing during the current COVID-19 outbreak. The PT R donned his facemask and covered his nose and mouth. The PT R said it was important to wear his mask while in close proximity of residents to prevent the risk of spreading infection to residents in the facility.<BR/>During an observation and interview on 01/09/2023 at 11:05 a.m., the Housekeeper had a facemask donned and said staff were required to wear facemasks in the hallways and in close proximity of residents and improper donning could put all residents at risk for getting sick. The Housekeeper said it was important to wear the facemasks properly to prevent the spread of infection.<BR/>During an interview on 01/09/2024 at 12:29 p.m., the DON and Administrator said the charge nurses, the ADON, and herself were ultimately responsible for ensuring proper PPE donning/doffing. The DON said staff were required to wear their masks when they were in a patient area or in the hallway. The DON said she ensured residents wore facemasks by doing daily reminders to encourage residents to wear them. The DON said there was no set schedule for monitoring of proper donning and doffing of PPE. The DON said she would continue to ensure compliance by frequent monitoring rounds to see if they were following protocols. The DON said if a staff member was observed without a facemask donned the employee would be stopped and provided education to review the importance for staff to wear their facemasks in order to prevent the risk of spreading infection. <BR/>During a telephone interview on 01/09/2024 at 12:39 p.m., the Attending Physician said he was aware of the COVID-19 outbreak at the facility and had a COVID-19 protocol for any resident that tested positive to include medication and staff must wear a mask in the facility if exposed to COVID-19 to prevent the spread of infection. <BR/>Record review of the facility policy, titled Infection Surveillance, dated 07/2022, reflected the following:<BR/>Policy:<BR/>A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. <BR/>Definitions:<BR/> .'Process measure' is a mechanism for evaluating specific steps in a process that lead, either positively or negatively, to a particular outcome metric. Also known as performance monitoring, a process measure is used to evaluate whether infection prevention and control practices are being followed .<BR/>Policy Explanation and Compliance Guidelines:<BR/>1. <BR/>The Infection Preventionist serves as the leader in surveillance activities . and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required .<BR/>Review of CDC Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19)Pandemic at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#SARS-CoV-2-metrics revealed the following:<BR/> .Source control is recommended for individuals in healthcare settings who:<BR/>Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or<BR/>Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure.<BR/>Source control is recommended more broadly as described in CDC's Core IPC Practices in the following circumstances:<BR/>By those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over (e.g., no new cases of SARS-CoV-2 infection have been identified for 14 days); or<BR/>Facility-wide or, based on a facility risk assessment, targeted toward higher risk areas (e.g., emergency departments, urgent care) or patient populations (e.g., when caring for patients with moderate to severe immunocompromise) during periods of higher levels of community SARS-CoV-2 or other respiratory virus transmission (See Appendix)<BR/>Have otherwise had source control recommended by public health authorities (e.g., in guidance for the community when COVID-19 hospital admission levels are high) .<BR/>Review of CDC's SARS-CoV-2 Community Transmission Level at https://covid.cdc.gov/covid-data-tracker/#maps_new-admissions-rate-county revealed Community Transmission Level was Low for the county.

**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 3 residents (Resident #1) reviewed for smoking.<BR/>The facility failed to ensure Resident #1 was provided supervision when he smoked. Resident #1 had a history of attempting to smoke while wearing his oxygen tank (secured to the back of his motorized wheelchair). On 03/26/2023, a lit cigarette was discarded on the ground and ignited his oxygen tubing and catheter bag that was laying at the bottom of his motorized wheelchair. <BR/>An Immediate Jeopardy (IJ) was identified on 04/01/2023 at 3:20 PM. While the IJ was removed on 04/03/2023 at 7:12 PM, the facility remained out of compliance at no actual harm because the facility needed to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents at risk of harm, severe injury, and possible death to residents who wear oxygen and were inadequately assessed for smoking safely unsupervised. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet, dated 04/02/2023, revealed Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia (occurs when disease of the heart or lungs leads to failure to maintain adequate blood oxygen levels), cognitive communication deficit (difficulty with thinking and how someone uses language), and paraplegia (impairment in motor (movement) or sensory (feeling) function of the lower extremities). <BR/>Record review of the order summary report, dated 04/01/2023, revealed Resident #1 had an order, which started on 03/18/2023, for Oxygen continuously via nasal cannula . <BR/>Record review of Resident #1's comprehensive MDS assessment, dated 03/24/2023, revealed it had not been completed. <BR/>Record review of the comprehensive care plan, initiated on 03/20/2023, revealed Resident #1 had altered respiratory status and difficulty breathing. The interventions included oxygen at 2 LPM via NC every shift. The comprehensive care plan further revealed a smoking care plan was initiated on 03/26/2023 after Resident #1 ignited his oxygen tubing on the smoking patio. The intervention included Resident is deemed unsafe smoker, he smoked with oxygen tank in place after being educated to leave oxygen concentrator at nurses' station when going out to smoke.<BR/>Record review of the occupational therapy treatment encounter note, dated 03/22/2023, revealed Resident #1 was educated on the safety concerns including the oxygen tank attached to his motorized wheelchair and not being allowed in the smoking courtyard. <BR/>Record review of the nursing progress note, dated 03/22/2023 at 2:35 PM, revealed Resident #1 was repeatedly going outside in the common smoking area to smoke while oxygen was connected. The progress notes further revealed the charge nurse, ADON, and DON provided education and Resident #1 agreed not to smoke while using oxygen.<BR/>Record review of the smoking assessment, effective date 03/22/2023, revealed Resident #1 had a history of smoking-related problems that would be hazardous to self or others. The smoking assessment revealed Resident went to smoking area in power chair with his oxygen tank. The tank was removed, and resident educated. The smoking assessment revealed Resident #1 was able to keep his lighter and cigarettes and was safe to smoke unsupervised. The assessment was signed by the DON on 03/27/2023. <BR/>Record review of the nursing progress note, dated 03/25/2023 at 11:47 PM, revealed Resident #1 was provided additional education regarding removing his oxygen tank prior to going outside to smoke. <BR/>Record review of the nursing progress note, dated 03/26/2023 at 3:45 PM, revealed Resident #1 had been off the hall for about an hour visiting another resident. Resident #1 went out to smoking area, and per resident witnesses' Resident #1 removed his nasal cannula and laid it on his foley catheter bag and proceeded to take out a cigarette and light it. While smoking, Resident #1 dropped his cigarette on top of oxygen tubing that was on ground. The oxygen tubing and foley catheter caught fire. A resident in the area grabbed the fire extinguisher and quickly put out the fire. There were no visible injuries, 911 was called, the doctor was notified, and a message with call back number was left for family.<BR/>Record review of the incident report, dated 03/26/2023 at 3:30 PM, revealed Resident #1 was outside smoking with oxygen tank on, per witnesses' he took the nasal cannula off and placed it on the ground on his foley tubing prior to lighting the cigarette. He dropped his cigarette and the oxygen tubing ignited burning the oxygen tubing and foley tubing. Another resident immediately got the fire extinguisher and put out fire, and someone else hollered for nurse. Charge nurse went into smoking area and noted white substance all over resident. Nurse observed resident sitting in his power chair, holding the power cord to chair, and burnt oxygen tubing. The incident report further revealed immediate action taken was 911 was called, fire extinguisher was used, resident transported to ER to rule out any injury. Oxygen tank was turned off and removed from chair. Resident returned to nurses' station for eval.<BR/>Record review of the Smoking Policy In-service, initiated on 03/26/2023, revealed staff were in-serviced on the smoking policy that was implemented in 06/2022 which indicated oxygen was prohibited in the smoking area. The in-service further revealed 7. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether supervision is required for smoking, or if resident is safe to smoke at all. 8. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan. The in-service further revealed 13. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff.<BR/>Record review of the Supervised Smoking Schedule, undated, revealed instructions that included: Do not throw cigarettes on the ground, use the ashtrays. No cigarettes, cigars, lighters or matches (any lighting instrument) in a resident's room or on your person at any time. The schedule further revealed the smoking times as follows:<BR/>6:00 AM - 6:15 AM supervised by the staff on duty<BR/>9:00 AM - 9:15 AM supervised by the staff on duty<BR/>12:45 PM - 1:00 PM supervised by the staff on duty<BR/>4:00 PM - 4:15 PM supervised by the staff on duty<BR/>7:00 PM - 7:15 PM supervised by the staff on duty<BR/>10:00 PM - 10:15 PM supervised by the staff on duty<BR/>During an interview on 04/01/2023 at 9:07 AM, LVN D stated the residents were able to take themselves out to the smoking area and smoke if they were able to smoke unsupervised. LVN D stated there were currently no designated smoking times in place and residents could go out whenever. LVN D stated the residents were able to keep their cigarettes and lighters. <BR/>During an observation on 04/01/2023 at 9:05 AM, four residents (Resident's #2, #5, #6, and #7) were outside in the smoking courtyard. Residents #2, #5, #6, and #7 had their own cigarettes and lighters. <BR/>During an interview 04/01/2023 at 9:10 AM, Resident #2 stated she was the person who used the fire extinguisher to put the fire out on 03/26/2023. Resident #2 stated it was windy the day of the incident and Resident #1 was sitting in his motorized wheelchair against the wall. Resident #2 stated Resident #1 had taken his nasal cannula out of his nose and placed it on top of his catheter bag. Resident #2 stated Resident #1 was not right in the head and had come out several times with his oxygen tank on the back of his motorized wheelchair. Resident #2 stated the nurses would have normally turned the oxygen tank off, but it was on the day of the incident. Resident #2 stated another resident had dropped his cigarette on the ground and the wind blew it toward the nasal cannula and the tubing ignited causing a fire. Resident #2 stated she immediately grabbed the fire extinguisher and put out the fire. Resident #2 stated she did not believe there were any injuries to Resident #1. <BR/>During an interview on 04/01/2023 at 9:16 AM, Resident #5 stated the facility staff told them during the past week that the residents were not allowed to smoke without supervision anymore. Resident #5 stated the staff members had not supervised them this morning, but she was under the impression it was to have started. Resident #5 stated the facility told the residents who smoked they would also have to give up their cigarettes and lighters and could only smoke during the designated smoking times for only 15 minutes. Resident #5 stated the staff had not taken her cigarettes or lighter and had not provided supervision at this time. <BR/>During an interview on 04/01/2023 at 9:47 AM, LVN C stated on the morning of the incident on 03/26/2023 and the day prior on 03/25/2023 she had talked to Resident #1 several times about going outside with his oxygen on. LVN C stated Resident #1 had gone to another hall to visit another resident. LVN C stated Resident #1 entered the smoking area after leaving the other resident's room. LVN C stated a CNA had come to tell her he was outside with oxygen on. LVN C stated RN F had beat her to the smoking area and the fire was already extinguished. LVN C stated paramedics had been called so Resident #1 could have been checked out. LVN C stated he had some redness to his bilateral lower extremities, but they looked like that prior to the incident. LVN C stated to her knowledge, he took his nasal cannula off and placed it at the bottom of his motorized wheelchair where it caught fire. LVN C stated he had no injuries. LVN C stated some residents required supervision and some did not dependent on their smoking assessment. LVN C stated the facility had no set times for residents who were able to smoke unsupervised. LVN C stated the facility did an in-service stating residents had to be supervised while smoking and should have designated times but was usure when it started. LVN C stated it should have been implemented by today. <BR/>During an observation on 04/01/2023 at 9:54 AM, four residents were outside smoking with no staff supervision. <BR/>During an interview on 04/01/2023 at 9:58 AM, Resident #3 stated she did not smoke but liked to sit outside. Resident #3 stated she witnessed the incident that happened on 03/26/2023 with Resident #1. Resident #3 stated Resident #1 was confused and would often become naked by taking his gown off. Resident #3 stated Resident #1 had taken his oxygen off and placed it on his catheter bag. Resident #3 stated Resident #1 threw his lit cigarette on the ground, and he started yelling he was on fire. Resident #3 stated the flames were going and another resident grabbed the fire extinguisher and put out the fire. Resident #3 stated a different resident hollered for a nurse. Resident #3 stated the fire department arrived at the facility and told her Everyone could have been blown to pieces. <BR/>During an interview on 04/01/2023 at 10:18 PM, the DON stated on 03/26/2023 Resident #1 had taken his oxygen tank attached to his motorized wheelchair out into the smoking area. The DON stated it was discovered during the investigation that Resident #1 was not actually smoking but another resident was smoking beside him and dropped his cigarette on the ground. The DON said the cigarette rolled toward Resident #1's motorized wheelchair where his oxygen tubing was laying on his catheter bag and ignited. The DON stated another resident put out the fire using the fire extinguisher and Resident #1 was sent to the emergency room as a precaution. The DON stated when Resident #1 returned to the facility he was re-assessed as an unsafe smoker and his smoking materials were taken. The DON stated Resident #1 had one prior incident on 03/22/2023 where he was found outside with his oxygen tank on. The DON stated herself, the ADON, the nurse, and therapy provided Resident #1 with education regarding taking his oxygen tank into the smoking area. The DON stated he was deemed a safe smoker at that time because he was able to verbalize understanding of the smoking policy. The DON stated the corporate office had changed the smoking policy and she had in-serviced the residents and the staff. The DON stated the supervised smoking at designated times was supposed to have been implemented on Monday, 04/03/2023. <BR/>During an observation and interview on 04/01/2023 at 12:35 PM, Resident #1 was sitting up in his hospital bed. Resident #1 looked frail and unkempt as evidenced by the hospital gown falling off his bony shoulders and his hair was disheveled and falling into his face. Resident #1 was wearing a nasal cannula and was struggling to breath during the interview. Resident #1 stated he remembered the incident that occurred on 03/26/2023. Resident #1 stated he was not smoking but another resident was sitting beside him and was smoking. Resident #1 stated the other resident dropped his cigarette and about 5 minutes later his nasal cannula and foley catheter tubing caught on fire. Resident #1 stated it was a small flame and he was not injured. Resident #1 stated the facility made him go to the hospital and he believed they made a mountain out of a molehill. Resident #1 stated he knew all about safety and for significant damage to have been done, it would have needed to happen in an enclosed space. Resident #1 stated he normally went into the smoking area with his oxygen tank, but the staff would turn off the oxygen or he would himself. <BR/>During an interview on 04/01/2023 at 1:22 PM, CNA B stated she worked the hall were Resident #1 resided and had taken care of him. CNA B stated Resident #1 wanted to do what he wanted to when he wanted to do it. CNA B stated Resident #1 had behaviors, but it seemed like they were getting better. CNA B stated she observed Resident #1 outside in the smoking area on multiple occasions with his oxygen tank on the back of his motorized wheelchair. CNA B stated Resident #1 was an unsupervised smoker, and she believed the nurses were turning the oxygen off. CNA B stated all the nurses were aware Resident #1 was going outside with his oxygen tank on. CNA B stated she was provided an in-service on the new smoking policy and stated all residents were going to be supervised while smoking and only allowed to smoke at designated times. <BR/>During an interview on 04/01/2023 at 1:41 PM, MA E stated she worked on the hall were Resident #1 resided. MA E stated Resident #1 was told things and he would forget them. <BR/>During an interview on 04/01/2023 at 2:29 PM, COTA R stated 03/22/2023 was the first day Resident #1 was out of the bed. COTA R stated she was performing a safe motorized wheelchair assessment on Resident #1 when he mentioned he wanted to go outside for a cigarette. COTA R stated she provided education on safety to Resident #1 and instructed him it was not appropriate to go outside with his oxygen tank hooked on the back of his motorized wheelchair. COTA R stated she informed the nurse he was asking for a cigarette. COTA R stated Resident #1 was later found outside with his oxygen tank on his motorized wheelchair. <BR/>Record review of the Resident Smoking policy, updated in 03/2023, revealed 7. Residents who smoke will be assessed, using the Resident Safe Smoking Assessment, to determine the level of supervision the resident requires. 8. All residents who smoke will be allowed to smoke in designated smoking areas (weather permitting), at designated times with supervision, and in accordance with his/her care plan. The policy further revealed 13. Smoking materials of residents who smoke will be maintained by nursing staff.<BR/>The Administrator was notified on 04/01/2023 at 3:52 PM that an immediate jeopardy situation was identified due to the above failures. The Administrator and the DON was provided the immediate jeopardy template on 04/01/2023 at 3:59 PM. <BR/>During an interview on 04/02/2023 at 10:55 AM, the DON stated before the incident on 03/26/2023, the facility assessed residents for safe smoking, the need for supervision, and whether residents were able to keep their smoking materials by performing a smoking assessment. The DON stated it had been the policy from the time she started at the facility. The DON stated there was no set person to complete the smoking assessment. The DON stated often the MDS nurse, the charge nurse, or herself would have completed the smoking assessments. The DON stated this was monitored during daily clinical meetings and if the assessment was not completed, she would do it. The DON stated Resident #1 had a BIMS score of 14, which indicated no cognitive impairment and was able to verbalize understanding of the smoking policy. <BR/>The facility's plan of removal was accepted on 04/03/2023 at 2:56 PM and included the following:<BR/>The facility failed to provide supervision to Resident #1 who required oxygen and smoked. All Smoking assessments and Care plans were reviewed for residents who smoke, and changes were made as necessary on 3/26/2023 by the director of nurses. Residents who smoke were reviewed for care plan and if a care plan was not noted, a care plan was completed. On 3/31/2023 residents who smoked and used oxygen were asked to attend a care plan meeting so that the care plan could be updated to reflect that they used oxygen and understood that they could not go outside to smoke with oxygen. Every resident who smokes verified they understood that they were not allowed go outside to smoke with oxygen. <BR/>Resident #1 was assessed and transferred to ER 3/26/2023 at approximately 3:45 PM to evaluate and treat as necessary. The Resident returned 3/26/2023 at approximately 9:00 PM with no new orders and with no injuries reported by the ER. <BR/>The facility smoking policy was updated on 3/31/2023 and at that time DON/ADON began in-servicing facility staff on the policy changes. <BR/>Facility policy was updated by corporate office to provide scheduled supervised smoking times for all residents who smoke on 3/31/2023.<BR/>Assigned smoking times are supervised as follows: <BR/>6:00am to 6:15am - Charge Nurse on North Wing will assign staff member to take residents smoking paraphernalia out to smoke area and allow residents to smoke while being supervised. <BR/>9:00am - 915am - Activity Director or her designee will supervise M-F, Housekeeping staff member on duty will supervise during this time on Sat - Sun.<BR/>12:45pm - 1:00pm - Social Services will supervise during this time frame and housekeeping staff member will supervise on Sat - Sun.<BR/>4:00pm - 4:15pm - North Wing Charge Nurse will assign Aide/C.N.A.<BR/>7:00pm- 715: pm - South Wing Charge Nurse will assign Aide/C.N.A.<BR/>10:00 pm - 10:15pm - East Wing Charge nurse will assign Aide/C.N.A. <BR/>DON, ADON, and the wound care nurse in-serviced all staff regarding the new smoking policy and the supervised smoking requirements. This will be monitored by the Administrator, DON and ADON. Smoking policy will be covered during orientation for new hires. All staff currently on duty were in-serviced at 11:00 AM on 4/3/2023.<BR/>Any staff members not available for in-service will be in-serviced prior to returning to shift. <BR/>All resident smokers were invited to a meeting on 3/31/2023 conducted by Social Worker and Administrator. Each resident in attendance was provided a copy of the changes. The Smoking policy is part of the admission agreement, and the revised policy will be placed in admission packet immediately. Not all residents who smoke showed up for the meeting. For those who did not attend, the ADON went to each resident on 4/2/2023 at 2:00PM to educate them on the new smoking policy to ensure they understood. Also, the residents were reminded that they must turn in all cigarettes and lighters to the nurse. <BR/>The new smoking policy was updated on 3/31/2023 to reflect that oxygen tanks are not allowed in the smoking area. <BR/> The person assigned to supervise smoking will ensure there are no oxygen tanks in the smoking area. <BR/>Policy related to supervision during smoking times has been implemented and is in place. The new smoking policy implementation explanation started 3/31/23 with all residents who smoke. The new smoking policy implementation was completed on 4/2/2023 for all residents who smoke.<BR/>All residents who smoke were asked again on 4/3/2023 at 11:00 AM to turn in cigarettes and lighters to the charge nurse for storage. Staff in-serviced again regarding the new smoking policy to ensure everyone understood on 4/03/2023 at 12:00PM.<BR/>On 04/03/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>During an observation on 04/03/2023 at 4:25 PM, 13 residents were outside smoking supervised by CNA B. <BR/>During resident interviews on 04/03/2023 between 4:33 PM - 5:09 PM, Resident's #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 were able to verbalize understanding of the new smoking policy, which included supervised smoking and designated smoking times, verbalize understanding of not going into the smoking area with oxygen, and verified all cigarettes and lighters were turned into the facility staff. <BR/>Record review of the comprehensive care plan for Resident's #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, and #27 revealed they had been reviewed and revised as necessary. <BR/>Record review of the smoking assessments for Resident's #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #17, #18, #19, #20, #22, #23, #24, #25, #26, and #27 revealed they had been reviewed and revised as necessary. <BR/>Record review of the new smoking policy in-service provided to staff, dated 03/31/2023, 04/01/2023, and 04/02/2023, revealed 42 staff members had signed and dated the read and understood the new smoking policy, which included oxygen was not allowed in the smoking area, residents were required to keep their cigarettes and lighters at the nurse's station, and designated smoking times and supervision. <BR/>During interview on 04/03/2023 between 4:25 PM and 6:28 PM, the following staff members, LVN K, MA L, LVN M, CNA N, CNA O, CNA P, CNA B, LVN D, CNA Q, and the ADON were interviewed and verbalized understanding that no oxygen was allowed in the smoking area, residents were required to keep their cigarettes and lighters at the nurse's station, and the new digitated smoking times and supervision. <BR/>On 04/03/2023 at 7:12 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy (an opening through the neck into the trachea to provide and airway) care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #2) reviewed for tracheostomy care. The facility failed to ensure Resident #2 had replacement tracheostomy supplies (tracheostomy tubes (a curved tube inserted into the tracheostomy to keep the airway open)) in the facility or at the bedside. This failure could place residents at risk of respiratory distress and prolong emergency care being provided.Findings included:1. Record review of the face sheet dated 8/14/25 indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including anoxic brain damage (brain damage that occurs when the brain does not receive enough oxygen), epilepsy (seizure disorder), hypertension (elevated blood pressure), and heart failure (the hearts inability to pump blood around the body properly). Record review of the MDS dated [DATE] indicated Resident #2 rarely/never understood others. The MDS indicated Resident #2 was rarely/never understood by others. The MDS indicated Resident #2 had a BIMS of 02 and was severely cognitively impaired. The MDS indicated Resident #2 required special treatments of oxygen therapy, suctioning, and tracheostomy care. Record review of the care plan revised on 8/8/25 indicated Resident #2 had a tracheostomy and was at risk for increased secretions, congestion, respiratory infections and infections to tracheostomy site. Record review of the physician orders dated 8/14/25 indicated Resident #2 had an order for emergency tracheostomy supplies are to be kept at bedside to include oxygen source, suction machine, additional tracheostomy tubes, and Ambu bag (a handheld device used to provide positive pressure ventilation to individual experiencing respiratory distress). During an observation and interview on 8/14/25 at 10:49 a.m. there was one size smaller replacement tracheostomy tube in the emergency kit at bedside that had been opened, and no replacement tracheostomy tube the same size as Resident #2's in the emergency tracheostomy kit. RN D showed the surveyor the tracheostomy tube size (number printed on the tracheostomy tube itself) on Resident #2's tracheostomy tube and verified to the surveyor Resident #2's tracheostomy tube size was an 8. RN D said the tracheostomy tube one size smaller could not be used due to the fact it was already opened and no longer sterile, RN D said there was not a usable replacement tracheostomy tube at bedside. RN D said in the event of respiratory distress, cardiac arrest, or decannulation (removal of the tracheostomy tube) the facility would be in trouble, and it could hamper efforts to provide emergency care to Resident #2 by not having a usable emergency tracheostomy tube replacement at bedside. During an observation and interview on 8/14/25 at 12:00 p.m. the facility had Silicone (specific type of tracheostomy tube without an inner cannula) replacement tracheostomy tubes in size 6 and 7. The facility did not have any Silicone replacement tracheostomy tubes in size 8 (the same size trach as Resident #2 currently had in place). RN D said the facility did not carry Silicone tracheostomy tubes in size 8. RN D said the DON stocked the tracheostomy emergency kits that were at bedside. During an interview on 8/14/25 at 12:01 p.m. the DON said she was responsible for stocking the emergency tracheostomy kits at bedside. The DON said she had checked the emergency tracheostomy kits on 8/8/25 and all kits had the proper, unopened supplies. The DON said she usually checked the emergency kits 1-2 times a week. The DON said the facility had not had any Silicone size 8 tracheostomy tubes since mid-July 2025. The DON said she had ordered the Silicone size 8 tracheostomy tubes in mid-July 2025. The DON said not having the proper supplies in the tracheostomy emergency bedside kits would prolong care and make the situation worse in the event of an emergency such as respiratory distress, cardiac arrest, or decannulation. During an interview on 8/14/25 at 2:56 p.m. the Physician said he did not know about tracheostomies and did not want to give his medical opinion as he is not familiar with facility policy. The Physician said the nurses should call emergency medical services in the event of an emergency and should be able to care for Resident #2 in the event of an emergency. The Physician said the surveyor should talk to a respiratory therapist regarding the importance of having necessary supplies in the facility for tracheostomy treatment as he was not sure of the facility policy. During an interview on 8/15/25 at 9:45 a.m. the RT said the facility should have in the emergency tracheostomy kit at bedside a tracheostomy tubes the same size and one size smaller than what the resident has inserted, an ambu bag, and a suction catheter. The RT said most of the time in the event of decannulation a tracheostomy tubes the same size was not able to be re-inserted and a tracheostomy tube one size smaller was required. The RT said in the event of a life-or-death emergency a tracheostomy tube one size smaller that the sterile packaging had been opened on could be used. The RT said most tracheostomy patients were able to breath without the tracheostomy unless it was a brand-new tracheostomy. Record review of the facility's Tracheostomy Care policy dated 2001 indicated, The purpose of this procedure is to guide tracheostomy care ant the cleaning of reusable tracheostomy cannulas.A replacement tracheostomy tube must be available at the bedside at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 4 (Resident #1) reviewed for pressure injuries. <BR/>The facility failed to ensure Resident #1's dressing to her sacrum was changed/re-applied after becoming saturated or dislodged per physician orders.<BR/>This failure could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 3/25/25 indicated Resident #1 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including pressure ulcer of the sacral region (the lower portion of the spine, located at the base of the vertebral column), muscle weakness, heart failure, and hypertension (elevated blood pressure).<BR/>Record review of the physician orders dated 3/25/25 indicated Resident #1 had an order for wound care: stage 4 pressure wound (involves full-thickness skin and tissue low, potentially exposing muscle, tendon, or bone and carries a high risk for infection) to the sacrum: cleanse with normal saline or wound cleanser, apply collagen powder (a specialized product derived from collagen that is applied directly to wound to promote healing and tissue regeneration) and pack with kerlix (gauze bandage rolls) dampened with Dakin's (a dilute solution of sodium hypochlorite, and antiseptic agent used to treat and prevent infections in wounds), and cover with foam dressing daily and PRN for saturation/dislodgement starting 3/17/25.<BR/>Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS score of 01 and was severely cognitively impaired. The MDS indicated Resident #1 had 1 stage 4 unhealed pressure ulcer that was present on admission/entry or reentry. <BR/>Record review of the care plan last updated 1/16/25 indicated Resident #1 had actual impairment to skin integrity with a stage 4 pressure ulcer to the sacrum with interventions including clean, apply medications, and dressings as ordered by the physician. <BR/>During an observation and interview on 3/25/25 at 8:56 a.m. the Treatment Nurse performed wound care on Resident #1. The Treatment Nurse said Resident #1 had a stage IV pressure wound to her sacrum. The Treatment Nurse said Resident #1 had been sent to a behavior hospital (dates unknown) and from the behavior hospital was transferred to a medical hospital. The Treatment Nurse said when Resident #1 returned to the facility she had a large stage IV pressure covering the majority of her bottom. The Treatment Nurse said most of the wound had healed and scar tissue was present. Resident #1 was observed without a dressing in place to her sacral wound. The Treatment Nurse said Resident #1 would urinate heavy and often saturate her dressing. The Treatment Nurse said the dressing to Resident #1's sacral wound should be changed/reapplied if it became wet. <BR/>During an interview on 3/25/25 at 9:00 a.m. Resident #1 said the night shift (did not provide names) changed her and her dressing was wet, so they removed the dressing, and did apply a new dressing.<BR/>During an interview on 3/25/25 at 12:36 p.m. the Wound Care Doctor said he was familiar with Resident #1 and felt her wound was trending in the right direction. The Wound Care Doctor said if a wound dressing became soiled or wet, he expected the nurses to reapply a dressing to the wound per his orders. The Wound Care Doctor said the importance of keeping a dressing on a wound was to prevent bacteria and soilage from entering the wound. <BR/>During an interview on 3/25/25 at 11:43 a.m. the DON said the facility did not have a policy specific to physician orders. <BR/>During an interview on 3/25/25 at 2:01 p.m. the DON said if a wound dressing became saturated or dislodged, she expected CNAs to report the dressing to the nurses and the nurses to change/reapply the dressing as soon as possible. The DON said the importance of changing/reapplying a dressing to a wound was so the wound was not left open and the wound was kept clean.<BR/>Record review of the facility's Comprehensive Care Plans policy dated 7/2022 indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe at minimum the following: .f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's culture identity, as indicated .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 12 residents (Resident #1, Resident #2, and Resident #4) reviewed for infection control. <BR/>1. The facility failed to ensure a resident COVID-19 outbreak that included one hospitalization, Resident #4, was reported to state regulatory authority.<BR/>2. The facility failed to ensure the OTA G, CNA D, and PT R maintained proper donning of facemasks for source control in the hallway and within 3 feet of Resident #1 and Resident #2 during a COVID-19 outbreak.<BR/>These failures could place residents at risk for development and spread of infection.<BR/>Findings include:<BR/>1. Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old female with an initial admission date of 12/05/2022. Resident #4 had diagnoses which included atrial fibrillation (irregular heartbeat), iron deficiency anemia secondary to blood loss (chronic) (decreased iron in the body due to excess bleeding), COVID-19, acute kidney failure, and chronic kidney disease, stage 4 (severe).<BR/>Record review of Resident #4's annual MDS, dated [DATE], reflected she had a BIMS score of 12, which indicated moderate cognitive impairment.<BR/>Record review of Resident #4's Care Plan, revised 01/02/2024, reflected she was at risk for signs and symptoms of COVID-19 and tested positive on 01/02/2024 with interventions to include: following facility protocol for COVID-19 screening/precautions and educate staff of COVID-19 signs and symptoms and precautions<BR/>Record review of the COVID-19 Log, dated 1/9/2024, and undated, Floorplan reflected Resident #4 tested positive for COVID-19 on 01/02/2024. The COVID-19 Log reflected 40 total COVID-19 positive residents and 5 positive staff since 12/30/2023. <BR/>Record review of Resident #4's Progress Notes, dated from 12/16/2023 through 01/07/2023, reflected multiple COVID-19 positive staff worked with Resident #4 to include LVN B, ADON, and LVN C. Progress Notes reflected Resident #4 was sent to the hospital on [DATE] per physician's orders following a change in condition to include labored breathing, fever, and altered mental status.<BR/>Record review of Resident #4's hospital records, dated 01/09/2024, reflected resident was being discharged from the hospital on [DATE] to return to nursing facility and had a hospital diagnosis which included .acute hypoxic respiratory failure (not enough oxygen in blood) secondary to pneumonia and COVID.<BR/>During an observation and interview on 01/09/2024 at 9:12 a.m., signage was posted at the entry notifying visitors there were COVID-19 positive residents in the facility.<BR/>During an interview on 01/09/2024 at 9:15 a.m., the Administrator and DON stated the facility had a COVID-19 outbreak and the ADON and DON was the IP and the ADON was not at work at the time of the survey. The DON stated 3 staff and 30 residents were currently positive for COVID-19 at the facility. The DON stated the facility did not have a designated COVID-19 unit; however, the majority of positives were located Hall S, and the outbreak initiated from LVN B who tested positive during routine testing on 12/29/2023 at another nursing facility, she was employed. The DON said facemasks were required for all staff in the building and physical therapy services were provided in the room for COVID-19 positive residents. The DON stated there was one COVID-19 positive resident who was hospitalized , Resident #4, who remained in the hospital. The Administrator said he did not report positive COVID-19 residents to HHSC, Program Manager, or any other regulatory agency because it was the first time he had COVID-19 in a facility and could not access the computer reporting system. The Administrator said it was important to notify regulatory agencies of COVID-19 positive residents upon first COVID-19 positive resident per COVID-19 policy and he anticipated to submit a self-report of COVID-19 outbreak to HHSC by the end of the day.<BR/>Record review of the facility policy, titled COVID-19 Prevention, Response, and Reporting, dated 06/22, reflected the following:<BR/>Policy: <BR/>It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections, COVID-19 information will be reported through the proper channels as per federal, state, and/or local health authority guidance.<BR/>Policy Explanation and Compliance Guidelines:<BR/>1. <BR/>The Infection Preventionist will assess facility risk associated with COVID-19 through surveillance activities of COVID-19 infection in the community and illnesses present in the facility .<BR/>b. Threat detected - the facility will respond promptly and implement emergency and/or outbreak procedures.<BR/>2. Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: heart failure, dementia (cognitive disorder), cancer, vitamin D deficiency, hallucinations, cognitive communication deficit (difficulty with thinking and using language), schizoaffective disorder (mental health condition with symptoms of both schizophrenia and mood disorders), neurocognitive disorder, chronic kidney disease stage 3, epilepsy (seizure disorder), and metabolic encephalopathy (brain dysfunction).<BR/>Record review of Resident #1's, undated, Care Plan reflected he had diabetes mellitus, was unaware of safety needs, and had an ADL self-care performance deficit requiring 1-2 staff assistance and had a skin infection with interventions to include: follow facility policy and procedures for line listing, summarizing, and reporting infections <BR/>Record review of Resident #1's quarterly MDS, dated [DATE], reflected he had a BIMS score of 12, which indicated moderate cognitive impairment.<BR/>During an observation and interview on 01/09/2024 at 10:00 a.m., the OTA G was providing physical therapy services and talking within 3 feet of Resident #1 who sat in his wheelchair in the physical therapy room. The OTA G had a facemask on that did not cover his nose and mouth and the resident was not wearing a facemask. The OTA G said he should be wearing a facemask while in the building within proximity to residents. The DOR, she said she oversaw proper PPE donning of facemasks and she did not know why the PT did not have his facemask donned properly while he was in close proximity with residents, and it may be due to the resident not being able to understand him and the DOR said she would address the concern. The DOR said the facility provided training on PPE donning and doffing during the current COVID-19 outbreak and it was important to properly don PPE to prevent the spread of infection for all residents at the facility. The DOR said her staff had not tested positive for COVID-19 and that therapy is provided in rooms for COVID-19 positive residents.<BR/>During an observation and interview on 01/09/2024 at 10:16 a.m., CNA D walked out of the shower room into the hallway directly across from the COVID-19 positive resident room with their door open and grabbed linen from the hallway storage rack. The CNA had no facemask donned in the hallway and said she was taking care of a positive COVID-19 resident today and indicated the room with isolation precaution signage and the PPE container directly across from the shower room where she had exited. The CNA said she was required to wear a facemask in the building and did not know why she did not have one on and facemasks were available at the nurse's station. The CNA said she received training on infection control and proper donning/doffing and said it was important to wear a facemask to prevent the spread of infection for all residents. The CNA D returned to the shower room with no facemask donned and donned a facemask at the nursing station to cover her nose and mouth. <BR/>During an interview on 01/09/2024 at 10:23 a.m., LVN A said CNA D was required to wear a facemask in the hallway and when showering residents and she had not noticed any staff not wearing their facemask. LVN A said she received training on PPE donning/doffing and said she would stop and remind staff to wear their facemask if she saw staff in the hallway without a facemask. LVN A said all charge nurses, the ADON, and the DON were responsible for ensuring facemasks were donned properly. LVN A said all residents were at risk for the spread of COVID-19 if facemasks were not properly donned, and it was important for staff to wear their facemasks to prevent the spread of infection. LVN A said she worked on Hall S that had the majority of COVID-19 positive residents on 01/07/2024 and that she had approximately 7 positive residents. <BR/>Record review of Resident #2's, undated, face sheet, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: asthma (lung disease), family history of HIV (Human Immunodeficiency Virus) (virus that attacks the body's immune system), disorder invol<BR/>ving the immune mechanism, and type 2 diabetes mellitus with diabetic neuropathy (nerve damage).<BR/>Record review of Resident #2's, undated, Care Plan reflected he was at risk for signs and symptoms of COVID-19 and he was unable to wear a mask due to needing his mouth to navigate his wheelchair with interventions to include: educate staff, resident, family, and visitors of COVID-19 signs and symptoms and precautions, and follow facility protocol for COVID-19 screening/precautions.<BR/>Record review of Resident #2's MDS section in electronic health record, revealed admission MDS had not been completed since his recent admission on [DATE].<BR/>During an observation and interview on 01/09/2024 at 11:00 a.m., the PT R was ambulating in the hallway with Resident #2. The PT was wearing a facemask that did not cover his nose and mouth while talking and ambulating in the hallway within 3 feet of Resident #2. Resident #2 did not have a facemask donned and they ambulated from Hall S, with the majority of reported COVID-19 positive residents. The PT R said he was supposed to wear his facemask when interacting with residents. The PT R said he was not sure if he was supposed to wear a face mask at all times in the facility and they provided training on infection control donning and doffing during the current COVID-19 outbreak. The PT R donned his facemask and covered his nose and mouth. The PT R said it was important to wear his mask while in close proximity of residents to prevent the risk of spreading infection to residents in the facility.<BR/>During an observation and interview on 01/09/2023 at 11:05 a.m., the Housekeeper had a facemask donned and said staff were required to wear facemasks in the hallways and in close proximity of residents and improper donning could put all residents at risk for getting sick. The Housekeeper said it was important to wear the facemasks properly to prevent the spread of infection.<BR/>During an interview on 01/09/2024 at 12:29 p.m., the DON and Administrator said the charge nurses, the ADON, and herself were ultimately responsible for ensuring proper PPE donning/doffing. The DON said staff were required to wear their masks when they were in a patient area or in the hallway. The DON said she ensured residents wore facemasks by doing daily reminders to encourage residents to wear them. The DON said there was no set schedule for monitoring of proper donning and doffing of PPE. The DON said she would continue to ensure compliance by frequent monitoring rounds to see if they were following protocols. The DON said if a staff member was observed without a facemask donned the employee would be stopped and provided education to review the importance for staff to wear their facemasks in order to prevent the risk of spreading infection. <BR/>During a telephone interview on 01/09/2024 at 12:39 p.m., the Attending Physician said he was aware of the COVID-19 outbreak at the facility and had a COVID-19 protocol for any resident that tested positive to include medication and staff must wear a mask in the facility if exposed to COVID-19 to prevent the spread of infection. <BR/>Record review of the facility policy, titled Infection Surveillance, dated 07/2022, reflected the following:<BR/>Policy:<BR/>A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. <BR/>Definitions:<BR/> .'Process measure' is a mechanism for evaluating specific steps in a process that lead, either positively or negatively, to a particular outcome metric. Also known as performance monitoring, a process measure is used to evaluate whether infection prevention and control practices are being followed .<BR/>Policy Explanation and Compliance Guidelines:<BR/>1. <BR/>The Infection Preventionist serves as the leader in surveillance activities . and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required .<BR/>Review of CDC Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19)Pandemic at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#SARS-CoV-2-metrics revealed the following:<BR/> .Source control is recommended for individuals in healthcare settings who:<BR/>Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or<BR/>Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure.<BR/>Source control is recommended more broadly as described in CDC's Core IPC Practices in the following circumstances:<BR/>By those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over (e.g., no new cases of SARS-CoV-2 infection have been identified for 14 days); or<BR/>Facility-wide or, based on a facility risk assessment, targeted toward higher risk areas (e.g., emergency departments, urgent care) or patient populations (e.g., when caring for patients with moderate to severe immunocompromise) during periods of higher levels of community SARS-CoV-2 or other respiratory virus transmission (See Appendix)<BR/>Have otherwise had source control recommended by public health authorities (e.g., in guidance for the community when COVID-19 hospital admission levels are high) .<BR/>Review of CDC's SARS-CoV-2 Community Transmission Level at https://covid.cdc.gov/covid-data-tracker/#maps_new-admissions-rate-county revealed Community Transmission Level was Low for the county.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an accurate MDS was completed for 6 of 12 residents (Residents #9, 25, 33, 50, 94, and 97) reviewed for MDS assessment accuracy.<BR/> The facility did not accurately code Resident #9's quarterly MDS assessment for assistance with eating and diuretic use.<BR/>The facility did not accurately code Resident # 25's annual MDS assessment for antipsychotic medication use. <BR/>The facility did not accurately code Resident #33's annual MDS assessment for Pressure Ulcer and insulin use, opioid use, antidepressant use, antibiotic use, and antianxiety use.<BR/>The facility did not accurately code Resident #50's quarterly MDS assessment for assistance with eating and diuretic use, opioid use, antidepressant use, and anticoagulant use.<BR/>The facility did not accurately code Resident #94's quarterly MDS assessment for antipsychotic use.<BR/>The facility did not accurately code Resident #97's admission MDS assessment for antianxiety use and anticoagulant use.<BR/>This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. <BR/>Findings included:<BR/>1.A review of Resident #9's face sheet and physician's orders for August 2023 indicated Resident #9 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including heart failure, diabetes, bipolar disorder (a disorder associated with mood swings ranging from depressive lows to manic highs), anxiety disorder, and depressive episodes. <BR/>A review of Resident #9's physician's order dated August 2023 indicated she had an order dated 11/22/2021 to receive a diuretic, acetazolamide, 500 mg twice a day. <BR/>A review of Resident #9's May 2023 MAR indicated the resident had received acetazolamide as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #9's quarterly MDS (Section N410: medications received) dated 05/11/2023 indicated she had not received a diuretic during the observation period. The same MDS (Section G: Functional status) indicated the resident required limited assistance of one-person physical assist with eating.<BR/>A review of a care plan initiated on 11/22/2021 and last revised on 06/17/2022 indicated Resident #9 required set up assistance by staff to eat.<BR/>During an observations and interview on 08/14/23 at12:37 PM Resident #9 was eating her lunch without assistance and having no problems. She said the food was pretty good and she was having no issues with eating.<BR/>During an observations and interview on 08/15/23 at12:40 PM Resident #9 was eating her lunch without assistance and having no problems. She was dipping the zucchini sticks into her salad dressing and said it was really good and wished she had some more.<BR/>2. A review of Resident #25's face sheet and physician's orders for August 2023 indicated Resident #25 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including psychosis and schizoaffective disorder (mental disorders). <BR/>A review of Resident #25's physician's order dated 05/21/2022 indicated he was to receive an antipsychotic, Seroquel, 100 mg daily at bedtime and an order dated 02/16/2023 indicated he was to also receive Seroquel 50 mg daily in the morning. <BR/>A review of Resident #25's June 2023 MAR indicated the resident had received both the morning and evening doses of the antipsychotic, Seroquel, as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #25's Annual MDS (Section N: Antipsychotic Medication Review) dated 06/21/2023 indicated he had not received an antipsychotic medication during the observation period. This incorrect coding led to the rest of the Antipsychotic Medication Review section of the MDS not being completed. <BR/>During an interview on 08/14/2023 at 10:30 AM with the MDS Coordinator from a sister facility, she said the facility did not have a full time MDS Coordinator and that she was helping at this facility a couple of days a week. She said she was not the person who completed Resident # 25's annual MDS.<BR/>During an interview on 08/17/2023 at 11:20 AM with the sister facility's MDS Coordinator, she said Section N0450-A should have been coded as the resident having received an antipsychotic medication which would have also led to the rest of the assessment being completed.<BR/>3. A review of Resident #33's face sheet and physician's orders for August 2023 indicated Resident #33 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including diabetes, stage 4 pressure ulcer of sacral region, chronic pain, paraplegia (paralysis of the legs and lower body), depressive disorder, anxiety disorder, urinary tract infection, and high blood pressure. <BR/>A review of Resident #33's physician's order dated August 2023 indicated she had orders dated 01/05/2023 to receive an antianxiety medication, venlafaxine, 75 mg daily; orders dated 09/03/2021 to receive an antianxiety medication, clonazepam, 0.5 mg twice a day; orders dated 03/15/2022 to receive an antibiotic, Hiprex, 1,000 mg twice a day; orders dated 02/25/2023 to receive an opioid, oxycodone ER, 15 mg twice a day, orders to receive an insulin, Levemir, 80 units subcutaneously twice a day.<BR/>A review of Resident #33's July 2023 MAR indicated the resident had received venlafaxine, clonazepam, antibiotic, opioid, and insulin as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #33's Wound Assessment Profile dated 07/06/2023, 07/13/2023, 08/03/2023, and 08/10/2023 indicated the resident had a stage 4 pressure ulcer on the sacrum (an injury that extends through muscle, tendon or bone).<BR/>A review of Resident #33's annual MDS dated [DATE] (Section M: Skin Conditions) indicated she did not have one or more unhealed pressure ulcer/injuries and (Section N410: medications received) indicated she had not received insulin injections, antianxiety medications, antidepressant medications, antibiotics, and opioid medications.<BR/>4. A review of Resident #50's face sheet and physician's orders for August 2023 indicated Resident #50 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular, often rapid, heart rate that commonly causes poor blood flow), chronic obstructive pulmonary disease, diabetes, pain, major depressive disorder, and peripheral venous insufficiency (walls of the veins not working properly making it difficult for the blood to return to the heart). <BR/>A review of Resident #50's physician's order dated August 2023 indicated she had an order dated 04/20/2023 to receive a diuretic, furosemide, 40 mg daily; an order dated 04/20/2023 to receive hydrocodone-acetaminophen 10-325 mg twice a day; , an order dated 07/04/2023 to receive insulin, Glargine 35 units subcutaneously in the morning before breakfast and Glargine 35 units subcutaneously (insertion under te skin by injection) at bedtime; an order dated 07/20/23 to receive Novolog insulin sliding scale before meals and at bedtime, an order dated 04/20/2023 to receive an anticoagulant, rivaroxaban, 20 mg in the evening; and an order dated 04/20/2023 to receive an antidepressant, trazadone, 50 mg at bedtime. <BR/>A review of Resident #50's July 2023 MAR indicated the resident had received rivaroxaban, furosemide, trazadone, hydrocodone-acetaminophen, Glargine, and Novolog, as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #50's quarterly MDS (Section N410: medications received) dated 07/25/2023 indicated she had not received insulin injections, an antidepressant, an anticoagulant, a diuretic, and an opioid during the observation period. The same MDS (Section G: Functional status) indicated the resident required limited assistance of two-persons physical assist with eating.<BR/>A review of a care plan initiated on 11/30/2018 and last revised on 12/05/2018 indicated Resident #50 required assistance of one staff member to eat<BR/>During an observation and interview on 08/14/23 at 12:39 PM Resident #50 was eating her lunch without assistance. She was sitting upright in bed and eating her lunch. She said it wasn't too bad.<BR/>During an observation and interview on 08/15/23 at 12:55 PM Resident #50 was eating her lunch without assistance. She was sitting upright in bed and eating her lunch. She was nodding off a little while eating.<BR/>5. A review of Resident #94's face sheet and physician's orders for August 2023 indicated Resident #94 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including schizophrenia (mental disorder), epilepsy (seizure disorder), major depressive disorder, and alcohol use. <BR/>A review of Resident #94's physician's order dated August 2023 indicated she had an order dated 10/27/2022 to receive an antipsychotic, Seroquel, 300 mg at bedtime and an order dated 03/31/2023 to receive Seroquel 150 mg in the morning. <BR/>A review of Resident #94's April and May 2023 MARs indicated the resident had received Seroquel as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #94's quarterly MDS (Section N410: medications received) dated 05/04/2023 indicated she had received an antipsychotic during the observation period. (Section N450: Antipsychotic Medication Review) dated 05/04/2023 indicated she had not received an antipsychotic medication during the observation period. This incorrect coding led to the rest of the Antipsychotic Medication Review section of the MDS not being completed. <BR/>6. A review of Resident #97's face sheet and physician's orders for August 2023 indicated Resident #97 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including atrial fibrillation an irregular, often rapid, heart rate that commonly causes poor blood flow), anxiety disorder (amental health disorder characterized by feelings of worry or fear), high blood pressure, and pneumonia.<BR/>A review of Resident #97's physician's order dated August 2023 indicated she had an order dated 05/11/2023 to receive an antianxiety, clonazepam, 0.5 mg twice a day and an anticoagulant, enoxaparin injectable 30 mg/0.3 ml injected subcutaneously every morning. <BR/>A review of Resident #97's May 2023 MAR indicated the resident had received 6 of 7 doses of enoxaparin of the 7 doses as ordered by the physician and clonazepam 5 of the 7 doses as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #97's admission MDS (Section N410: medications received) dated 05/17/2023 indicated she had not received an antianxiety medication or an anticoagulant during the observation period. <BR/>During an interview on 08/16/2023 at 01:35 PM with the sister facility's MDS Coordinator, she said she had been helping with the MDS since about June 2023. She said the RAI manual was used as the guideline for performing the MDS assessment. She said the policy would be to follow the RAI.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of 3 of 5 residents reviewed for pharmacy services (Residents #45, #57, and #173).<BR/>The facility failed to ensure the physician's order for Vitamin C included the dose of Vitamin C to be administered to Resident #45. <BR/>The facility failed to ensure three (3) physician prescribed medications including Vitamin B12 (a vitamin present in foods of animal origin), Brimonidine tartrate ophthalmic (refers to the eye) solution (eye drops to treat glaucoma, a condition wherein the nerve connecting the eye to the brain is damaged and can result in blindness)), and Latanoprost ophthalmic eye drops (to treat glaucoma) were available for administration to Resident #57 as ordered by the physician.<BR/>The facility failed to obtain a stop date for an antibiotic dated 9/16/2024 per the hospital discharge summary, resulting in Resident #173 receiving the medications beyond the intended stop date. <BR/>These failures could place residents at risk for not receiving their medications as ordered and resulting in a decline in health and decreased quality of life. <BR/>Findings included:<BR/>1. A review of Resident #45's face sheet and physician orders dated 09/24/2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included epilepsy, systemic lupus erythematosus (an illness that occurs when the immune system attacks healthy tissues and organs) cerebral infarction (stroke), hemiparesis of the right side (right-sided paralysis), atrial fibrillation (heart disorder), and a history of blood and blood-forming organs.<BR/>During observation of medication administration on 09/24/2024 at 08:40 AM, MA C was observed to administer one Vitamin C 500mg tablet (helps the immune system work properly) to Resident #45. <BR/>A review of Resident #45's physician orders indicated an incomplete order, initiated on 05/06/2022, for 1 tablet Vitamin C to be given two times daily. The order did not include the dose to be administered. <BR/>A review of Resident #45's MAR dated for September 2024 indicated incomplete instructions for 1 tablet of Vitamin C to be administered two times daily. The order did not specify the dose of Vitamin C to be administered. <BR/>A review of pharmacy reviews for the months of July, August, and September 2024 indicated the facility's pharmacy had not addressed the incomplete order of Vitamin C regarding the specific dose of Vitamin C to be administered twice daily. <BR/>2.A review of Resident #57's face sheet and physician orders dated for 09/24/2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included protein calorie malnutrition and glaucoma (a condition wherein the nerve connecting the eye to the brain is damaged and can result in blindness). <BR/>During observation of medication administration on 09/24/2024 at 09:25 AM, RN D did not administer two (2) physician prescribed medications which included 1 tablet Vitamin B12 100mcg and Brimonidine tartrate ophthalmic solution 0.2% (eye drops) one (1) drop each eye to Resident #57. After a search of the medication cart and medication rooms, it was determined the medications were not available for administration. <BR/>A review of Resident #57's physician's orders dated for September 2024 was observed to include an order dated 05/11/2023 for 1 tablet of Vitamin B12 100mcg to be administered one time daily and an order dated 05/26/2024 for one drop (1) of Brimonidine tartrate ophthalmic solution 0.2% to be instilled into each eye three times daily.<BR/>A review of Resident #57's MAR dated for September 2024 indicated the Vitamin B12 100mcg tablet and the Brimonidine ophthalmic solution were documented as not being administered on 09/24/2024 at 09:25 AM due to unavailability. <BR/>Further review of Resident 57's September MAR on 09/25/2024 indicated Resident #57 did not receive any of the three scheduled (3) doses of Brimonidine ophthalmic solution on 09/24/2025 due to unavailability. Instructions to administer one (1) drop of Latanoprost 0.005% ophthalmic solution was also noted as not being administered on the evening of 09/24/2024.<BR/>Further review of Resident #57's physician orders indicated Resident #57 did have an order for one (1) drop of Latanoprost ophthalmic solution to be administered every evening. <BR/>3.A review of Resident #173's face sheet and physician's orders for September 2024 indicated he was a [AGE] year-old male who admitted [DATE] with diagnosis which included acquired absence of right leg below knee, age-related cognitive decline, cognitive communication deficit, muscle wasting and atrophy, not elsewhere classified, multiple sites, and paroxysmal atrial fibrillation, type 2 diabetes mellitus with diabetic neuropathy.<BR/>A review of Resident #173's physicians order dated 8/27/2024 indicated he was to receive Levofloxacin 750 mg tablet, orally once a day. There was no stop order for this antibiotic.<BR/>A review of Resident #173's care plan dated 9/17/2024 indicated Antibiotics and Nurse to monitor.<BR/>During an interview with RN D on 09/24/2024 at 09:45 AM, she said she did not have any B12 100mcg tablets nor the Brimonidine ophthalmic solution in her cart. She said she checked the cart and med rooms and did not find any of the two (20 medications. She said the RN Nurse Consultant told her to call the doctor and obtain clarification of the Vitamin B12 dose and to call the pharmacy and ask them to stat out the Brimonidine eye drops. RN D explained stat out meant the pharmacy would either send it or get another local pharmacy to send it out to the facility immediately. <BR/>During an interview with LVN A on 09/24/2024 at 11:30 AM, she said she was the charge nurse, and she would check on why there was not a stop date on antibiotic for resident#173. She said she was the nurse responsible for transcribing the orders and acknowledged to the surveyor that she had not read the hospital discharge summary and did not ask for a stop date from the hospital physician or medical director. She said but she would check with the medical director for orders and currently there was no monitoring for adverse reactions being done.<BR/>During an interview with the IP Nurse on 09/25/2024 at 11:40 AM, she said she was new at this job, just got her certification 9/18/2024, and was still learning the policies on antibiotic stewardship.<BR/>During an interview with the ADON on 9/24/2024 at 11:45 AM, he said all antibiotics are to have an end date per facility policy.<BR/>During an interview with the DON on 09/25/2024 at 11:50 AM, he said he expected medications to be administered as ordered to prevent negative results that could adversely affect the residents. He said that according to facility policy all antibiotics should have a stop date. He said the facility did not have a contract with infectious disease and they use the policy on Antibiotic Prescribing Practices and will have to call the medical director to get a stop date and appointment for follow up with infectious disease for stop order.<BR/>A review of the facility's policy titled Pharmacy Services and dated 07/2022 indicated the following:<BR/>Policy:<BR/>It is the policy of this facility to ensure that pharmacological services .are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. <BR/>A review of facilities policy titled Antibiotic Stewardship Program, dated 06/2022 indicated the following:<BR/>Policy: All prescriptions for antibiotics shall specify the dose, duration and indication for use.<BR/>A review of facilities policy titled Antibiotic Prescribing Practices indicated the following:<BR/>Policy: The facility will utilize a 5D's approach to antibiotic prescribing:<BR/>a. <BR/>Diagnosis<BR/>b. <BR/>Drug<BR/>c. <BR/>Dose<BR/>d. <BR/>Duration: Documentation shall include start date, end date and planned days of therapy<BR/>e. <BR/>De-escalation - reassessment of empiric precautions will be conducted after 2-3 days or appropriateness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate less that 5 percent. There were 3 errors out of 31 opportunities, resulting in a 9 percent medication error rate involving 2 of 4 residents (Residents #45 and #57) reviewed for medication administration.<BR/>MA C administered Vitamin C to Resident #45 without verifying the dose to be given. <BR/>RN D failed to administer Vitamin B12 and Brimonidine ophthalmic solution 2% to Resident # 57 as ordered by the physician. <BR/>These failures could place residents at risk for inaccurate drug administration resulting in a decline in health and decreased quality of life. <BR/>Findings included:<BR/>1.A review of Resident #45's face sheet and physician orders dated 09/24/2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included epilepsy, systemic lupus erythematosus (an illness that occurs when the immune system attacks healthy tissues and organs) cerebral infarction (stroke), hemiparesis of the right side (right-sided paralysis), atrial fibrillation (heart disorder), and a history of blood and blood-forming organs.<BR/>During observation of medication administration on 09/24/2024 at 08:42 AM, MA C administered medications to Resident #45 which included one (1) tablet of Vitamin C 500mg. <BR/>Record review of the Resident #45's physician orders dated for 09/24/2024 indicated an incomplete order, initiated on 05/06/2022, for one (1) tablet of Vitamin C to be administered twice daily. The order did not include the dose of Vitamin C to be administered. <BR/>2. A review of Resident #57's face sheet and physician orders dated for 09/24/2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included protein calorie malnutrition and glaucoma (a condition wherein the nerve connecting the eye to the brain is damaged and can result in blindness). <BR/>During observation of medication administration on 09/24/2024 at 09:25 AM, RN D was observed to administer two (2) medications (metoprolol and apixaban) to Resident #57 via the Resident's gastrostomy tube. <BR/>Record review of Resident #57's physician's orders dated for September 2023 indicated Resident #57 was also to receive <BR/>one (1) tablet of Vitamin B12 100mcg and one (1) drop of Brimonidine 2% ophthalmic solution instilled in each eye.<BR/>These two (2) medications were not administered the observed medication pass at 09:25 AM on 09/24/2024. <BR/>During an interview on 09/25/2024 at 09:10 AM with MA C, she said she had not noticed the order for Vitamin C was missing the dose to be given. She said Vitamin C 500mg was the dose she was used to giving the other residents. MA C said she should have observed the basic rights of medication administration and if she had, she would have noticed the dose was missing and told the charge nurse. She said the basic Rights of Medication Administration included checking for the right dose of medications to be administered. <BR/>During an interview with RN D on 09/24/2024 at 09:35 AM, she said she did not have any Vitamin B12 100mcg tablets nor did she have any Brimonidine eye drops to administer to Resident #57. She said she could not locate any in the facility's emergency supply, the medication carts, nor the medication rooms. She said the RN Consultant told her to call the physician and get the Vitamin B12 and Vitamin C doses verified. She said the RN Consultant also told her to call the pharmacy and ask them to stat out the Brimonidine eye drops. RN D explained stat out meant the pharmacy would either send it or get another local pharmacy to send it out to the facility immediately. <BR/>During an interview with the DON on 09/25/2024 at 11:40 AM, he said he expected medications to be administered as ordered to prevent negative results that could adversely affect the residents. <BR/>During an interview with the RN Nurse Consultant on 09/25/2024 at 11:00 AM, she said Resident #45's Vitamin C order had been clarified to read one tablet of Vitamin C 500mg twice daily. She said the Vitamin C order had probably been incomplete since it was initially written. She said Resident #57's Vitamin B12 order had been clarified and changed to Vitamin B12 1000mcg daily. She said Resident #57's Brimonidine and Latanoprost ophthalmic solutions had been delivered and the physician was made aware of the missed doses. She said she did not know why the eye drops were not delivered on 09/24/2024. <BR/>A review of the facility's policy dated 07/2022 and titled Pharmacy Services included the following:<BR/>Compliance Guidelines: <BR/>8. The pharmacist, in collaboration with the facility and medical director, should include within its services to:<BR/>f. strive to assure that medications are requested , received, and administered in a timely manner as ordered by the authorized prescriber .<BR/>A review of the facility's policy dated and titled Medication Administration indicated the following:<BR/>Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. <BR/>10.Ensure that the six rights of medication administration are followed:<BR/>a. <BR/>Right resident<BR/>b. <BR/>Right drug <BR/>c. <BR/>Right dosage **<BR/>d. <BR/>Right route<BR/>e. <BR/>Right time<BR/>f. <BR/>Right documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 12 residents (Resident #1, Resident #2, and Resident #4) reviewed for infection control. <BR/>1. The facility failed to ensure a resident COVID-19 outbreak that included one hospitalization, Resident #4, was reported to state regulatory authority.<BR/>2. The facility failed to ensure the OTA G, CNA D, and PT R maintained proper donning of facemasks for source control in the hallway and within 3 feet of Resident #1 and Resident #2 during a COVID-19 outbreak.<BR/>These failures could place residents at risk for development and spread of infection.<BR/>Findings include:<BR/>1. Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old female with an initial admission date of 12/05/2022. Resident #4 had diagnoses which included atrial fibrillation (irregular heartbeat), iron deficiency anemia secondary to blood loss (chronic) (decreased iron in the body due to excess bleeding), COVID-19, acute kidney failure, and chronic kidney disease, stage 4 (severe).<BR/>Record review of Resident #4's annual MDS, dated [DATE], reflected she had a BIMS score of 12, which indicated moderate cognitive impairment.<BR/>Record review of Resident #4's Care Plan, revised 01/02/2024, reflected she was at risk for signs and symptoms of COVID-19 and tested positive on 01/02/2024 with interventions to include: following facility protocol for COVID-19 screening/precautions and educate staff of COVID-19 signs and symptoms and precautions<BR/>Record review of the COVID-19 Log, dated 1/9/2024, and undated, Floorplan reflected Resident #4 tested positive for COVID-19 on 01/02/2024. The COVID-19 Log reflected 40 total COVID-19 positive residents and 5 positive staff since 12/30/2023. <BR/>Record review of Resident #4's Progress Notes, dated from 12/16/2023 through 01/07/2023, reflected multiple COVID-19 positive staff worked with Resident #4 to include LVN B, ADON, and LVN C. Progress Notes reflected Resident #4 was sent to the hospital on [DATE] per physician's orders following a change in condition to include labored breathing, fever, and altered mental status.<BR/>Record review of Resident #4's hospital records, dated 01/09/2024, reflected resident was being discharged from the hospital on [DATE] to return to nursing facility and had a hospital diagnosis which included .acute hypoxic respiratory failure (not enough oxygen in blood) secondary to pneumonia and COVID.<BR/>During an observation and interview on 01/09/2024 at 9:12 a.m., signage was posted at the entry notifying visitors there were COVID-19 positive residents in the facility.<BR/>During an interview on 01/09/2024 at 9:15 a.m., the Administrator and DON stated the facility had a COVID-19 outbreak and the ADON and DON was the IP and the ADON was not at work at the time of the survey. The DON stated 3 staff and 30 residents were currently positive for COVID-19 at the facility. The DON stated the facility did not have a designated COVID-19 unit; however, the majority of positives were located Hall S, and the outbreak initiated from LVN B who tested positive during routine testing on 12/29/2023 at another nursing facility, she was employed. The DON said facemasks were required for all staff in the building and physical therapy services were provided in the room for COVID-19 positive residents. The DON stated there was one COVID-19 positive resident who was hospitalized , Resident #4, who remained in the hospital. The Administrator said he did not report positive COVID-19 residents to HHSC, Program Manager, or any other regulatory agency because it was the first time he had COVID-19 in a facility and could not access the computer reporting system. The Administrator said it was important to notify regulatory agencies of COVID-19 positive residents upon first COVID-19 positive resident per COVID-19 policy and he anticipated to submit a self-report of COVID-19 outbreak to HHSC by the end of the day.<BR/>Record review of the facility policy, titled COVID-19 Prevention, Response, and Reporting, dated 06/22, reflected the following:<BR/>Policy: <BR/>It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections, COVID-19 information will be reported through the proper channels as per federal, state, and/or local health authority guidance.<BR/>Policy Explanation and Compliance Guidelines:<BR/>1. <BR/>The Infection Preventionist will assess facility risk associated with COVID-19 through surveillance activities of COVID-19 infection in the community and illnesses present in the facility .<BR/>b. Threat detected - the facility will respond promptly and implement emergency and/or outbreak procedures.<BR/>2. Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: heart failure, dementia (cognitive disorder), cancer, vitamin D deficiency, hallucinations, cognitive communication deficit (difficulty with thinking and using language), schizoaffective disorder (mental health condition with symptoms of both schizophrenia and mood disorders), neurocognitive disorder, chronic kidney disease stage 3, epilepsy (seizure disorder), and metabolic encephalopathy (brain dysfunction).<BR/>Record review of Resident #1's, undated, Care Plan reflected he had diabetes mellitus, was unaware of safety needs, and had an ADL self-care performance deficit requiring 1-2 staff assistance and had a skin infection with interventions to include: follow facility policy and procedures for line listing, summarizing, and reporting infections <BR/>Record review of Resident #1's quarterly MDS, dated [DATE], reflected he had a BIMS score of 12, which indicated moderate cognitive impairment.<BR/>During an observation and interview on 01/09/2024 at 10:00 a.m., the OTA G was providing physical therapy services and talking within 3 feet of Resident #1 who sat in his wheelchair in the physical therapy room. The OTA G had a facemask on that did not cover his nose and mouth and the resident was not wearing a facemask. The OTA G said he should be wearing a facemask while in the building within proximity to residents. The DOR, she said she oversaw proper PPE donning of facemasks and she did not know why the PT did not have his facemask donned properly while he was in close proximity with residents, and it may be due to the resident not being able to understand him and the DOR said she would address the concern. The DOR said the facility provided training on PPE donning and doffing during the current COVID-19 outbreak and it was important to properly don PPE to prevent the spread of infection for all residents at the facility. The DOR said her staff had not tested positive for COVID-19 and that therapy is provided in rooms for COVID-19 positive residents.<BR/>During an observation and interview on 01/09/2024 at 10:16 a.m., CNA D walked out of the shower room into the hallway directly across from the COVID-19 positive resident room with their door open and grabbed linen from the hallway storage rack. The CNA had no facemask donned in the hallway and said she was taking care of a positive COVID-19 resident today and indicated the room with isolation precaution signage and the PPE container directly across from the shower room where she had exited. The CNA said she was required to wear a facemask in the building and did not know why she did not have one on and facemasks were available at the nurse's station. The CNA said she received training on infection control and proper donning/doffing and said it was important to wear a facemask to prevent the spread of infection for all residents. The CNA D returned to the shower room with no facemask donned and donned a facemask at the nursing station to cover her nose and mouth. <BR/>During an interview on 01/09/2024 at 10:23 a.m., LVN A said CNA D was required to wear a facemask in the hallway and when showering residents and she had not noticed any staff not wearing their facemask. LVN A said she received training on PPE donning/doffing and said she would stop and remind staff to wear their facemask if she saw staff in the hallway without a facemask. LVN A said all charge nurses, the ADON, and the DON were responsible for ensuring facemasks were donned properly. LVN A said all residents were at risk for the spread of COVID-19 if facemasks were not properly donned, and it was important for staff to wear their facemasks to prevent the spread of infection. LVN A said she worked on Hall S that had the majority of COVID-19 positive residents on 01/07/2024 and that she had approximately 7 positive residents. <BR/>Record review of Resident #2's, undated, face sheet, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: asthma (lung disease), family history of HIV (Human Immunodeficiency Virus) (virus that attacks the body's immune system), disorder invol<BR/>ving the immune mechanism, and type 2 diabetes mellitus with diabetic neuropathy (nerve damage).<BR/>Record review of Resident #2's, undated, Care Plan reflected he was at risk for signs and symptoms of COVID-19 and he was unable to wear a mask due to needing his mouth to navigate his wheelchair with interventions to include: educate staff, resident, family, and visitors of COVID-19 signs and symptoms and precautions, and follow facility protocol for COVID-19 screening/precautions.<BR/>Record review of Resident #2's MDS section in electronic health record, revealed admission MDS had not been completed since his recent admission on [DATE].<BR/>During an observation and interview on 01/09/2024 at 11:00 a.m., the PT R was ambulating in the hallway with Resident #2. The PT was wearing a facemask that did not cover his nose and mouth while talking and ambulating in the hallway within 3 feet of Resident #2. Resident #2 did not have a facemask donned and they ambulated from Hall S, with the majority of reported COVID-19 positive residents. The PT R said he was supposed to wear his facemask when interacting with residents. The PT R said he was not sure if he was supposed to wear a face mask at all times in the facility and they provided training on infection control donning and doffing during the current COVID-19 outbreak. The PT R donned his facemask and covered his nose and mouth. The PT R said it was important to wear his mask while in close proximity of residents to prevent the risk of spreading infection to residents in the facility.<BR/>During an observation and interview on 01/09/2023 at 11:05 a.m., the Housekeeper had a facemask donned and said staff were required to wear facemasks in the hallways and in close proximity of residents and improper donning could put all residents at risk for getting sick. The Housekeeper said it was important to wear the facemasks properly to prevent the spread of infection.<BR/>During an interview on 01/09/2024 at 12:29 p.m., the DON and Administrator said the charge nurses, the ADON, and herself were ultimately responsible for ensuring proper PPE donning/doffing. The DON said staff were required to wear their masks when they were in a patient area or in the hallway. The DON said she ensured residents wore facemasks by doing daily reminders to encourage residents to wear them. The DON said there was no set schedule for monitoring of proper donning and doffing of PPE. The DON said she would continue to ensure compliance by frequent monitoring rounds to see if they were following protocols. The DON said if a staff member was observed without a facemask donned the employee would be stopped and provided education to review the importance for staff to wear their facemasks in order to prevent the risk of spreading infection. <BR/>During a telephone interview on 01/09/2024 at 12:39 p.m., the Attending Physician said he was aware of the COVID-19 outbreak at the facility and had a COVID-19 protocol for any resident that tested positive to include medication and staff must wear a mask in the facility if exposed to COVID-19 to prevent the spread of infection. <BR/>Record review of the facility policy, titled Infection Surveillance, dated 07/2022, reflected the following:<BR/>Policy:<BR/>A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. <BR/>Definitions:<BR/> .'Process measure' is a mechanism for evaluating specific steps in a process that lead, either positively or negatively, to a particular outcome metric. Also known as performance monitoring, a process measure is used to evaluate whether infection prevention and control practices are being followed .<BR/>Policy Explanation and Compliance Guidelines:<BR/>1. <BR/>The Infection Preventionist serves as the leader in surveillance activities . and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required .<BR/>Review of CDC Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19)Pandemic at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#SARS-CoV-2-metrics revealed the following:<BR/> .Source control is recommended for individuals in healthcare settings who:<BR/>Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or<BR/>Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure.<BR/>Source control is recommended more broadly as described in CDC's Core IPC Practices in the following circumstances:<BR/>By those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over (e.g., no new cases of SARS-CoV-2 infection have been identified for 14 days); or<BR/>Facility-wide or, based on a facility risk assessment, targeted toward higher risk areas (e.g., emergency departments, urgent care) or patient populations (e.g., when caring for patients with moderate to severe immunocompromise) during periods of higher levels of community SARS-CoV-2 or other respiratory virus transmission (See Appendix)<BR/>Have otherwise had source control recommended by public health authorities (e.g., in guidance for the community when COVID-19 hospital admission levels are high) .<BR/>Review of CDC's SARS-CoV-2 Community Transmission Level at https://covid.cdc.gov/covid-data-tracker/#maps_new-admissions-rate-county revealed Community Transmission Level was Low for the county.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of residents for 1 of 5 residents (Resident #1) reviewed for laboratory services. <BR/>The facility did not obtain UA labs as ordered by the physician for Resident #1.<BR/>This failure could place residents at risk of not receiving treatment and services to meet their needs. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet, printed on [DATE], reflected he was a [AGE] year-old male who originally admitted to facility on [DATE], readmitted to facility on [DATE] and expired in the facility on [DATE] with diagnoses which included Type 2 diabetes mellitus diabetic neuropathy (A chronic condition that affects the way the body processes blood sugar (glucose);With type 2 diabetes, the body either doesn't produce enough insulin, or it resists insulin) Diabetic neuropathy, which affects people with diabetes, causes pain or numbness in the hands, feet or limbs because the nerves are damaged.); Peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs); Lack of coordination (a neurological sign that causes a lack of voluntary muscle coordination. It can affect any part of the body, but people often have difficulty with balance and walking, speaking, swallowing, writing, and eating.); and Muscle weakness (occurs when your muscles don't contract properly, making them weaker than usual.)<BR/>Record review of Resident #1's quarterly MDS date [DATE] reflected he had a BIMS of 13 and was cognitively intact. Resident #1 was able to make himself understood and had no issues understanding others. Also, revealed Resident #1 required moderate to substantial assistance with most ADLs.<BR/>Record review of Resident #1's progress notes reflected the following: <BR/>-On [DATE] at 11:56pm - Urine amber color [Physician] called at that time n.o lab order Urinalysis collected and ready to be picked up. Completed by: LVN B.<BR/>-On [DATE] at 2:32am - n.o lab waiting to be collected at this time. Completed by: LVN B.<BR/>Record review Resident #1's physician order dated [DATE] indicated LVN B created the order on [DATE] for UA with C/S. Directions: one time only to rule out UTI.<BR/>Record review of Resident #1's electronic health records from [DATE] to [DATE] indicated there was no documentation of the UA results.<BR/>During an attempted telephone interview on [DATE] at 2:35 p.m., LVN B was called but an unknown female answered, and denied knowing LVN B and ended the phone call.<BR/>During an interview on [DATE] at 6:38 pm at 7:18 p.m., with LVN C who said she reviewed Resident #1's electronic chart and said LVN B ordered Resident #1 UA lab but did not see documentation of the UA results in Resident #1's chart. LVN C said she was not working on [DATE] and did not know if Resident #1's UA was picked up by the lab company who they were using at the time. LVN C said during the period of Resident #1's UA lab they were in the process of using a new lab company so it was possible something could have got missed. LVN C contacted the previous lab company who the facility used at the time Resident #1's UA lab was ordered, and the previous lab company told LVN C they did not have any information or UA labs regarding Resident #1 for the [DATE] period and was not aware of what she was talking about. LVN C said it was possible Resident #1's UA was never picked up by the previous lab company. <BR/>During an interview on [DATE] at 7:30 p.m., VP of Clinical Operations said the previous DON no longer worked at the facility and said she had been working as the Interim DON until facility can find a new DON. The VP of Clinical Operations said reviewed Resident #1's electronic chart and said she did see an UA order for Resident #1, but she did not see the UA lab results on the chart. She said ultimately it was the DON's responsibility to ensure all labs were being done. The VP of Clinical operations said the following morning during morning meetings was when DON should have followed up and verified Resident #1's UA labs were done, said she was not sure if the previous DON did that. She said LVN C just informed her the previous lab company told her on the phone they did not have UA labs for Resident #1 and for [DATE] period. VP of Clinical Records explained the previous lab company who they were using at the time of the incident used a binder they kept at the nurse stations with Labs to pick up. VP of Clinical Operations said she tried looking for the previous Lab's company binder and she said she could not locate it and could not confirm if Resident #1's UA labs had been done.<BR/>Record review of facility's laboratory services and reporting policy dated 07/2022 revealed the following:<BR/>The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law.<BR/>Policy Explanation and Compliance Guidelines:<BR/>1. The facility must provide or obtain laboratory services to meet the needs of its residents. <BR/>2. The facility is responsible for the timeliness of the services.<BR/>3. Should the facility provide its own laboratory services, the services must meet the applicable requirement for laboratories.<BR/>6. All laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the resident's clinical record.<BR/>7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range.

Based on record review and interview, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis for 1 of 1 facility reviewed for social worker qualifications. <BR/>The facility did not have a qualified social worker since May 05/10/2024. <BR/>This failure could affect residents in need of social services and place them at risk of psycho-social decline and poor-quality of life.<BR/>Findings included:<BR/>Record review of the Facility Summary Report dated 7/8/2024 revealed the facility had a maximum capacity of 172.<BR/>In an interview with the Administrator, on 07/10/2024 at 9:30 AM, said, the Social Worker's last day at the facility was May 10, 2024 and there was not a current full time Social Worker and there has been an attempt to hire a new Social Worker with no success.<BR/>In an interview with the DON, on 7/10/2024 at 10:30 AM, she said the Social Worker's last day at the facility was May 2024 and there was not a current full time Social Worker. DON said she had been attempting to do what she could in the Social Worker's absence, but she was not a licensed Social Worker.<BR/>In an interview with the Regional Director of Operations on 7/10/2024, at 10:40AM, was asked why the facility did not have a Social Worker, she said the last Social Worker's last day at the facility was in May 2024, the Social Worker had quit for another job and there was not a current Social Worker, she said the facility was currently using DON and Administrator to meet the needs of Social Worker.<BR/>In an interview with the HR Director on 07/10/2024 at 10:45AM, said the last Social Workers last day at the facility was 5/10/2024.<BR/>Record review of information for on-site visit , dated 7/10/2024 provided by Health and Human Services and completed by administrator, indicated there was not a Social Worker on staff.<BR/>Record review of facility policy Social Services dated 7/2022 revealed the following [in part]:<BR/>The facility, regardless of size, will provide medically related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. <BR/>Definitions:<BR/>Medically related social services are services provided by the facility's staff to assist residents in attainment or maintenance of a resident's highest practicable well-being.<BR/>Policy Explanation and Compliance Guidelines:<BR/>A facility with more than 120 beds will employ a qualified social worker on a full-time basis. A qualified social worker is an individual with:<BR/>A bachelor's degree in social work or a bachelor's degree in a human services field including but not limited to sociology, gerontology, special education, rehabilitation counseling, and psychology.<BR/>One year of supervised social work experience in a health care setting working directly with individuals.<BR/>The social worker will pursue the provision of any identified need for medically related social services of the resident. Attempts to meet the needs of the resident will be handled by the appropriate discipline(s). Services to meet the resident's needs may include:<BR/>Advocating for residents and assisting them in assertion of their rights within the facility.<BR/>Assisting residents in voicing and obtaining resolution to grievances about treatment, living conditions, visitation rights and accommodation of needs.<BR/>Assisting or arranging for a resident's communication of needs through the resident's primary method of communication or in a language that the resident understands.<BR/>Making arrangement for obtaining items, such as adaptive equipment, clothing, and personal items.<BR/>Maintaining contact with the facility (with the resident's permission) to report on changes in health, current goals, discharge planning, and encouragement to participate in care planning.<BR/>Assisting with informing and educating residents, their family, and/or representative(s) about health care options and their ramifications.<BR/>Making referrals and obtaining needed services from outside entities (e.g., talking books, absentee ballots, community wheelchair transportation).<BR/>Assisting residents with financial and legal matters.<BR/>Transitions of care services (e.g., assisting the resident with identifying community placement options and completion of the application process, arranging intake for home care services for residents returning home, assisting with transfer arrangements to other facilities).<BR/>Providing or arranging for needed mental and psychosocial counseling services.<BR/>Identifying and seeking ways to support residents' individual needs through the assessment and care planning process.<BR/>Encouraging staff to maintain or enhance each resident's dignity in full recognition of each resident's individuality.<BR/>Assisting residents with advance care planning, including but not limited to completion of advance directives.<BR/>Identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident.<BR/>Meeting the needs of residents who are grieving from losses and coping with stressful events.<BR/>The facility should provide social services or obtain needed services from outside entities during situations that include but not limited to the following:<BR/>Lack of an effective family or community support system or legal representative.<BR/>Expressions or indications of distress that affect the resident's mental and psychosocial well-being, resulting from depression, chronic diseases (e.g., Alzheimer's disease and other dementia related diseases, schizophrenia, multiple sclerosis), difficulty with personal interaction and socialization skills, and resident to resident altercations.<BR/>Abuse of any kind (e.g., alcohol or other drugs, physical, psychological, sexual, neglect, exploitation);<BR/>Difficulty coping with change or loss (e.g., change in living arrangement, change in condition or functional ability, loss of meaningful employment or activities, loss of a loved one); <BR/>Need for emotional support.<BR/>Record review of Indeed (website the facility used to advertise for Social Worker) (Indeed is a search engine for jobs that aggregates job listings from major job boards, newspapers, associations, and company career pages. 1. Job seekers can upload their resumes and search for jobs based on location, full-time or part-time status, and job type. 2. Employers can also post job openings for free on Indeed. This facility has instructed) dated 7/1/2024 - 7/10/2024 accessed revealed: As the Social Worker, you will assist with marketing, admissions, discharge, and transfer needs. Under the direction of the Administrator, you will assist in the planning, organization, and development of residents to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. You will also be responsible for maintaining written documentation in the resident medical records per facility policy and state and federal guidelines.

**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 be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 (Resident #1) of 7 residents reviewed for abuse and/or neglect.<BR/>The facility failed to prevent CNA B from physically abuse abusing Resident #1 when she slapped her arm and left a bruise.<BR/>This failure could place residents at risk of abuse and neglect. <BR/>Findings included:<BR/>Record review of the Resident #1's face sheet, dated 5/17/24, indicated she was readmitted to the facility on [DATE] with diagnoses including, hypothyroidism (abnormally low activity of the thyroid gland), dysphagia (difficulty swallowing), diabetes, mild protein-calorie malnutrition, high blood pressure, muscle weakness, lack of coordination, heart failure and anxiety. <BR/>Record review of the Resident #1's MDS, dated [DATE], reflected Resident #1 usually made herself understood and usually understood others. Resident #1 had severe cognitive impairment with a (BIMS of 7). Resident #1 had no physical or verbal behaviors symptoms directed towards herself or others. Resident #1 had no behavior of rejecting care. Resident #1 used a manual wheelchair for locomotion and required supervision or touch assistance with eating and oral hygiene. Resident #1 required patrial/moderate assistance with dressing her upper/lower body, personal hygiene, rolling side to side in the bed, moving from a sitting position to lying flat in the bed, and lying to sitting on the side of the bed. The MDS indicated Resident #1 required substantial/maximal assistance with showers/bathing, putting on/taking off footwear, the ability to stand from a sitting position, chair to bed/ bed to chair transfers, toilet transfers, and tub/shower transfers. The MDS indicated Resident #1 was dependent on staff for toileting.<BR/>Record review of Resident #1's care plan dated 3/12/24, reflected Resident #1 had a risk for bruising and bleeding due to anticoagulant therapy. The care plan interventions included encourage resident to be aware of extremities in relation to environment. The care plan also indicated Resident #1 reported alleged mistreatment by staff and was at risk for increased anxiety. <BR/>Record review of the facility's provider investigation report dated 5/17/24, reflected Resident #1 reported CNA B struck her arm. The police were notified. CNA B was terminated, detained and placed under arrest by the police. <BR/>Record review of CNA B's signed statement, dated 5/13/24, reflected I'm not the only one that hits them . (Resident #1) was just mad because we didn't have a diaper that would fit her. She got mad and pulled the yellow diaper off. She hit me. I never hit anybody . <BR/>During an observation and interview on 5/17/24 at 12:50 p.m., Resident #1 said she called for help in the early morning hours of 5/13/24 because her brief was coming off. Resident #1 demonstrated and described she pulled at the brief showing the CNA the brief did not fit and was coming off. Resident #1 then demonstrated and described that as she was doing this (pulling at the brief) CNA B slapped her arm and indicated she slapped her left arm hard while she (CNA B) stood on the left side of her bed. Resident #1 had a large bruise (approximately 7 inches in length and 3 inches in width) to the posterior aspect of her left forearm. Resident #1 said the bruise was where CNA B hit her. <BR/>During an interview on 5/17/24 at 1:00 p.m., CNA C said it was not acceptable to hit a resident under any circumstances. CNA C said even if they (the residents) hit us (the staff), we the staff do not hit them back. CNA C said this was abuse.<BR/>During an interview on 5/17/24 at 2:15 p.m., LVN D said Resident #1 was very descriptive and named CNA B as the aide who slapped her arm. LVN D said CNA B slapping Resident #1 no matter the reason was abuse.<BR/>During an interview on 5/17/24 at 2:30 p.m., The Corporate RN said she was the acting DON. The Corporate RN said Resident #1 was consistent with her details of the event and had bruising to her left arm where she said a nurse had hit her. The Corporate RN said because of Resident #1's description of the staff member and her (Resident #1's) report that the staff member worked double almost every night- CNA B was identified. The Corporate RN said the Resident #1 had reported the incident happened sometime in the early morning hours. The Corporate RN said when the facility was made aware of the allegation they promptly reported the incident to the state agency and began their investigation. The Corporate RN said safety surveys were completed with no additional findings. The Corporate RN said the CNA B was not at work when they were notified of the allegation (she had worked 10:00 p.m. to 6:00 a.m.) so she was called to facility for interview and they kept here there until the police arrived and detained her. The Corporate RN said the police were notified and walked CNA B out in handcuffs. The Corporate RN said what CNA B did (slapping Resident #1's arm) was abuse and would not be tolerated. The Corporate RN said all staff were in-serviced over ANE. <BR/>During an interview on 5/17/24 at 2:50 p.m., the Administrator said CNA B was immediately terminated and all other staff were in-serviced over abuse, neglect and exploitation. The Administrator said abuse of residents would not be tolerated at the facility. <BR/>Record review of CNA B's personnel action form, dated 5/13/24, indicated she was terminated for misconduct regarding allegations of Abuse and was not eligible for rehire. The personnel action form also indicated criminal charges had were filed.<BR/>Record review of the facility's policy and procedure, dated July 2022, titled Abuse, Neglect and Exploitation, stated It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish, It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 1 of 7 residents (Resident #2) reviewed for abuse and neglect.<BR/>The facility failed to conduct a thorough investigation when Resident #2 alleged LVN A slapped at her hand and cursed at her during wound care. <BR/>This failure could place residents at risk of abuse and neglect. <BR/>Findings included:<BR/>Record review of Resident #2's face sheet, dated 5/17/24, reflected she was a [AGE] years old admitted to the facility on [DATE], with diagnoses which included COPD (chronic obstructive pulmonary disease is a group of lung diseases that block airflow and make it difficult to breathe), dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus), heart disease, muscle weakness and atrophy (wasting or thinning of muscle mass) unspecified open wound of the abdominal wall, chronic pain and depression. <BR/>Record review of the MDS dated [DATE] indicated Resident #2 had clear speech, understood others and made herself understood. The MDS indicated she had moderate cognitive impairment (BIMS of 11). The MDS indicated Resident #2 had no physical or verbal behaviors towards others and had no behavior of rejecting care. The MDS indicated Resident #2 required supervision or touching assistance with oral hygiene, and eating. The MDS indicated she required partial/moderate assistance with dressing the upper body and personal hygiene. The MDS indicated Resident #2 required substantial/maximal assistance with toileting, showering/bathing and dressing the lower body. The MDS indicated she was dependent on staff for the putting on ad taking off of footwear and all transfers. The MDS indicated she required staff assistance for locomotion in her manual wheelchair. The MDS indicated she had an ostomy (urostomy, ilestomy or colostomy) present. The MDS indicated she was always incontinent of bowel and bladder. <BR/>Record review of the care plan for Resident #2 dated 4/29/24, indicated Resident #2 had a surgical wound to her abdomen. The care plan interventions included wound protocol. The care plan did not indicate Resident #2 had any history of making false allegations directed toward staff. <BR/>Record review of the provider investigation report dated 5/9/24 indicated Resident #2's family member reported to the facility on 5/8/24 LVN A slapped Resident #2's hand away and cursed at her (Resident #2) during wound care. The investigation report indicated Resident #2 was assessed on 5/8/24 and was found without injury. The investigation report indicated Resident #2 denied the allegation against LVN A had occurred. The investigation report indicated LVN A denied the allegation and that she (LVN A) stated she never slapped or even moved Resident #2's hand away and certainly did not curse at Resident #2. The investigation report stated Alleged perpetrator was immediately suspended, pending investigation. Statements were obtained from resident, alleged perpetrator, Director of Nurses interviewed resident, as well as Administrator, at two separate times. Resident complained of pain during wound care, but denied the allegation made by .(Resident #2's family member). LVN [LVN A] was in-serviced by Director of Nurses regarding procedure, if resident complains of pain with wound care. Abuse and Neglect in-service provided by Director of Nurses. Safe Surveys completed by social worker. Physician and RP[Resident Representative] informed of allegation. Assessment performed by Director of Nurses, no physical or emotional harm was reported by resident.<BR/>Record review of LVN A's employee file found that all appropriate trainings regarding abuse, neglect and exploitation had been completed by LVN A. The employee file revealed all appropriate background checks ( criminal history, LVN licensure verification, NAR and EMR) had been conducted prior to hire. The employee file review found no disciplinary actions against LVN A related to abuse, neglect and exploitation or attitude towards residents/other staff. <BR/>During an interview on 5/10/24 at 10:00 a.m., Resident #2's family member said Resident #2 called her on the evening of 5/7/24 and told her LVN A had performed wound care. Resident #2's family member said during the care LVN A had slapped at her hand and told her to get her motherfing hand down. The family member said Resident #2 was very with it and was only [AGE] years old and that she could tell me exactly what occurred. <BR/>During an observation on 5/10/24 at 10:30 a.m., LVN A provided a breathing treatment to Resident #2. During the care, Resident #2 smiled and talked with the LVN A. Resident #2 displayed no signs of fear during the interaction. <BR/>During an observation and interview on 5/10/24 at 11:00 a.m., Resident #2 lay in her bed. Resident #2 had no scratches, bruising or marks to her hands or lower arms. Resident #2 said in the evening on 5/7/24, LVN A came into her room and performed wound care. Resident #2 said LVN A ripped off the old bandage and it hurt. Resident #2 said and demonstrated she had a tendency to hold her hands in fist shape with hands up to her shoulders during wound care because the wound care was uncomfortable. Resident #2 said when she held her hands up to her shoulders in the shape of fists, LVN A slapped at her hand and told her to get her motherfing hand away from there. Resident #2 said she told her family member about the situation on the phone that night (5/7/24). Resident #2 said LVN A came back later in the shift and apologized to her and said she was frustrated with another staff member. Resident #2 said she did not feel LVN A being frustrated with another staff member was a reason to treat her like that. Resident #2 said the incident made her mad, but she was not scared of LVN A. Resident #2 said LVN A had not provided wound care to her since the incident and that was fine with her because she felt LVN A could have been more careful when taking of her bandage. Resident #2 said wound care was provided by other nurses but not LVN A. Resident #2 said LVN A had not actually hit her hand but slapped at her hand. Resident #2 said the next day the Administrator did come ask her about the situation. Resident #2 said she reported to him just want she told the surveyor. Resident #2 said she absolutely did not deny that LVN A had slapped at her hand and cursed at her. Resident #2 said the DON came in and asked about the situation as well. Resident #2 said she told the DON the same thing she told the Administrator, LVN A had slapped at her hand and told her to get her motherfing hand away. Resident #2 said at no point when she was asked about the situation she denied that LVN A had cursed at her and slapped at her hand. <BR/>During an interviews on 5/10/24 from 11:10 a.m. to 12:50 p.m., Residents #'s 3, 4, 5, 6, 7, 8, 9, and 10 were interviewed and asked specifically if they had received rough car, were abused/neglected, or treated disrespectfully by LVN A. All of Residents (#3, #4, #5, #6, #7, #8, #9, #10) said they received regular care from LVN A but had not been abused, neglected, treated roughly, or disrespected by LVN A. <BR/>During an interview on 5/10/24 at 1:00 p.m., an unidentified staff member said she cared for Resident #2 on 5/8/24. The unidentified staff member said he/she entered Resident #2's room and family member #2 was at her (Resident #2's) bedside. The unidentified staff member said Resident #2's family member said tell (him/her) what happened. The unidentified staff member said Resident #2 then said LVN A performed wound care last night (5/7/24) and when LVN A ripped off the bandage, she (Resident #2) raised her hands up in shape of fists. The unidentified staff member said Resident #2 said while she (Resident #2) had her hands raised LVN A slapped at her hand and told her to move her motherfing hand. LVN A said she believed the DON and Administrator asked her (Resident #2) about the situation but was not present in the room at the time so she could not say what was said during their conversations. <BR/>During an observation on 5/10/24 at 1:50 p.m., LVN A provided responded to Resident #2's call light. During the interaction, Resident #2 smiled and talked with the LVN A. Resident #2 displayed no signs of fear during the interaction. <BR/>During an interview on 5/10/24 at 2:57 p.m., LVN A said she provided wound care to Resident #2 in the evening of 5/7/24. LVN A said she did not have to move Resident #2's hand out of the way during the wound care because Resident #2 did not put her hands in the way. LVN A said she did not slap at Resident #2's hand during the wound care. LVN A said she did not curse at Resident #2 during the wound care. LVN A said Resident #2 voiced no complaints during the wound care and did not complain of pain during the wound care. LVN A said she did not apologize to Resident #2 for anything on the evening of 5/7/24 because there had been nothing to apologize about. LVN A said the following day (5/8/24) she had been called into the conference room sometime around 3:00 pm in the afternoon. LVN A said she was notified Resident #2's family member reported she (LVN A) had slapped at Resident #2's hand and cursed at her. LVN A said she was told she would be suspended the investigation. LVN A said she turned over her keys and clocked out. LVN A said on her way to her car she was called back into the building and asked to sit in the conference room. LVN A said she was told by the DON to get her keys and go back to the floor. LVN A said she clocked out at 3:22 p.m. and clocked back in at 3:29 p.m. <BR/>During an interview on 5/17/24 at 9:45 a.m., the former facility social worker on 5/8/24 said she was instructed to complete safety surveys as a result of Resident #2's allegation against LVN A. LVN A said while she was completing the safety surveys several residents had negative responses. The former social worker said a negative response meant residents reported they were not being treated with respect/dignity or they did not feel safe or they weren't getting the care they needed. The former social worker said she was told she did not have to finish the safety surveys because the investigation was over about 30 minutes later. The former social worker said she told the DON about the negative safety survey findings and left them on her (the former social worker's) desk when she walked out on the morning of 5/9/24. The social worker said she was really upset about all the complaints from the safety surveys and felt a good investigation was not completed because LVN A was back on the floor within 30 minutes of being suspended. <BR/>During an interview on 5/17/24 at 12:00 p.m., the former DON said when she interviewed Resident #2 she denied LVN A slapped at her hand or cursed at her. The DON said the social worker had not come to her with any negative findings regarding the safety surveys but believed she (the social worker) said something to the Administrator because she overheard something to that effect. The former DON said she could not specifically say what was said or reported.<BR/>During an interview on 5/17/24 at 2:50 p.m., the Administrator said the investigation was terminated because the complaint came from a family member but when Resident #2 was interviewed she (Resident #2) denied LVN A had slapped at her hand or cursed at her. The Administrator said he had interviewed Resident #2 himself. The Administrator said he felt LVN A's length of suspension was appropriate because the investigation had been terminated due to the Resident denying it occurred. The Administrator said the former social worker was instructed initially to complete safety surveys but because the investigation was terminated, he was not sure they were completed. The Administrator said the social worker was very upset about Resident #2's allegation and because she was so upset he sent her home late in the afternoon on 5/8/24. The Administrator said the social worker reported to him that there were a lot of complaints (from the safety surveys). The Administrator said he was never told any of the complaints were related to abuse or neglect. The Administrator said he did not ask the social worker if any of the complaints were about abuse or neglect. The Administrator said he would expect the social worker to communicate that directly and would not expect he would have to ask that specifically. <BR/>Record review of the facility's policy and procedure dated July 2022 titled Abuse, Neglect and Exploitation, stated . V. Investigation of Alleged Abuse, Neglect and Exploitation .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations included: Identifying staff responsible for the investigation; .Investigating different types of alleged violations; . Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; .Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 7 (Resident #1) residents reviewed for quality of care.<BR/>1.The facility failed to provide wound care to Resident #1's right lower extremity stump (the remaining part of the right leg after amputation) as ordered resulting in infection and surgical debridement (the removal of damaged tissues from a wound) to rule out osteomyelitis (inflammation of the bone caused by infection).<BR/>2.The facility failed to report redness to Resident #1's abdomen to the Nurse Practitioner or Wound Care Physician resulting in hospitalization related to cellulitis (bacterial skin infection) and panniculitis (inflammation of the subcutaneous fat) requiring intravenous (IV) antibiotics.<BR/>3.The facility failed to document wound care assessments per facility policy.<BR/>This failure resulted in an identification of an Immediate Jeopardy (IJ) at 2:35 p.m. on 4/2/24. While the IJ was removed on 4/3/24, the facility remained out of compliance with a scope identified as patterned and a severity of no actual harm with a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>These failures could result in residents with venous stasis ulcer of not having their treatments performed as ordered, wounds becoming infected wounds, and decreased wound healing.<BR/>Findings Included:<BR/>1. Record review of the face sheet dated 4/3/24 indicated Resident #1 was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including panniculitis, morbid obesity, diabetes, acquired absence of right leg below the knee, localized edema (swelling), and congestive heart failure (chronic condition in which the heart does not pump blood as well as it should).<BR/>Record review of the physician orders dated 4/3/24 indicated Resident #1 had an order to cleanse right below the knee amputation with normal saline, pat dry, apply calcium alginate (highly absorptive, non-occlusive dressing made of soft, non-woven calcium alginate fibers), collagen (wound dressing derived from collagen used to absorb exudate (fluids excreted by a wound), and cover with a dry dressing daily and as needed starting on 2/5/24. The physician orders indicated Resident #1 had an order for lymphedema (swelling caused by a lymphatic system blockage) wound of left abdomen skin prep daily starting 4/2/24. <BR/>Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 15 and was cognitively intact. The MDS indicated Resident #1 had a surgical wound and moisture associated skin damage.<BR/>Record review of the care plan revised 4/3/24 indicated Resident #1 had actual impairment to skin integrity: unstageable [wound] to the right leg with interventions including cleanse wound, apply medications and dressings as ordered. The care plan indicated Resident #1 had an infection of the wound. The care plan indicated Resident #1 had panniculitis . The care plan indicated had potential impairment to skin integrity of the lower abdomen and skin folds related to morbid obesity/incontinence. Resident had wound to right leg with treatment continued.<BR/>Record review of the TAR dated 2/1/24 through 2/29/24 indicated Resident #1's treatment to cleanse right below the knee amputation with normal saline, pat dry, apply calcium alginate, collagen and cover with a dry dressing daily and as needed was only performed on 2/7/24, 2/8/24, 2/10/24, 2/12/24, 2/13/24, 2/15/24, 2/16/24, 2/17/24, 2/22/24, 2/26/24, 2/27/24, 2/28/24, and 2/29/24. <BR/>Record review of the TAR dated 3/1/24 through 3/31/24 indicated Resident #1's treatment to cleanse right below the knee amputation with normal saline, pat dry, apply calcium alginate, collagen and cover with a dry dressing daily and as needed was only performed on 3/1/24, 3/3/24, 3/10/24, 3/11/24, 3/30/24, and 3/31/24.<BR/>Record review of the skin assessment dated [DATE] indicated Resident #1 had a right lower leg wound infection measuring 1.5cm x 0.3cm x 0.2cm. The skin assessment indicated Resident #1 had a wound to the right leg with treatment in place. <BR/>Record review of the skin assessment dated [DATE] indicated Resident #1 had a right lower leg wound infection measuring 1.5cm x 0.3cm x 0.2cm. The skin assessment indicated Resident #1 had a wound to the right leg with treatment in place. The skin assessment indicated Resident #1 had redness to left lateral side of abdomen with barrier cream (a product applied to the skin to help maintain the skins physical barrier, providing protection from irritants and preventing the skin from drying out) applied and Resident #1 was instructed to change positions every 2 hours. <BR/>Record review of the skin assessment dated [DATE] indicated Resident #1 had a wound to the right leg with treatment in place. The skin assessment indicated Resident #1 had redness to left lateral side of abdomen with barrier cream applied and Resident #1 was instructed to change positions every 2 hours. <BR/>Record review of the skin assessment dated [DATE] indicated Resident #1 had a wound to the right leg with treatment in place. The skin assessment indicated Resident #1 had redness to left lateral side of abdomen with barrier cream applied and Resident #1 was instructed to change positions every 2 hours. <BR/>Record review of wound assessments indicated Resident #1 did not have a wound assessment performed by the facility from 2/1/24 through 3/13/24 when Resident #1 was transferred to the hospital.<BR/>Record review of the Wound Care Physician's note dated 2/12/24 indicated Resident #1 had a right leg wound measuring 1cm x 0.3cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound was healing as evidenced by 0% decrease in surface area within the wound bed. <BR/>Record review of the Wound Care Physician's note dated 2/19/24 indicated Resident #1 had a right leg wound measuring 1cm x 0.3cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound was at goal.<BR/>Record review of the Wound Care Physician's note dated 2/26/24 indicated Resident #1 had a right leg wound measuring 2cm x 1.4cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound had exacerbated due to more edema in the leg. <BR/>Record review of the Wound Care Physician's note dated 3/4/24 indicated Resident #1 had a right leg wound measuring 2cm x 1.4cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound was at goal.<BR/>Record review of the Wound Care Physician's note dated 3/11/24 indicated Resident #1 had a right leg wound measuring 2cm x 1.4cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound was at goal.<BR/>Record review of the nursing progress note dated 3/11/24 indicated Resident #1 received an order for Doxycycline (antibiotic) 100mg twice a day for 7 days related to right stump wound. <BR/>Record review of the nursing progress note dated 3/13/24 indicated Resident #1 noted with change in condition including not feeling well, body aches, chills, fever, and right leg pain and swelling. The nursing progress note indicated a new order was received to send Resident #1 to the emergency department for evaluation and treatment. <BR/>Record review of the nursing progress note dated 3/27/24 indicated Resident #1 returned to the facility.<BR/>Record review of the hospital paperwork for hospital admission dated 3/13/24 through 3/27/24 indicated Resident #1 was admitted to the hospital with a primary diagnosis of acute panniculitis. The hospital paperwork indicated Resident #1 had discharge diagnoses including acute panniculitis, bacteremia (viable bacteria in the blood), and osteomyelitis of right tibia. The hospital paperwork indicated Resident #1 was admitted to the hospital with fever, chills and brought to emergency room for he was found to have an elevated white cell count of 17,200 (normal range 4,500 to 11,000) and large left-sided cellulitis involving his entire left abdominal wall pannus (excess skin and fat that hangs down from the abdomen). The hospital paperwork indicated Resident #1 was started on broad-spectrum IV antibiotics and based cellulitis spread from left flank to across his left midline. The hospital paperwork indicated Resident #1 had some evidence of wounds in his left abdominal wall. The hospital paperwork indicated Resident #1 had a right below-knee amputation stump ulcer with x-ray revealing osteomyelitis. The hospital paperwork indicated after right below the knee stump debridement on 03/21/2024 there was not any evidence of bone involvement.<BR/>During an interview on 3/28/24 at 1:26 p.m. Resident #1 said there had been staffing issues with treatment nurses. Resident #1 said his wound care had not been done as scheduled. Resident #1 said he had just returned from the hospital due to infection to wound and cellulitis to abdomen. Resident #1 said he had surgery on his below the knee amputation while in the hospital to determine in the infection was in the bone. Resident #1 said the infection had not made it to the bone and was only in the soft tissue. Resident #1 said he had not been receiving proper wound care prior to being hospitalized .<BR/>During an interview on 4/2/24 at 9:59 a.m. LVN A said she was familiar with Resident #1. LVN A said Resident #1's wound care was performed daily. LVN A said LVN F or LVN E were responsible for performing Resident #1's wound care. LVN A said the nurses were responsible for completing skin assessments. LVN A said she did not know if the increased redness to Resident #1's abdomen had been reported. LVN A said all wound treatments from the wound care physician were recommendations. LVN A said she would have to find out if the wound care physician recommendations were implemented or needed to be approved by the resident's primary care physician. LVN A said Resident #1 had a skin assessment dated [DATE] which indicated redness to left lateral abdomen.<BR/>During an interview on 4/2/24 at 10:14 a.m. the Wound Care Physician said he was familiar with Resident #1. The Wound Care Physician said Resident #1 had lots of lymphedema (swelling, most often in an arm or leg, caused by lymphatic system blockage) in his right stump. The Wound Care Physician said the facility had not had a treatment nurse in months. The Wound Care Physician said it was not ideal for dressing changes that were ordered daily not to be performed. The Wound Care Physician said it was not out of the realm for a dressing change ordered daily and not being performed daily to lead to infection. The Wound Care Physician said he was not informed of redness or increased redness to Resident #1's abdomen but the facility may have informed his primary care physician. The Wound Care Physician said wound treatments in his notes were recommendations. The Wound Care Physician said he saw residents at the facility weekly. The Wound Care Physician said he could not say if lymphedema treatment recommendation not being performed would lead to worsening lymphedema or infection. <BR/>During an interview on 4/2/24 at 10:21 a.m. the Nurse Practitioner said she was familiar with Resident #1. The Nurse Practitioner said she had not had any reports from the facility regarding Resident #1 having redness or increased redness to his abdomen. The Nurse Practitioner said most facilities notify them of changes in skin conditions or treatment orders, but this facility did not. The Nurse Practitioner said communication from this facility was lacking. The Nurse Practitioner said wound care treatments not performed as ordered could possibly lead to infection, but the surveyor would need to refer to the Wound Care Doctor. <BR/>During an interview on 4/2/24 at 12:23 p.m. LVN B said charge nurses were responsible for wound care and skin assessments at this time. LVN B said the last training she had received at the facility regarding skin assessments, wound documentation, or wound care policies was a couple of months ago. LVN B said the TAR indicated whether wound care had been performed. LVN B said if it was not charted in the TAR wound care was performed you could look at the date on the dressing. LVN B said if it was further back than one day and was not charted in the TAR wound care was performed it could not be proved it was performed. LVN B said skin assessment should be completed weekly.<BR/>Record review of the facility's Documentation of Wound Treatments policy dated 7/2022 indicated, The facility completes accurate documentation of the wound assessments and treatments, including response to treatments, change in condition, and changes in treatment. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates .Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift. Additional documentation shall include but is not limited to .e. Notification to physician and/or responsible party regarding wound or treatment changes.<BR/>The Administrator was notified on 4/2/24 at 2:48 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 4/2/24 at 2:56 p.m.<BR/>The facility's Plan of Removal was accepted on 4/3/24 at 9:40 a.m. and included:<BR/>Plan of Removal<BR/>1. <BR/>Immediate actions<BR/>The Medical Director and Resident #1's Primary Care Physician were notified by the Assistant Director of Nursing on 04/02/2024. <BR/>A full skin sweep was completed on all residents on 03/27-28/2024 by the Assistant Director of Nursing and the Director of Nursing. All residents admitted or readmitted from 03/27/2024 forward were reviewed to ensure for head-to-toe skin and wound assessments were completed appropriately. <BR/>Any admitted or readmitted residents from 03/27/2024 forward that were identified to not have skin assessments were assessed immediately on 04/02/2024.<BR/>An omissions report was pulled from 03/27/2024 forward and all omissions were addressed by the Director of Nursing. This was completed on 04/02/2024 and all staff were trained on how to pull the omissions report and directed to check it daily prior to the end of their shift to ensure no treatments are missed going forward. The omissions report identified staff who had not completed their treatments as ordered. <BR/>Resident #1 was immediately provided a head-to-toe skin assessment by the Director of Nursing and treatment was provided according to the Physician's orders for all areas on 04/02/2024. <BR/>2. <BR/>Education (provided by DON, ADON or Designee)<BR/>The Regional Director of Clinical Services in-serviced the Director of Nursing and Assistant Director of Nursing on all of the below in-services on 04/02/2024.<BR/>All nurses were in-serviced by the Director of Nursing/Assistant Director of Nursing on appropriately completing skin assessments and notifying the Physician of all newly identified skin issues in a timely manner on 04/02/2024. Each nurse will be in-serviced prior to returning to shift. This will be completed by 04/03/2024 and nurses will not return to shift without the in-service. The Director of Nursing and Assistant Director of Nursing are responsible for ensuring each nurse completes their skin assessments.<BR/>All nurses were in-serviced by the Director of Nursing/Assistant Director of Nursing on Policy and Procedure for Pressure Injury Prevention and Skin and Wound Care Management on 04/02/2024. This in-service will be completed by 04/03/2024 and nurses will not return to shift without the in-service. This in-service includes appropriately completing skin assessments, information on pressure and injury prevention, treatment for non-pressure injuries, the importance of wound care management and following the treatment orders. <BR/>All nurses were in-serviced by the Director of Nursing/Assistant Director of Nursing on pulling an omission's report prior to the end of each shift and correcting any absence of documentation on 04/02/2024. The Omission report would show any order on the TAR that was not completed during the scheduled shift. This in-service will be completed by 04/03/2024 and nurses will not return to shift without the in-service. <BR/>All nurses were in-serviced by the Director of Nursing/Assistant Director of Nursing on pulling and signing all MARs and TARs prior to the end of their shift on 04/02/2024. This in-service will be completed by 04/03/2024 and nurses will not return to shift without the in-service. If a nurse is unable to complete an assessment or wound care during their shift, they will notify the Director of Nurses and Assistant Director of nurses prior to leaving their shift. The oncoming shift will be notified during report that an assessment or treatment was not completed. <BR/>3. <BR/>Medical Director - The Medical Director has been notified of the Immediate Jeopardy.<BR/>4. <BR/>QAPI Committee Review - An interim QAPI committee meeting was completed on 04/02/2024. <BR/>5. <BR/>Plan of removal date: 04/02/2024<BR/>On 4/3/24 it was onfirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review on 4/3/24 of 3 of 3 new admissions or re-admission from 3/27/24 through 4/3/24 indicated all admissions had skin assessments performed and wound assessments performed if applicable.<BR/>Record review of a random sample of 16 of 66 residents on 4/3/24 indicated all sampled residents had skin assessments performed between 3/27/24 and 4/2/24.<BR/>Record review of the QAPI sign-in sheet indicated the facility had an ad-hoc QAPI meeting on 4/2/24 regarding wound treatments, skin and wound assessments, physician notification, and omission report. The QAPI sign-in sheet indicated all appropriate members of the IDT team were present for the QAPI meeting.<BR/>During interviews with staff (LVN C, LVN D, LVN E, LVN B, and the ADON) on 4/3/24 between 11:00 a.m. and 12:19 p.m. staff were able to explain importance of ensuring TARs and MARs were signed off, how to pull an omission audit to check to make sure all TARs and MARs had been signed off and treatments had been completed, how often skin and wound assessments should be performed, the importance of reporting changes in skin conditions to the PCP or wound care doctor, and interventions to prevent pressure ulcers including offloading, turning and repositioning every 2 hours, pressure relieving cushions in a resident's wheelchair, and bathing to aide in circulation.<BR/>On 4/3/24 at 12:21 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance the facility remained out of compliance with a scope identified as patterned and a severity of no actual harm with a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**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 had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and pain for 1 of 7 (Resident #2) residents reviewed for urinary catheters. <BR/>The facility did not ensure Resident #2's urinary catheter (a tube inserted into the bladder to drain urine) bag was not lying in the floor .<BR/>This failure could place residents at risk for urinary catheter bags busting by being stepped on or wheeled over by a wheelchair allowing bacteria into the catheter tubing, pain, and infection.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 4/3/24 indicated Resident #2 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including muscle weakness, dementia, overactive bladder, chronic kidney disease, hypertension (elevated blood pressure), and lack of coordination.<BR/>Record review of the MDS dated [DATE] indicated Resident #2 was understood others and was usually understood by others. The MDS indicated Resident #2 had a BIMS of 15 and was cognitively intact. The MDS indicated Resident #2 had an indwelling catheter (urinary catheter that is left in place) and was always incontinent of urine. <BR/>Record review of the care plan revised on 2/7/24 indicated Resident #2 had impaired cognitive function/dementia or impaired thought processes related to dementia.<BR/>During an observation on 4/2/24 at 1:36 p.m. Resident #2's urinary catheter bag was lying on floor. <BR/>During an observation and interview on 4/3/24 at 9:34 a.m. Resident #2's urinary catheter drain bag was lying in the floor. Resident #2 said she did not put the catheter drain bag in the floor. Resident #2 said she could not reach the catheter drain bag to hang it on the bed where she liked it. Resident #2 said a staff member stepped on her catheter drain bag yesterday when it was in the floor and busted it. Resident #2 said staff replace the busted catheter drain bag and mopped the urine out of the floor. <BR/>During an interview on 4/3/24 at 12:33 p.m. the ADON said a foley catheter drain bag should be positioned below the abdomen unless otherwise requested by the resident. The ADON said a foley catheter drain bag should not ever be in the floor. The ADON said the importance of ensuring a foley catheter drain bag was not in the floor was for infection control. The ADON said there were approximately 3 residents in the facility she thought would put their foley catheter drain bag in the floor. The ADON said one of those residents was Resident #2.<BR/>During an interview on 4/3/24 at 1:00 p.m. CNA G said she usually worked the 200 hall. CNA G said urinary catheter drain bags should be below the waist of the resident with the tubing straight without kinks. CNA G said urinary catheter drain bags should not be in the floor. CNA G said the importance of catheter drain bags not being in the floor was for sanitary purposes and to ensure they do not get busted by being stepped on or rolled over with a wheelchair. CNA G said she was not aware of any residents who would place their foley catheter drain bag in the floor.<BR/>During an interview on 4/3/24 at 1:31 p.m. the DON said she expected a urinary catheter drain bag to be positioned below the level of the bladder. The DON said a urinary catheter drain bag should not be in the floor. The DON said the importance of a foley catheter drain bag not being in the floor was infection control.<BR/>During an interview on 4/3/24 at 1:33 p.m. the Administrator said she expected a foley catheter drain bag to be covered, anchored, and not in the floor. The Administrator said the importance of a foley catheter drain bag not being in the floor was infection control. <BR/>Record review of the facility's Indwelling Catheter Use and Removal policy dated 7/2020 indicated, It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice .Additional care practices include .c. Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter; and d. Securement of the catheter facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the bladder .<BR/>Record review of the facility's Infection Prevention and Control Program policy dated 3/2022 indicated, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the transfer or discharge in writing for 1 of 4 residents (Residents #1) reviewed for transfer and discharge.<BR/>The facility initiated a discharge for Resident #1 due to a change of condition and did not notify the State Long-Term Care Ombudsman by phone or in writing. <BR/>This failure could place residents at risk of improper discharge planning and diminished quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 03/18/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Huntington's disease (an uncurable neurodegenerative disease that is mostly inherited), encephalopathy (disease that alters the brain), depression, and traumatic brain injury. The face sheet also indicated Resident #1 was his own responsible party. <BR/>Record review of Resident #1's admission MDS assessment dated [DATE] indicated Resident #1 was usually able to be understood by others, usually able to understand others, had a BIMS of 03 which indicated Resident #1 had severe cognitive impairment. The MDS also required limited assistance from 1 person for dressing and personal hygiene, supervision for bed mobility and toileting, and extensive assistance from 2 people with bathing. <BR/>Record review of Resident #1's order summary report dated as of 03/18/2024 indicated he had orders as followed:<BR/>1. <BR/>I certify the resident Requires/Continues to require Long Term Nursing Care at this facility for the next 90 days dated 06/29/2023.<BR/>2. <BR/>Orders are reviewed and renewed every 30 days dated 06/29/2023.<BR/>3. <BR/>Resident may be transferred out to hospital for a higher level of care dated 02/18/24. <BR/>There was no discharge order noted. <BR/>Record review of Resident #1's Discharge summary dated [DATE] unsigned by Resident #1's physician indicated Resident #1 was discharged from the facility while he continued to be in the hospital. <BR/>During an interview on 03/18/24 at 2:30 PM, the Ombudsman said the facility did not notify her of the discharge of Resident #1. <BR/>During an interview on 03/18/24 at 5:45 PM, the Administrator said the Ombudsman should have been notified of Resident #1's discharge. She said she could not find the paperwork validating the Ombudsman had been notified. She said the failure of not notifying the Ombudsman placed Resident #1 at risk of not having other options the Ombudsman would have been capable of assisting in placement. <BR/>During an interview on 03/18/24 at 6:15 PM, the Social Worker said she was responsible for issuing 30-day notices, notifying the Ombudsman, and assisting with discharges. She said she would have normally notified the Ombudsman when residents discharged from the facility, but she was told by the Administrator that the Administrator would handle all calls and paperwork dealing with Resident #1. She said failing to notify the Ombudsman made it more difficult for the resident to have assistance with finding placement. <BR/>Record review of facility's Policy for Transfer and discharge date d June 2022 indicated:<BR/>It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances .<BR/>Policy Explanation and Compliance Guidelines:<BR/>4. <BR/>The facility will evaluate and determine the level of care needed for the resident prior to admission to the facility's ability to meet resident's needs. <BR/>5. <BR/>Once admitted , the resident has the right to remain in the facility unless their transfer or discharge meets one of the following specified exemptions:<BR/>b. <BR/>The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .<BR/> 12. Emergency Transfer/Discharges- initiated by the facility for medical reasons to an acute care setting such as a hospital, for immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified).<BR/>a. Obtain a physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis .<BR/>h. The Social Services Director, or designee, will provide copies of emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as list meets all requirements for content if such notices.<BR/>i. The resident will be permitted to return to the facility upon discharge from the acute care setting .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish and follow written policy on permitting residents to return to the facility after they were hospitalized for 1 (Resident #1) of 4 residents reviewed for transfer/discharge. <BR/>1. The facility failed to admit Resident #1 back to facility after he was sent to the hospital on [DATE].<BR/>2.The facility failed to give Resident #1 a 30-day discharge notice.<BR/>These failures could place residents at risk of not receiving the care and services to meet their needs and could affect their mental and emotional well-being. <BR/>The findings included: <BR/>Record review of Resident #1's face sheet dated 03/18/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Huntington's disease (an uncurable neurodegenerative disease that is mostly inherited), encephalopathy (disease that alters the brain), depression, and traumatic brain injury. The face sheet also indicated Resident #1 was his own responsible party. <BR/>Record review of Resident #1's admission MDS assessment dated [DATE] indicated Resident #1 was usually able to be understood by others, usually able to understand others, had a BIMS of 03 which indicated Resident #1 had severe cognitive impairment. The MDS also required limited assistance from 1 person for dressing and personal hygiene, supervision for bed mobility and toileting, and extensive assistance from 2 people with bathing. <BR/>Record review of Resident #1's Discharge summary dated [DATE] unsigned by Resident #1's physician indicated Resident #1 was discharged from the facility while he continued to be in the hospital. <BR/>During an interview 03/18/24 at 1:50 PM, Resident #1 said he was the only person left in his family. Resident #1 said he did not remember the facility giving him any notice of being discharged and having to find somewhere else to go. Resident #1 said he was sorry for his outbursts, being mean to anyone, and the Bible said we were all imperfect. He said he would be good if he could go back to the facility because he had nowhere to go. <BR/>During an interview on 03/18/24 at 3:15 PM, the Administrator stated Resident #1 was still at the hospital. The Administrator stated the hospital tried to send him back, but she told the hospital that the facility would not accept him back because he needed psych services. She said it was an emergency when the facility sent Resident #1 out so there was no time for a 30-day notice. The Administrator said the failure of not following their policy would make it difficult for Resident #1 to find placement elsewhere. <BR/>During an interview on 03/18/24 at 6:15 PM, the Social Worker said she was responsible for issuing 30-day notices and assisting with discharges. She said Resident #1 was sent out on Sunday 02/18/24. The Social Worker said she was instructed on 02/19/24 to route all calls from the hospital to the Administrator because the facility was not accepting Resident #1 back into the facility. She said she did not feel it was right because the resident would have a difficult time finding somewhere to go. <BR/>Record review of facility's Policy for Transfer and discharge date d June 2022 indicated:<BR/>It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances .<BR/>Policy Explanation and Compliance Guidelines:<BR/>6. <BR/>The facility will evaluate and determine the level of care needed for the resident prior to admission to the facility's ability to meet resident's needs. <BR/>7. <BR/>Once admitted , the resident has the right to remain in the facility unless their transfer or discharge meets one of the following specified exemptions:<BR/>c. <BR/>The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .<BR/> 12. Emergency Transfer/Discharges- initiated by the facility for medical reasons to an acute care setting such as a hospital, for immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified).<BR/>a. Obtain a physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis .<BR/>h. The Social Services Director, or designee, will provide copies of emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as list meets all requirements for content if such notices.<BR/>i. The resident will be permitted to return to the facility upon discharge from the acute care setting .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility, failed to ensure sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in the central bath and 8 of 35 resident rooms (106, 211,226,.227,.228,.229,315 and 329) reviewed for environment.,<BR/>The facility failed to ensure resident used common areas and rooms were clean and did not need repair.<BR/>These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being. <BR/>Findings include:<BR/>Observation on 8/14/2023 at 9:08 AM in room [ROOM NUMBER], revealed resident's wheelchair was dirty with brown residue in the seat and toilet paper around the wheels of the wheelchair. The seat of the wheelchair smelled of feces and observed feces on the seat. The over the bed table was dirty with brown residue on legs of table.<BR/>Observation on 8/14/2023 at 9:30 AM, room [ROOM NUMBER] had a foul order, when open the restroom door was opened, the odor was coming from the resident's toilet. The toilet was full of feces and urine. This restroom was shared with room [ROOM NUMBER]. <BR/>Observation on 8/14/2023 at 9:40AM room [ROOM NUMBER] the floor was dirty and sticky. <BR/>Observation on 8/14/2023 at 9:44 AM in room [ROOM NUMBER], the floor was dirty with brown streaks, foul odor and privacy curtains were stained with blood. There were, bags of dirty [NAME] in the corner of the room.<BR/>Observation on 8/14/2023 at 9:50 AM., in room [ROOM NUMBER], there was a lingering urine odor in the room, spilled food under the bed and on the floor surrounding the B bed.<BR/>Observation on 8/14/2023 at 9:55 AM in room [ROOM NUMBER], there was a lingering urine odor in the room and there were bags of dirty linen on the floor.<BR/>Observation on 8/14/2023 at 9:55 AM in room [ROOM NUMBER], the floors were dirty, with paper trash and noted dead bugs and cobwebs in the window seals.<BR/>Observation on 8/14/2023 and 8/15/2023 at 10:00 AM of Central bathroom there were no paper towels in the central bathroom and the toilet bowel had dried feces for two consecutive days.<BR/>On 8/15/2023 at 9:00 AM an interview and record review were conducted with the Housekeeping Supervisor regarding the cleaning schedules. He stated housekeeping staff sweep, mop, disinfect resident rooms daily. Housekeeping, and nursing, cleaned the chairs and over the bed tables. He said he does daily rounds to check to see that cleaning schedules are being followed. He further stated the Nursing staff is to let housekeeping or maintenance know of any privacy curtains that may need to be replaced, they are to fill out a housekeeping or maintenance request and submit it to the housekeeping and or maintenance supervisor. <BR/> On 8/15/2023 at 9:15 AM an interview with the Maintenance Supervisor regarding maintenance issues found, he stated, the facility staff is to notify the Maintenance Department when there is an issue of something not working or the need for example a privacy curtain needing to be replaced.<BR/>On 8/15/2023 at 10:20 PM an interview was conducted with CNA's P and R regarding cleaning wheelchairs and over the bed tables. Both said that if they see issues that they report to housekeeping but wheelchair and over the bed table they attempt to clean as they are assigned to that room. Both admit that the wheelchairs and over the bed tables get missed sometimes. <BR/>During an observation of room [ROOM NUMBER] on 08/15/23 at 11:15 AM with CNA P, she said she smell the urine odor. She said Resident #30 uses his urinal and he knocks it over a lot, and when this happens, she will call housekeeping to clean the room. CNA P acknowledged a large pool of liquid fluid on the floor, near Resident #30 bed, during this observation. <BR/>During an interview with LVN Q at the nurses' station, on 08/15/23 at 11:28 AM, she said yes, there is a lingering urine odor in resident #30 room. She said Resident #30 will urinate in his urinal and he knocks it over on the floor often. <BR/>During an observation of resident room [ROOM NUMBER], on 08/16/23 at 9:15 AM, the smell of urine lingered at the entry door to resident room [ROOM NUMBER] and inside of resident room [ROOM NUMBER]. <BR/>During an interview with CNA C on 08/16/23 at 9:28 AM, she said resident room [ROOM NUMBER] does smells like urine. She said Resident #30 uses a urinal and he knocks it over a lot.<BR/>During interview and observation of resident room [ROOM NUMBER], on 08/17/23 at 10:22 AM, the DON said yes, the room smell of urine. She said she knows housekeeping has been trying to keep the room clean and she was not certain, but she believes housekeeping has replaced one of the mattresses, in room [ROOM NUMBER]. <BR/>During interview with the Administrator, on 08/16/23 at 10:45 AM, he said he was aware of a urine smell on the 100 halls, a while ago, but he thought 1 or 2 of the mattress, in a room with the urine smell, had be changed out, but he was not sure. He said he was not aware if a log is kept when mattresses are changed out. He suggested speaking with the Maintenance Director. <BR/>During interview with the Maintenance Director on 08/17/23 at 11:05 AM, he said he was not aware if either mattress had been changed out in resident room [ROOM NUMBER]. He said housekeeping changes out mattresses and said Housekeeper D would know.<BR/>During interview with Housekeeper D on 08/17/23 at 11:24 PM, he said housekeeping mops up and tries to keep the resident rooms clean. When urine is on the floor, housekeeping cleans it up. He said housekeeping has not replaced either mattress in resident room [ROOM NUMBER]. <BR/>Record review of the Maintenance log for May, June, July and August 2023 there was no report of need to replace privacy curtain in room [ROOM NUMBER] . <BR/>Record review of the facility policy, titled Routine Cleaning and Disinfection dated 7/2022.<BR/>Policy: It is the policy of this facility to ensure the prevention of routine cleaning and disinfection to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible.<BR/> Policy Explanation and Compliance Guidelines:<BR/>*Routine cleaning and disinfection of frequently touched or visible soiled surfaces will be performed in common areas, resident rooms and at the time of discharge<BR/>*Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high areas to include, but not limited to: Toilet flush handles, Bed rails, Tray tables, Call buttons, TV remote, Telephones, Toilet seats, monitor control panels, touch screens and cables, Resident chairs, IV poles, Blood pressure cuffs, Sinks and faucets, Light switches doorknobs.<BR/>*Cleaning of walls, blinds and window curtain will be conducted when visibly soiled.<BR/>*Privacy curtains in residents' rooms will be changed when visibly dirty by laundering or cleaning with an Environmental Protection Agency (EPA) registered disinfectant per the curtain and disinfectant manufacturer's instructions<BR/>Review of the facility's Policy, Routine Cleaning and Disinfection, dated 07/2022, indicated - Policy: 12. Horizontal surfaces with infrequent hand touch (windowsills and hard surface flooring) in routine resident-care areas should be cleaned: A) on a regular basis, B) when spoiling and spills occur, and C) when a resident is discharged from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene that promotes maintenance or enhancement of his or her quality of life, for Resident (Resident #34) review for activities of daily living<BR/>The facility failed to provide Resident #34 with personal grooming for nail care<BR/>These failures could place residents at risk for poor hygiene, dignity issues and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #34's admission record dated 12/28/2021 reflected Resident #34 was a [AGE] year-old male. Resident #34's diagnoses included full code, Chronic Obstructive Pulmonary Disease(refers to a group of diseases that cause airflow blockage and breathing-related problems) Type 2 diabetes Mellitus with foot ulcer, morbid obesity due to excess calories, major depressive disorder, single episode, presence of cardiac pacemaker. <BR/>Record review of Resident #34's activities of Daily living (ADL) MDS, dated [DATE] reflected,<BR/>-resident's cognitive status 15 BIMS( the patient is cognitively intact)<BR/>-requiring extensive assistance for transfers, bed mobility.<BR/>-required supervision for dressing, eating, and extensive assistance with toilet use and personal hygiene. <BR/>Record review of Resident #34's care plans, initiated on 08/02/23 reflected Resident #34 had a <BR/>Focused area for ADL Self Care, the resident has diabetic ulcer of the left, first toe related to Diabetes, refer to foot care nurse/Podiatrist<BR/>Observation and interview on 8/14/2023 at 09:55 AM revealed Resident #34 in room [ROOM NUMBER], there was a lingering urine odor in the room and there were bags of dirty linen on the floor. Noted toes on left foot were thick and elongated, he said he hadn't seen a podiatrist in months and nurses won't cut his nails.<BR/>Record Review of the ADL task for personal grooming for Resident #34 dated 7/28/23 to 08/14/2023 reflected Resident #34 had not refused personal grooming during those dates, there was no indication of foot care done, rResident#34 is scheduled for Monday, Wednesday, and Friday showers.<BR/>Record review of Podiatrist care (Podiatry Note) for Resident #34 revealed the last date for care was 11/15/2022 and record states Resident #34 should be treated in 60 days for foot care due to systemic conditions or sooner should complication arise.<BR/>Interview on 8/16/2023 at 10 am with the DON, she said that in the case of no Podiatrist that Nurses can perform foot care, but it is the Social Service and Nurses responsibility to schedule follow up Podiatrist Appointment.<BR/>Interview on 8/17/2023 at 11:15 AM with WCN and review of care plan on 8/17/2023 she said she updated the care plan to reflect that nail care to be done by nurse/Podiatrist. During a record review care plans updated by wound care nurse.<BR/>Interview on 8/17/2023 at 11;20 AM with CNAs P and R, both said that only the nurses can do foot care especially a diabetic foot, this is on the ADL flow sheet.<BR/>Record review of Shower Report dated 08/14/2023 for Resident #34 revealed complete bed bath given, linens changed no indication of nail care given.<BR/>Record Review of the facility Policy for Foot Care, dated 7/2022: <BR/>It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of the practice and state scope of practice, as applicable, to maintain mobility and good health. The policy pertains to maintaining the skin integrity of the foot.<BR/>Policy Explanation and Compliance Guidelines:<BR/>*The facility will provide foot care and treatment in accordance with professional standard of practice, including the prevention of complications from the residents' medical conditions.<BR/>*Assessment of Risk, Skin assessments, Assessment of the feet for disorders, Nursing assistants will inspect skin during bath and will report any concerns to the resident's, nurse immediately after the task<BR/>*Interventions for prevention and to Promote Healing, Referrals to podiatrist, vascular or orthopedic surgeons<BR/>*Monitoring, RN's and LPN's will participate in the management of medical conditions by following physicians' orders, assessment of residents and reporting changes in condition to the resident's physicians.<BR/>

**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 be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 (Resident #1) of 7 residents reviewed for abuse and/or neglect.<BR/>The facility failed to prevent CNA B from physically abuse abusing Resident #1 when she slapped her arm and left a bruise.<BR/>This failure could place residents at risk of abuse and neglect. <BR/>Findings included:<BR/>Record review of the Resident #1's face sheet, dated 5/17/24, indicated she was readmitted to the facility on [DATE] with diagnoses including, hypothyroidism (abnormally low activity of the thyroid gland), dysphagia (difficulty swallowing), diabetes, mild protein-calorie malnutrition, high blood pressure, muscle weakness, lack of coordination, heart failure and anxiety. <BR/>Record review of the Resident #1's MDS, dated [DATE], reflected Resident #1 usually made herself understood and usually understood others. Resident #1 had severe cognitive impairment with a (BIMS of 7). Resident #1 had no physical or verbal behaviors symptoms directed towards herself or others. Resident #1 had no behavior of rejecting care. Resident #1 used a manual wheelchair for locomotion and required supervision or touch assistance with eating and oral hygiene. Resident #1 required patrial/moderate assistance with dressing her upper/lower body, personal hygiene, rolling side to side in the bed, moving from a sitting position to lying flat in the bed, and lying to sitting on the side of the bed. The MDS indicated Resident #1 required substantial/maximal assistance with showers/bathing, putting on/taking off footwear, the ability to stand from a sitting position, chair to bed/ bed to chair transfers, toilet transfers, and tub/shower transfers. The MDS indicated Resident #1 was dependent on staff for toileting.<BR/>Record review of Resident #1's care plan dated 3/12/24, reflected Resident #1 had a risk for bruising and bleeding due to anticoagulant therapy. The care plan interventions included encourage resident to be aware of extremities in relation to environment. The care plan also indicated Resident #1 reported alleged mistreatment by staff and was at risk for increased anxiety. <BR/>Record review of the facility's provider investigation report dated 5/17/24, reflected Resident #1 reported CNA B struck her arm. The police were notified. CNA B was terminated, detained and placed under arrest by the police. <BR/>Record review of CNA B's signed statement, dated 5/13/24, reflected I'm not the only one that hits them . (Resident #1) was just mad because we didn't have a diaper that would fit her. She got mad and pulled the yellow diaper off. She hit me. I never hit anybody . <BR/>During an observation and interview on 5/17/24 at 12:50 p.m., Resident #1 said she called for help in the early morning hours of 5/13/24 because her brief was coming off. Resident #1 demonstrated and described she pulled at the brief showing the CNA the brief did not fit and was coming off. Resident #1 then demonstrated and described that as she was doing this (pulling at the brief) CNA B slapped her arm and indicated she slapped her left arm hard while she (CNA B) stood on the left side of her bed. Resident #1 had a large bruise (approximately 7 inches in length and 3 inches in width) to the posterior aspect of her left forearm. Resident #1 said the bruise was where CNA B hit her. <BR/>During an interview on 5/17/24 at 1:00 p.m., CNA C said it was not acceptable to hit a resident under any circumstances. CNA C said even if they (the residents) hit us (the staff), we the staff do not hit them back. CNA C said this was abuse.<BR/>During an interview on 5/17/24 at 2:15 p.m., LVN D said Resident #1 was very descriptive and named CNA B as the aide who slapped her arm. LVN D said CNA B slapping Resident #1 no matter the reason was abuse.<BR/>During an interview on 5/17/24 at 2:30 p.m., The Corporate RN said she was the acting DON. The Corporate RN said Resident #1 was consistent with her details of the event and had bruising to her left arm where she said a nurse had hit her. The Corporate RN said because of Resident #1's description of the staff member and her (Resident #1's) report that the staff member worked double almost every night- CNA B was identified. The Corporate RN said the Resident #1 had reported the incident happened sometime in the early morning hours. The Corporate RN said when the facility was made aware of the allegation they promptly reported the incident to the state agency and began their investigation. The Corporate RN said safety surveys were completed with no additional findings. The Corporate RN said the CNA B was not at work when they were notified of the allegation (she had worked 10:00 p.m. to 6:00 a.m.) so she was called to facility for interview and they kept here there until the police arrived and detained her. The Corporate RN said the police were notified and walked CNA B out in handcuffs. The Corporate RN said what CNA B did (slapping Resident #1's arm) was abuse and would not be tolerated. The Corporate RN said all staff were in-serviced over ANE. <BR/>During an interview on 5/17/24 at 2:50 p.m., the Administrator said CNA B was immediately terminated and all other staff were in-serviced over abuse, neglect and exploitation. The Administrator said abuse of residents would not be tolerated at the facility. <BR/>Record review of CNA B's personnel action form, dated 5/13/24, indicated she was terminated for misconduct regarding allegations of Abuse and was not eligible for rehire. The personnel action form also indicated criminal charges had were filed.<BR/>Record review of the facility's policy and procedure, dated July 2022, titled Abuse, Neglect and Exploitation, stated It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish, It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .

Based on interview and record review, the facility failed to implement their written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents for 1 of 7 new hire staff reviewed for criminal history checks. (Staff B)<BR/>The facility failed to follow the A/N/E policy and procedure with regard to failing to screen applicants prior to hire.<BR/>This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.<BR/>Findings included:<BR/>Record review of the facility staff roster, undated indicated Staff B was hired on 5/19/23 and listed as CNA in training.<BR/>Record review of criminal history conviction name search history printed on 5/31/23 indicated search date of 5/23/23 for Staff B had 1 hit.<BR/>Record review criminal history conviction name search dated 7/12/23 for Staff B indicated the criminal history review documented an offense that made Staff B ineligible for hire. <BR/>Record review of undated and untitled document listing offense penal codes provided by the HR Clerk on 7/14/23 indicated staff B was determined to not be employable under Health and Safety Code (HSC) &sect;250.003(a)(1).<BR/>Record Review of Staff B's employment application says he was hired as a Kitchen Aide/Hospitality Aide. <BR/>Record review of general duties/schedule for Hospitality Helper indicated: Pass out ice and water on North, South and East Wings. Ice and water will be pass out one time on 6:00 - 2:00 pm, and 2:00 - 10:00 shift. Each Ice cart and Ice chest will be clean every Monday, Wednesday, and Friday. <BR/>Record review of Staff B's time sheet indicated the following:<BR/>*5/1/23 to 5/31/23 indicated Staff B worked a total of 76.77 hours;<BR/>*6/1/23 to 6/30/23 indicated Staff B worked a total of 238.27 hours;<BR/>*7/1/23 to 7/31/23 indicated Staff B worked a total of 90.28 hours and his last date of employment was 7/13/23.<BR/>Record review of Staff B's personnel file did not include documentation or date of his termination. <BR/>Record review of email thread from the HR Clerk to the Regional Director of HR dated 5/22/23 indicated we don't have enough funds to run backgrounds and I am desperately needing these people ran .Dishwasher Staff B . On 5/23/23, the Regional Director of HR emailed the HR Clerk .Let me know when you received them, please so I can shred the ones I have .<BR/>Record review of a petty cash voucher dated 5/30/31(5/30/23) and receipt indicated on 5/30/23 at 6:22 pm a $500 prepaid debit card was purchased for a total of 504.95 to be used for Criminal history check/gas for van.<BR/>Record review indicated Safe Surveys were completed on 07/14/23 and the facility continued training on eligibility for hire. The facility also completed additional background checks on all current employees to verify that all were eligible to work. <BR/>During an interview on 7/14/23 at 1:47 p.m., the HR Clerk said she had been the HR Clerk for three years. She said criminal history checks were done on all staff upon hire and annually. The HR Clerk said around the time Staff B was hired on 5/19/23, the facility was in-between Administrators, the previous Administrator was leaving, and the current Administrator was just starting. So a few new hires background checks were possibly missed. The HR Clerk said the background checks cost about three dollars each and she used a debit card to purchase the background checks. She said most of the times, she would use the previous Administrator's debit card or she would use her personal debit card to pay for the criminal history checks. She said when the previous Administrator left, the current Administrator did not want his personal card used for purchasing criminal history checks. So she did not know what to do. The HR Clerk said she was advised to reach out to corporate and that was when she reached out via email to the Regional Director of HR on 5/22/23 to assist with getting background checks. She said the Regional Director of HR ran the background checks on 5/23/23 and faxed the results, but she never received the fax. She stated the Regional Director of HR gave her the verbal approval to proceed with hiring Staff B.<BR/>During an interview on 7/14/23 at 2:02 p.m., Regional Director of HR said the HR Clerk had reached out to her via email on 5/22/23 requesting assistance with getting background checks on a few staff. She said she personally did Staff B's background checks and faxed over the results to the HR Clerk. She said she was not aware the HR Clerk did not receive the fax and shredded the paperwork. The Regional Director of HR said she provided the HR Clerk a printout verifying she ran a search on Staff B on 5/23/23. She said she gave the HR Clerk verbal approval to hire Staff B because she reviewed his criminal history and there were no issues. <BR/>During an interview on 7/14/23 at 3:38 p.m., the HR Clerk said Staff B was hired prior to his background checks being done. She said Staff B was hired as a Dishwasher, he worked two days 5/19/23 and on 5/20/23 as dishwasher and effective 5/22/22 to current he worked as the assigned smoke break staff and whenever it was not a smoke break, Staff B worked as Hospitality Aide and passed ice. The HR Clerk said she personally would not have hired Staff B due to his background charges. The HR Clerk said her first-time seeing Staff B's criminal history was on 7/13/23 when she ran it herself, she said Staff B was not eligible for hire until 2024. The HR Clerk said she followed the list penal codes she provided State Investigator, when determining if a person was eligible for hire. The HR Clerk said she told the Administrator on 7/13/23 about Staff B's criminal history and she said he told her since the Regional Director of HR gave her approval not to worry about it since Staff B had already been hired and working.<BR/>During an interview on 7/14/23 at 3:46 p.m., Administrator said he was the Abuse Coordinator and started on 05/08/23, as the Administrator. He said all staff were to have background checks done before hire and those were done by the HR Clerk. <BR/>During an interview on 8/2/2023 at 9:00 a.m., the HR Clerk said the current Administrator purchased a $500 Visa prepaid card at the end of May 2023 that is used to pay for Criminal background checks and the corporate office set up a line of credit at the agency to complete background checks. The card was set up to notify the Administrator when the balance is low. The HR Clerk said Staff B was terminated on 7/13/23. The HR Clerk said before a person was hired, their criminal history must be completed, clear, and completed annually after hire. She said the facility had completed in-services since May 2023 related to background checks being ran prior to hire and that continued training on eligibility was being completed. She said she and the department heads had been in-serviced on HR policies by the Corporate HR. The in-services included the Policy on Hiring and Firing of employees, and that criminal history checks are to be done prior to hiring an employee. She said Staff B was hired as a Hospitality Aide/Kitchen Aide.<BR/>During an interview on 8/2/2023 at 9:30 a.m., the DON said that Staff B was hired as a hospitality helper/Kitchen Aide and would issue cigarettes to residents when out for smoking breaks or pass ice. She said Staff B did not provide any 1-on-1 care to residents and was not in a closed room with any residents.<BR/>During an interview on 8/2/2023 at 11:00 a.m. the Administrator said he was not aware Staff B was not eligible for hire due to barrable charges because Staff B was hired before he became the Administrator. He said he established a new process that he will review all criminal history checks of potential new hires prior to sending them to the hiring managers. He said he also purchased a pre-paid Visa card for HR to use when running a criminal history. He said when he found out that Staff B was not eligible for hire, he was terminated effective 07/13/23. The Administrator said the policy on criminal history eligibility was discussed in morning meetings and QA/QAPI.<BR/>Record review of Background Investigation policy dated January 2023 indicated .Job reference checks, drug screenings, licensure verifications and criminal conviction record checks are conducted on all personnel making application for employment with this company .1) The Human Resource department will conduct all applicable background investigation(s) on each individual making application for employment with this company an on any current employee if such background investigation is appropriate for position for which the individual has applied .4)If the background investigation(s) disclose any material misrepresentation or omissions by the applicant or employment on the application form or reveal information indicating that the individual many not be appropriate for hire, the company will investigate the matter further. Upon completion of such investigation, if the company determines that the applicant's or employee's background makes him/her unsuitable for the position he/she is seeking, the applicant will not be employed, or if already employed will be terminated .<BR/>Record review abuse policy dated 6/2022 indicated .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of residential property .1.Screening: A)Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1)Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, student affiliated with academic institutions, volunteers, and consultants. 2)Screenings may be conducted by the facility itself, third party agency or academic institution. 3)The facility will maintain documentation of proof that the screening occurred .

**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, are reported immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 2 of 7 (Resident #1 and Resident #2) residents reviewed for abuse and neglect.<BR/>The facility did not report the allegations of verbal and physical abuse of Resident #1 and Resident #2 by CNA B to the state agency.<BR/>This failure could place residents at risk of injuries, abuse, and/or neglect.<BR/>Findings Include:<BR/>1. Record review of the face sheet orders dated 8/08/23 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including dementia, abnormalities of gait and mobility, amputation of right and left leg below the knee, muscle weakness, lack of coordination, and anxiety.<BR/>Record review of the MDS dated [DATE] indicated Resident # 1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 12 and was moderately cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility. The MDS did not indicate Resident #1 used limb prosthesis (artificial device that replaces a missing body part) for mobility.<BR/>Record review of the care plan last updated 7/14/23 indicated Resident #1 had an ADL self-care deficit with interventions including resident requires 1 staff member to assist with transfers and resident requires 1-2 staff members to assist with bed mobility. <BR/>Record review of a complaint intake worksheet in TULIP dated 8/07/23 indicated the complainant had witnessed abuse and neglect at the facility.<BR/>Record review in TULIP on 8/08/23 indicated there was not a facility report regarding abuse for Resident #1.<BR/>During an interview on 8/08/23 at 11:17 a.m. RN A said she started at the facility in 2023. RN A said the weekend of August 4-6th she had witnessed abuse to Resident #1. RN A said the CNA B had asked her to help get Resident #1 up about 7:00 a.m. RN A said Resident #1 was a double amputee and needed assistance with his prosthetics. RN A said Resident #1 could not hold his legs up at the same time as he was a large man. RN A said she got one prosthetic on and CNA B was trying to put on the other prosthetic and Resident #1 could not lift his leg. RN A said the CNA B slapped the Resident #1's leg, cursed at him, and referred to him as an idiot. RN A said she asked CN B to leave the room and she finished putting the other prosthetic on for Resident #1. RN A said she reported the incident to the DON and was informed to call the Administrator. RN A said she called the Administrator and left a message regarding the alleged abuse and had to leave him a message. RN A said she called the Administrator back on Monday and left another message. RN A said she had not heard back from the Administrator and reported the incident to the state agency.<BR/>During an interview on 8/08/23 at 11:24 a.m. Resident #1 said there might have been an issue over assisting him with putting his prosthetic legs on over the weekend. Resident #1 said if someone had cussed him he would not have heard it because he chooses not to hear those words and said he does not know those type of words. Resident #1 said the surveyor would have to ask the staff about what happened and he was not saying anything.<BR/>During an interview on 8/08/23 at 12:53 p.m. the DON said CNA B had been suspended on 8/08/23 pending investigation of abuse allegation. The DON said the abuse allegation was involving Resident #1 and happened over the weekend of August 4-6, 2023. The DON said she had been notified by RN A on 8/05/23 of the alleged abuse by CNA B to Resident #1. DON said she advised the RN A to contact the Administrator who was the Abuse Coordinator. The DON said she never told the Administrator of the alleged abuse because she was under the impression RN A had reported to him.<BR/>During an interview on 8/08/23 at 12:54 p.m. the Administrator said CNA B had been suspended on 8/08/23 pending investigation of alleged abuse of Resident #1. The Administrator said he had spoken to RN A on 8/08/23 regarding the allegation of abuse. The Administrator said RN A had called and left him messages stating she need to speak with him. The Administrator said he was not aware she needed to speak with him regarding an abuse allegation. <BR/>Record review on 8/11/23 in TULIP indicated the allegation of abuse of Resident #1 by CNA B had not been reported to the state agency by the facility.<BR/>2. Record review of the face sheet dated 8/11/23 indicated Resident #2 was a [AGE] year-old woman admitted to the facility on [DATE] with diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis), muscle weakness, lack of coordination, and glaucoma (an eye condition where the nerve connecting the eye to the brain is damaged, usually due to high eye pressure, and can cause blindness)<BR/>Record review of the MDS dated [DATE] indicated Resident #2 usually understood others and was usually understood by others. The MDS indicated Resident #2 had a BIMS of 13 and was cognitively intact. The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene.<BR/>Record review of the care plan dated 6/12/23 indicated Resident #2 had a potential for an activities of daily living self-care performance deficit. <BR/>Record review of a grievance dated 7/13/23 indicated the Social Worker form Resident #2's dialysis center reported to the facility that Resident #2 informed the dialysis center that CNA B had cursed her and pulled her leg causing pain. The grievance indicated the facility's resolutions were to have Resident #2 be a two-person transfer, not have CNA B provide care to Resident #2, and refer to psych services to ensure she is psychosocially and emotionally stable. <BR/>During an interview on 8/11/23 at 3:06 p.m. the DON said she was aware of the allegation of abuse made by the dialysis center's Social Work against CNA B. The DON said CNA B was working the date of 7/13/23 and completed her entire shift. The DON said since Resident #2 was at dialysis CNA B was not a threat to her pending investigation. The DON said CNA B's shift had ended and she was not at the facility when Resident #2 returned from dialysis. The DON said CNA B was permitted to return to work the next day (7/14/23) as it was determined no abuse occurred during the investigation.<BR/>During an interview on 8/11/23 at 3:17 p.m. Resident #2 said the incident on 7/13/23 had been taken care of by the facility. Resident #2 said CNA B no longer provided care for her. Resident #2 said she needed assistance with sitting up and transferring. Resident #2 said CNA B would drop her legs and let them fall to the floor via gravity and not provide her support for sitting upright when transferring her. Resident #2 said CNA B called her a heifer. <BR/>During an interview on 8/11/23 at 3:26 p.m. the Administrator said the grievance filed on 7/13/23 regarding CNA B and Resident #2 would be considered an allegation of abuse. The Administrator said Resident #2 was interviewed upon her return to the facility from dialysis and Resident #2 relayed a different story than what the Dialysis Social Worker reported. The Administrator said CNA B was not suspended following the allegation of abuse on 7/13/23 and the allegation was not reported to the state agency. <BR/>Record review of the facility's Abuse Investigation and Reporting policy dated 7/2022 indicated, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property . Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies within specific time frames: a. Immediately, but no later than 2 hours after the allegation is made, if the event that cause the allegation involve abuse or result in seriously bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in seriously bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 1 of 7 residents (Resident #2) reviewed for abuse and neglect.<BR/>The facility failed to conduct a thorough investigation when Resident #2 alleged LVN A slapped at her hand and cursed at her during wound care. <BR/>This failure could place residents at risk of abuse and neglect. <BR/>Findings included:<BR/>Record review of Resident #2's face sheet, dated 5/17/24, reflected she was a [AGE] years old admitted to the facility on [DATE], with diagnoses which included COPD (chronic obstructive pulmonary disease is a group of lung diseases that block airflow and make it difficult to breathe), dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus), heart disease, muscle weakness and atrophy (wasting or thinning of muscle mass) unspecified open wound of the abdominal wall, chronic pain and depression. <BR/>Record review of the MDS dated [DATE] indicated Resident #2 had clear speech, understood others and made herself understood. The MDS indicated she had moderate cognitive impairment (BIMS of 11). The MDS indicated Resident #2 had no physical or verbal behaviors towards others and had no behavior of rejecting care. The MDS indicated Resident #2 required supervision or touching assistance with oral hygiene, and eating. The MDS indicated she required partial/moderate assistance with dressing the upper body and personal hygiene. The MDS indicated Resident #2 required substantial/maximal assistance with toileting, showering/bathing and dressing the lower body. The MDS indicated she was dependent on staff for the putting on ad taking off of footwear and all transfers. The MDS indicated she required staff assistance for locomotion in her manual wheelchair. The MDS indicated she had an ostomy (urostomy, ilestomy or colostomy) present. The MDS indicated she was always incontinent of bowel and bladder. <BR/>Record review of the care plan for Resident #2 dated 4/29/24, indicated Resident #2 had a surgical wound to her abdomen. The care plan interventions included wound protocol. The care plan did not indicate Resident #2 had any history of making false allegations directed toward staff. <BR/>Record review of the provider investigation report dated 5/9/24 indicated Resident #2's family member reported to the facility on 5/8/24 LVN A slapped Resident #2's hand away and cursed at her (Resident #2) during wound care. The investigation report indicated Resident #2 was assessed on 5/8/24 and was found without injury. The investigation report indicated Resident #2 denied the allegation against LVN A had occurred. The investigation report indicated LVN A denied the allegation and that she (LVN A) stated she never slapped or even moved Resident #2's hand away and certainly did not curse at Resident #2. The investigation report stated Alleged perpetrator was immediately suspended, pending investigation. Statements were obtained from resident, alleged perpetrator, Director of Nurses interviewed resident, as well as Administrator, at two separate times. Resident complained of pain during wound care, but denied the allegation made by .(Resident #2's family member). LVN [LVN A] was in-serviced by Director of Nurses regarding procedure, if resident complains of pain with wound care. Abuse and Neglect in-service provided by Director of Nurses. Safe Surveys completed by social worker. Physician and RP[Resident Representative] informed of allegation. Assessment performed by Director of Nurses, no physical or emotional harm was reported by resident.<BR/>Record review of LVN A's employee file found that all appropriate trainings regarding abuse, neglect and exploitation had been completed by LVN A. The employee file revealed all appropriate background checks ( criminal history, LVN licensure verification, NAR and EMR) had been conducted prior to hire. The employee file review found no disciplinary actions against LVN A related to abuse, neglect and exploitation or attitude towards residents/other staff. <BR/>During an interview on 5/10/24 at 10:00 a.m., Resident #2's family member said Resident #2 called her on the evening of 5/7/24 and told her LVN A had performed wound care. Resident #2's family member said during the care LVN A had slapped at her hand and told her to get her motherfing hand down. The family member said Resident #2 was very with it and was only [AGE] years old and that she could tell me exactly what occurred. <BR/>During an observation on 5/10/24 at 10:30 a.m., LVN A provided a breathing treatment to Resident #2. During the care, Resident #2 smiled and talked with the LVN A. Resident #2 displayed no signs of fear during the interaction. <BR/>During an observation and interview on 5/10/24 at 11:00 a.m., Resident #2 lay in her bed. Resident #2 had no scratches, bruising or marks to her hands or lower arms. Resident #2 said in the evening on 5/7/24, LVN A came into her room and performed wound care. Resident #2 said LVN A ripped off the old bandage and it hurt. Resident #2 said and demonstrated she had a tendency to hold her hands in fist shape with hands up to her shoulders during wound care because the wound care was uncomfortable. Resident #2 said when she held her hands up to her shoulders in the shape of fists, LVN A slapped at her hand and told her to get her motherfing hand away from there. Resident #2 said she told her family member about the situation on the phone that night (5/7/24). Resident #2 said LVN A came back later in the shift and apologized to her and said she was frustrated with another staff member. Resident #2 said she did not feel LVN A being frustrated with another staff member was a reason to treat her like that. Resident #2 said the incident made her mad, but she was not scared of LVN A. Resident #2 said LVN A had not provided wound care to her since the incident and that was fine with her because she felt LVN A could have been more careful when taking of her bandage. Resident #2 said wound care was provided by other nurses but not LVN A. Resident #2 said LVN A had not actually hit her hand but slapped at her hand. Resident #2 said the next day the Administrator did come ask her about the situation. Resident #2 said she reported to him just want she told the surveyor. Resident #2 said she absolutely did not deny that LVN A had slapped at her hand and cursed at her. Resident #2 said the DON came in and asked about the situation as well. Resident #2 said she told the DON the same thing she told the Administrator, LVN A had slapped at her hand and told her to get her motherfing hand away. Resident #2 said at no point when she was asked about the situation she denied that LVN A had cursed at her and slapped at her hand. <BR/>During an interviews on 5/10/24 from 11:10 a.m. to 12:50 p.m., Residents #'s 3, 4, 5, 6, 7, 8, 9, and 10 were interviewed and asked specifically if they had received rough car, were abused/neglected, or treated disrespectfully by LVN A. All of Residents (#3, #4, #5, #6, #7, #8, #9, #10) said they received regular care from LVN A but had not been abused, neglected, treated roughly, or disrespected by LVN A. <BR/>During an interview on 5/10/24 at 1:00 p.m., an unidentified staff member said she cared for Resident #2 on 5/8/24. The unidentified staff member said he/she entered Resident #2's room and family member #2 was at her (Resident #2's) bedside. The unidentified staff member said Resident #2's family member said tell (him/her) what happened. The unidentified staff member said Resident #2 then said LVN A performed wound care last night (5/7/24) and when LVN A ripped off the bandage, she (Resident #2) raised her hands up in shape of fists. The unidentified staff member said Resident #2 said while she (Resident #2) had her hands raised LVN A slapped at her hand and told her to move her motherfing hand. LVN A said she believed the DON and Administrator asked her (Resident #2) about the situation but was not present in the room at the time so she could not say what was said during their conversations. <BR/>During an observation on 5/10/24 at 1:50 p.m., LVN A provided responded to Resident #2's call light. During the interaction, Resident #2 smiled and talked with the LVN A. Resident #2 displayed no signs of fear during the interaction. <BR/>During an interview on 5/10/24 at 2:57 p.m., LVN A said she provided wound care to Resident #2 in the evening of 5/7/24. LVN A said she did not have to move Resident #2's hand out of the way during the wound care because Resident #2 did not put her hands in the way. LVN A said she did not slap at Resident #2's hand during the wound care. LVN A said she did not curse at Resident #2 during the wound care. LVN A said Resident #2 voiced no complaints during the wound care and did not complain of pain during the wound care. LVN A said she did not apologize to Resident #2 for anything on the evening of 5/7/24 because there had been nothing to apologize about. LVN A said the following day (5/8/24) she had been called into the conference room sometime around 3:00 pm in the afternoon. LVN A said she was notified Resident #2's family member reported she (LVN A) had slapped at Resident #2's hand and cursed at her. LVN A said she was told she would be suspended the investigation. LVN A said she turned over her keys and clocked out. LVN A said on her way to her car she was called back into the building and asked to sit in the conference room. LVN A said she was told by the DON to get her keys and go back to the floor. LVN A said she clocked out at 3:22 p.m. and clocked back in at 3:29 p.m. <BR/>During an interview on 5/17/24 at 9:45 a.m., the former facility social worker on 5/8/24 said she was instructed to complete safety surveys as a result of Resident #2's allegation against LVN A. LVN A said while she was completing the safety surveys several residents had negative responses. The former social worker said a negative response meant residents reported they were not being treated with respect/dignity or they did not feel safe or they weren't getting the care they needed. The former social worker said she was told she did not have to finish the safety surveys because the investigation was over about 30 minutes later. The former social worker said she told the DON about the negative safety survey findings and left them on her (the former social worker's) desk when she walked out on the morning of 5/9/24. The social worker said she was really upset about all the complaints from the safety surveys and felt a good investigation was not completed because LVN A was back on the floor within 30 minutes of being suspended. <BR/>During an interview on 5/17/24 at 12:00 p.m., the former DON said when she interviewed Resident #2 she denied LVN A slapped at her hand or cursed at her. The DON said the social worker had not come to her with any negative findings regarding the safety surveys but believed she (the social worker) said something to the Administrator because she overheard something to that effect. The former DON said she could not specifically say what was said or reported.<BR/>During an interview on 5/17/24 at 2:50 p.m., the Administrator said the investigation was terminated because the complaint came from a family member but when Resident #2 was interviewed she (Resident #2) denied LVN A had slapped at her hand or cursed at her. The Administrator said he had interviewed Resident #2 himself. The Administrator said he felt LVN A's length of suspension was appropriate because the investigation had been terminated due to the Resident denying it occurred. The Administrator said the former social worker was instructed initially to complete safety surveys but because the investigation was terminated, he was not sure they were completed. The Administrator said the social worker was very upset about Resident #2's allegation and because she was so upset he sent her home late in the afternoon on 5/8/24. The Administrator said the social worker reported to him that there were a lot of complaints (from the safety surveys). The Administrator said he was never told any of the complaints were related to abuse or neglect. The Administrator said he did not ask the social worker if any of the complaints were about abuse or neglect. The Administrator said he would expect the social worker to communicate that directly and would not expect he would have to ask that specifically. <BR/>Record review of the facility's policy and procedure dated July 2022 titled Abuse, Neglect and Exploitation, stated . V. Investigation of Alleged Abuse, Neglect and Exploitation .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations included: Identifying staff responsible for the investigation; .Investigating different types of alleged violations; . Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; .Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation .

**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 be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 (Resident #1) of 7 residents reviewed for abuse and/or neglect.<BR/>The facility failed to prevent CNA B from physically abuse abusing Resident #1 when she slapped her arm and left a bruise.<BR/>This failure could place residents at risk of abuse and neglect. <BR/>Findings included:<BR/>Record review of the Resident #1's face sheet, dated 5/17/24, indicated she was readmitted to the facility on [DATE] with diagnoses including, hypothyroidism (abnormally low activity of the thyroid gland), dysphagia (difficulty swallowing), diabetes, mild protein-calorie malnutrition, high blood pressure, muscle weakness, lack of coordination, heart failure and anxiety. <BR/>Record review of the Resident #1's MDS, dated [DATE], reflected Resident #1 usually made herself understood and usually understood others. Resident #1 had severe cognitive impairment with a (BIMS of 7). Resident #1 had no physical or verbal behaviors symptoms directed towards herself or others. Resident #1 had no behavior of rejecting care. Resident #1 used a manual wheelchair for locomotion and required supervision or touch assistance with eating and oral hygiene. Resident #1 required patrial/moderate assistance with dressing her upper/lower body, personal hygiene, rolling side to side in the bed, moving from a sitting position to lying flat in the bed, and lying to sitting on the side of the bed. The MDS indicated Resident #1 required substantial/maximal assistance with showers/bathing, putting on/taking off footwear, the ability to stand from a sitting position, chair to bed/ bed to chair transfers, toilet transfers, and tub/shower transfers. The MDS indicated Resident #1 was dependent on staff for toileting.<BR/>Record review of Resident #1's care plan dated 3/12/24, reflected Resident #1 had a risk for bruising and bleeding due to anticoagulant therapy. The care plan interventions included encourage resident to be aware of extremities in relation to environment. The care plan also indicated Resident #1 reported alleged mistreatment by staff and was at risk for increased anxiety. <BR/>Record review of the facility's provider investigation report dated 5/17/24, reflected Resident #1 reported CNA B struck her arm. The police were notified. CNA B was terminated, detained and placed under arrest by the police. <BR/>Record review of CNA B's signed statement, dated 5/13/24, reflected I'm not the only one that hits them . (Resident #1) was just mad because we didn't have a diaper that would fit her. She got mad and pulled the yellow diaper off. She hit me. I never hit anybody . <BR/>During an observation and interview on 5/17/24 at 12:50 p.m., Resident #1 said she called for help in the early morning hours of 5/13/24 because her brief was coming off. Resident #1 demonstrated and described she pulled at the brief showing the CNA the brief did not fit and was coming off. Resident #1 then demonstrated and described that as she was doing this (pulling at the brief) CNA B slapped her arm and indicated she slapped her left arm hard while she (CNA B) stood on the left side of her bed. Resident #1 had a large bruise (approximately 7 inches in length and 3 inches in width) to the posterior aspect of her left forearm. Resident #1 said the bruise was where CNA B hit her. <BR/>During an interview on 5/17/24 at 1:00 p.m., CNA C said it was not acceptable to hit a resident under any circumstances. CNA C said even if they (the residents) hit us (the staff), we the staff do not hit them back. CNA C said this was abuse.<BR/>During an interview on 5/17/24 at 2:15 p.m., LVN D said Resident #1 was very descriptive and named CNA B as the aide who slapped her arm. LVN D said CNA B slapping Resident #1 no matter the reason was abuse.<BR/>During an interview on 5/17/24 at 2:30 p.m., The Corporate RN said she was the acting DON. The Corporate RN said Resident #1 was consistent with her details of the event and had bruising to her left arm where she said a nurse had hit her. The Corporate RN said because of Resident #1's description of the staff member and her (Resident #1's) report that the staff member worked double almost every night- CNA B was identified. The Corporate RN said the Resident #1 had reported the incident happened sometime in the early morning hours. The Corporate RN said when the facility was made aware of the allegation they promptly reported the incident to the state agency and began their investigation. The Corporate RN said safety surveys were completed with no additional findings. The Corporate RN said the CNA B was not at work when they were notified of the allegation (she had worked 10:00 p.m. to 6:00 a.m.) so she was called to facility for interview and they kept here there until the police arrived and detained her. The Corporate RN said the police were notified and walked CNA B out in handcuffs. The Corporate RN said what CNA B did (slapping Resident #1's arm) was abuse and would not be tolerated. The Corporate RN said all staff were in-serviced over ANE. <BR/>During an interview on 5/17/24 at 2:50 p.m., the Administrator said CNA B was immediately terminated and all other staff were in-serviced over abuse, neglect and exploitation. The Administrator said abuse of residents would not be tolerated at the facility. <BR/>Record review of CNA B's personnel action form, dated 5/13/24, indicated she was terminated for misconduct regarding allegations of Abuse and was not eligible for rehire. The personnel action form also indicated criminal charges had were filed.<BR/>Record review of the facility's policy and procedure, dated July 2022, titled Abuse, Neglect and Exploitation, stated It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish, It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .

**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 3 residents (Resident #1) reviewed for smoking.<BR/>The facility failed to ensure Resident #1 was provided supervision when he smoked. Resident #1 had a history of attempting to smoke while wearing his oxygen tank (secured to the back of his motorized wheelchair). On 03/26/2023, a lit cigarette was discarded on the ground and ignited his oxygen tubing and catheter bag that was laying at the bottom of his motorized wheelchair. <BR/>An Immediate Jeopardy (IJ) was identified on 04/01/2023 at 3:20 PM. While the IJ was removed on 04/03/2023 at 7:12 PM, the facility remained out of compliance at no actual harm because the facility needed to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents at risk of harm, severe injury, and possible death to residents who wear oxygen and were inadequately assessed for smoking safely unsupervised. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet, dated 04/02/2023, revealed Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia (occurs when disease of the heart or lungs leads to failure to maintain adequate blood oxygen levels), cognitive communication deficit (difficulty with thinking and how someone uses language), and paraplegia (impairment in motor (movement) or sensory (feeling) function of the lower extremities). <BR/>Record review of the order summary report, dated 04/01/2023, revealed Resident #1 had an order, which started on 03/18/2023, for Oxygen continuously via nasal cannula . <BR/>Record review of Resident #1's comprehensive MDS assessment, dated 03/24/2023, revealed it had not been completed. <BR/>Record review of the comprehensive care plan, initiated on 03/20/2023, revealed Resident #1 had altered respiratory status and difficulty breathing. The interventions included oxygen at 2 LPM via NC every shift. The comprehensive care plan further revealed a smoking care plan was initiated on 03/26/2023 after Resident #1 ignited his oxygen tubing on the smoking patio. The intervention included Resident is deemed unsafe smoker, he smoked with oxygen tank in place after being educated to leave oxygen concentrator at nurses' station when going out to smoke.<BR/>Record review of the occupational therapy treatment encounter note, dated 03/22/2023, revealed Resident #1 was educated on the safety concerns including the oxygen tank attached to his motorized wheelchair and not being allowed in the smoking courtyard. <BR/>Record review of the nursing progress note, dated 03/22/2023 at 2:35 PM, revealed Resident #1 was repeatedly going outside in the common smoking area to smoke while oxygen was connected. The progress notes further revealed the charge nurse, ADON, and DON provided education and Resident #1 agreed not to smoke while using oxygen.<BR/>Record review of the smoking assessment, effective date 03/22/2023, revealed Resident #1 had a history of smoking-related problems that would be hazardous to self or others. The smoking assessment revealed Resident went to smoking area in power chair with his oxygen tank. The tank was removed, and resident educated. The smoking assessment revealed Resident #1 was able to keep his lighter and cigarettes and was safe to smoke unsupervised. The assessment was signed by the DON on 03/27/2023. <BR/>Record review of the nursing progress note, dated 03/25/2023 at 11:47 PM, revealed Resident #1 was provided additional education regarding removing his oxygen tank prior to going outside to smoke. <BR/>Record review of the nursing progress note, dated 03/26/2023 at 3:45 PM, revealed Resident #1 had been off the hall for about an hour visiting another resident. Resident #1 went out to smoking area, and per resident witnesses' Resident #1 removed his nasal cannula and laid it on his foley catheter bag and proceeded to take out a cigarette and light it. While smoking, Resident #1 dropped his cigarette on top of oxygen tubing that was on ground. The oxygen tubing and foley catheter caught fire. A resident in the area grabbed the fire extinguisher and quickly put out the fire. There were no visible injuries, 911 was called, the doctor was notified, and a message with call back number was left for family.<BR/>Record review of the incident report, dated 03/26/2023 at 3:30 PM, revealed Resident #1 was outside smoking with oxygen tank on, per witnesses' he took the nasal cannula off and placed it on the ground on his foley tubing prior to lighting the cigarette. He dropped his cigarette and the oxygen tubing ignited burning the oxygen tubing and foley tubing. Another resident immediately got the fire extinguisher and put out fire, and someone else hollered for nurse. Charge nurse went into smoking area and noted white substance all over resident. Nurse observed resident sitting in his power chair, holding the power cord to chair, and burnt oxygen tubing. The incident report further revealed immediate action taken was 911 was called, fire extinguisher was used, resident transported to ER to rule out any injury. Oxygen tank was turned off and removed from chair. Resident returned to nurses' station for eval.<BR/>Record review of the Smoking Policy In-service, initiated on 03/26/2023, revealed staff were in-serviced on the smoking policy that was implemented in 06/2022 which indicated oxygen was prohibited in the smoking area. The in-service further revealed 7. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether supervision is required for smoking, or if resident is safe to smoke at all. 8. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan. The in-service further revealed 13. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff.<BR/>Record review of the Supervised Smoking Schedule, undated, revealed instructions that included: Do not throw cigarettes on the ground, use the ashtrays. No cigarettes, cigars, lighters or matches (any lighting instrument) in a resident's room or on your person at any time. The schedule further revealed the smoking times as follows:<BR/>6:00 AM - 6:15 AM supervised by the staff on duty<BR/>9:00 AM - 9:15 AM supervised by the staff on duty<BR/>12:45 PM - 1:00 PM supervised by the staff on duty<BR/>4:00 PM - 4:15 PM supervised by the staff on duty<BR/>7:00 PM - 7:15 PM supervised by the staff on duty<BR/>10:00 PM - 10:15 PM supervised by the staff on duty<BR/>During an interview on 04/01/2023 at 9:07 AM, LVN D stated the residents were able to take themselves out to the smoking area and smoke if they were able to smoke unsupervised. LVN D stated there were currently no designated smoking times in place and residents could go out whenever. LVN D stated the residents were able to keep their cigarettes and lighters. <BR/>During an observation on 04/01/2023 at 9:05 AM, four residents (Resident's #2, #5, #6, and #7) were outside in the smoking courtyard. Residents #2, #5, #6, and #7 had their own cigarettes and lighters. <BR/>During an interview 04/01/2023 at 9:10 AM, Resident #2 stated she was the person who used the fire extinguisher to put the fire out on 03/26/2023. Resident #2 stated it was windy the day of the incident and Resident #1 was sitting in his motorized wheelchair against the wall. Resident #2 stated Resident #1 had taken his nasal cannula out of his nose and placed it on top of his catheter bag. Resident #2 stated Resident #1 was not right in the head and had come out several times with his oxygen tank on the back of his motorized wheelchair. Resident #2 stated the nurses would have normally turned the oxygen tank off, but it was on the day of the incident. Resident #2 stated another resident had dropped his cigarette on the ground and the wind blew it toward the nasal cannula and the tubing ignited causing a fire. Resident #2 stated she immediately grabbed the fire extinguisher and put out the fire. Resident #2 stated she did not believe there were any injuries to Resident #1. <BR/>During an interview on 04/01/2023 at 9:16 AM, Resident #5 stated the facility staff told them during the past week that the residents were not allowed to smoke without supervision anymore. Resident #5 stated the staff members had not supervised them this morning, but she was under the impression it was to have started. Resident #5 stated the facility told the residents who smoked they would also have to give up their cigarettes and lighters and could only smoke during the designated smoking times for only 15 minutes. Resident #5 stated the staff had not taken her cigarettes or lighter and had not provided supervision at this time. <BR/>During an interview on 04/01/2023 at 9:47 AM, LVN C stated on the morning of the incident on 03/26/2023 and the day prior on 03/25/2023 she had talked to Resident #1 several times about going outside with his oxygen on. LVN C stated Resident #1 had gone to another hall to visit another resident. LVN C stated Resident #1 entered the smoking area after leaving the other resident's room. LVN C stated a CNA had come to tell her he was outside with oxygen on. LVN C stated RN F had beat her to the smoking area and the fire was already extinguished. LVN C stated paramedics had been called so Resident #1 could have been checked out. LVN C stated he had some redness to his bilateral lower extremities, but they looked like that prior to the incident. LVN C stated to her knowledge, he took his nasal cannula off and placed it at the bottom of his motorized wheelchair where it caught fire. LVN C stated he had no injuries. LVN C stated some residents required supervision and some did not dependent on their smoking assessment. LVN C stated the facility had no set times for residents who were able to smoke unsupervised. LVN C stated the facility did an in-service stating residents had to be supervised while smoking and should have designated times but was usure when it started. LVN C stated it should have been implemented by today. <BR/>During an observation on 04/01/2023 at 9:54 AM, four residents were outside smoking with no staff supervision. <BR/>During an interview on 04/01/2023 at 9:58 AM, Resident #3 stated she did not smoke but liked to sit outside. Resident #3 stated she witnessed the incident that happened on 03/26/2023 with Resident #1. Resident #3 stated Resident #1 was confused and would often become naked by taking his gown off. Resident #3 stated Resident #1 had taken his oxygen off and placed it on his catheter bag. Resident #3 stated Resident #1 threw his lit cigarette on the ground, and he started yelling he was on fire. Resident #3 stated the flames were going and another resident grabbed the fire extinguisher and put out the fire. Resident #3 stated a different resident hollered for a nurse. Resident #3 stated the fire department arrived at the facility and told her Everyone could have been blown to pieces. <BR/>During an interview on 04/01/2023 at 10:18 PM, the DON stated on 03/26/2023 Resident #1 had taken his oxygen tank attached to his motorized wheelchair out into the smoking area. The DON stated it was discovered during the investigation that Resident #1 was not actually smoking but another resident was smoking beside him and dropped his cigarette on the ground. The DON said the cigarette rolled toward Resident #1's motorized wheelchair where his oxygen tubing was laying on his catheter bag and ignited. The DON stated another resident put out the fire using the fire extinguisher and Resident #1 was sent to the emergency room as a precaution. The DON stated when Resident #1 returned to the facility he was re-assessed as an unsafe smoker and his smoking materials were taken. The DON stated Resident #1 had one prior incident on 03/22/2023 where he was found outside with his oxygen tank on. The DON stated herself, the ADON, the nurse, and therapy provided Resident #1 with education regarding taking his oxygen tank into the smoking area. The DON stated he was deemed a safe smoker at that time because he was able to verbalize understanding of the smoking policy. The DON stated the corporate office had changed the smoking policy and she had in-serviced the residents and the staff. The DON stated the supervised smoking at designated times was supposed to have been implemented on Monday, 04/03/2023. <BR/>During an observation and interview on 04/01/2023 at 12:35 PM, Resident #1 was sitting up in his hospital bed. Resident #1 looked frail and unkempt as evidenced by the hospital gown falling off his bony shoulders and his hair was disheveled and falling into his face. Resident #1 was wearing a nasal cannula and was struggling to breath during the interview. Resident #1 stated he remembered the incident that occurred on 03/26/2023. Resident #1 stated he was not smoking but another resident was sitting beside him and was smoking. Resident #1 stated the other resident dropped his cigarette and about 5 minutes later his nasal cannula and foley catheter tubing caught on fire. Resident #1 stated it was a small flame and he was not injured. Resident #1 stated the facility made him go to the hospital and he believed they made a mountain out of a molehill. Resident #1 stated he knew all about safety and for significant damage to have been done, it would have needed to happen in an enclosed space. Resident #1 stated he normally went into the smoking area with his oxygen tank, but the staff would turn off the oxygen or he would himself. <BR/>During an interview on 04/01/2023 at 1:22 PM, CNA B stated she worked the hall were Resident #1 resided and had taken care of him. CNA B stated Resident #1 wanted to do what he wanted to when he wanted to do it. CNA B stated Resident #1 had behaviors, but it seemed like they were getting better. CNA B stated she observed Resident #1 outside in the smoking area on multiple occasions with his oxygen tank on the back of his motorized wheelchair. CNA B stated Resident #1 was an unsupervised smoker, and she believed the nurses were turning the oxygen off. CNA B stated all the nurses were aware Resident #1 was going outside with his oxygen tank on. CNA B stated she was provided an in-service on the new smoking policy and stated all residents were going to be supervised while smoking and only allowed to smoke at designated times. <BR/>During an interview on 04/01/2023 at 1:41 PM, MA E stated she worked on the hall were Resident #1 resided. MA E stated Resident #1 was told things and he would forget them. <BR/>During an interview on 04/01/2023 at 2:29 PM, COTA R stated 03/22/2023 was the first day Resident #1 was out of the bed. COTA R stated she was performing a safe motorized wheelchair assessment on Resident #1 when he mentioned he wanted to go outside for a cigarette. COTA R stated she provided education on safety to Resident #1 and instructed him it was not appropriate to go outside with his oxygen tank hooked on the back of his motorized wheelchair. COTA R stated she informed the nurse he was asking for a cigarette. COTA R stated Resident #1 was later found outside with his oxygen tank on his motorized wheelchair. <BR/>Record review of the Resident Smoking policy, updated in 03/2023, revealed 7. Residents who smoke will be assessed, using the Resident Safe Smoking Assessment, to determine the level of supervision the resident requires. 8. All residents who smoke will be allowed to smoke in designated smoking areas (weather permitting), at designated times with supervision, and in accordance with his/her care plan. The policy further revealed 13. Smoking materials of residents who smoke will be maintained by nursing staff.<BR/>The Administrator was notified on 04/01/2023 at 3:52 PM that an immediate jeopardy situation was identified due to the above failures. The Administrator and the DON was provided the immediate jeopardy template on 04/01/2023 at 3:59 PM. <BR/>During an interview on 04/02/2023 at 10:55 AM, the DON stated before the incident on 03/26/2023, the facility assessed residents for safe smoking, the need for supervision, and whether residents were able to keep their smoking materials by performing a smoking assessment. The DON stated it had been the policy from the time she started at the facility. The DON stated there was no set person to complete the smoking assessment. The DON stated often the MDS nurse, the charge nurse, or herself would have completed the smoking assessments. The DON stated this was monitored during daily clinical meetings and if the assessment was not completed, she would do it. The DON stated Resident #1 had a BIMS score of 14, which indicated no cognitive impairment and was able to verbalize understanding of the smoking policy. <BR/>The facility's plan of removal was accepted on 04/03/2023 at 2:56 PM and included the following:<BR/>The facility failed to provide supervision to Resident #1 who required oxygen and smoked. All Smoking assessments and Care plans were reviewed for residents who smoke, and changes were made as necessary on 3/26/2023 by the director of nurses. Residents who smoke were reviewed for care plan and if a care plan was not noted, a care plan was completed. On 3/31/2023 residents who smoked and used oxygen were asked to attend a care plan meeting so that the care plan could be updated to reflect that they used oxygen and understood that they could not go outside to smoke with oxygen. Every resident who smokes verified they understood that they were not allowed go outside to smoke with oxygen. <BR/>Resident #1 was assessed and transferred to ER 3/26/2023 at approximately 3:45 PM to evaluate and treat as necessary. The Resident returned 3/26/2023 at approximately 9:00 PM with no new orders and with no injuries reported by the ER. <BR/>The facility smoking policy was updated on 3/31/2023 and at that time DON/ADON began in-servicing facility staff on the policy changes. <BR/>Facility policy was updated by corporate office to provide scheduled supervised smoking times for all residents who smoke on 3/31/2023.<BR/>Assigned smoking times are supervised as follows: <BR/>6:00am to 6:15am - Charge Nurse on North Wing will assign staff member to take residents smoking paraphernalia out to smoke area and allow residents to smoke while being supervised. <BR/>9:00am - 915am - Activity Director or her designee will supervise M-F, Housekeeping staff member on duty will supervise during this time on Sat - Sun.<BR/>12:45pm - 1:00pm - Social Services will supervise during this time frame and housekeeping staff member will supervise on Sat - Sun.<BR/>4:00pm - 4:15pm - North Wing Charge Nurse will assign Aide/C.N.A.<BR/>7:00pm- 715: pm - South Wing Charge Nurse will assign Aide/C.N.A.<BR/>10:00 pm - 10:15pm - East Wing Charge nurse will assign Aide/C.N.A. <BR/>DON, ADON, and the wound care nurse in-serviced all staff regarding the new smoking policy and the supervised smoking requirements. This will be monitored by the Administrator, DON and ADON. Smoking policy will be covered during orientation for new hires. All staff currently on duty were in-serviced at 11:00 AM on 4/3/2023.<BR/>Any staff members not available for in-service will be in-serviced prior to returning to shift. <BR/>All resident smokers were invited to a meeting on 3/31/2023 conducted by Social Worker and Administrator. Each resident in attendance was provided a copy of the changes. The Smoking policy is part of the admission agreement, and the revised policy will be placed in admission packet immediately. Not all residents who smoke showed up for the meeting. For those who did not attend, the ADON went to each resident on 4/2/2023 at 2:00PM to educate them on the new smoking policy to ensure they understood. Also, the residents were reminded that they must turn in all cigarettes and lighters to the nurse. <BR/>The new smoking policy was updated on 3/31/2023 to reflect that oxygen tanks are not allowed in the smoking area. <BR/> The person assigned to supervise smoking will ensure there are no oxygen tanks in the smoking area. <BR/>Policy related to supervision during smoking times has been implemented and is in place. The new smoking policy implementation explanation started 3/31/23 with all residents who smoke. The new smoking policy implementation was completed on 4/2/2023 for all residents who smoke.<BR/>All residents who smoke were asked again on 4/3/2023 at 11:00 AM to turn in cigarettes and lighters to the charge nurse for storage. Staff in-serviced again regarding the new smoking policy to ensure everyone understood on 4/03/2023 at 12:00PM.<BR/>On 04/03/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>During an observation on 04/03/2023 at 4:25 PM, 13 residents were outside smoking supervised by CNA B. <BR/>During resident interviews on 04/03/2023 between 4:33 PM - 5:09 PM, Resident's #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 were able to verbalize understanding of the new smoking policy, which included supervised smoking and designated smoking times, verbalize understanding of not going into the smoking area with oxygen, and verified all cigarettes and lighters were turned into the facility staff. <BR/>Record review of the comprehensive care plan for Resident's #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, and #27 revealed they had been reviewed and revised as necessary. <BR/>Record review of the smoking assessments for Resident's #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #17, #18, #19, #20, #22, #23, #24, #25, #26, and #27 revealed they had been reviewed and revised as necessary. <BR/>Record review of the new smoking policy in-service provided to staff, dated 03/31/2023, 04/01/2023, and 04/02/2023, revealed 42 staff members had signed and dated the read and understood the new smoking policy, which included oxygen was not allowed in the smoking area, residents were required to keep their cigarettes and lighters at the nurse's station, and designated smoking times and supervision. <BR/>During interview on 04/03/2023 between 4:25 PM and 6:28 PM, the following staff members, LVN K, MA L, LVN M, CNA N, CNA O, CNA P, CNA B, LVN D, CNA Q, and the ADON were interviewed and verbalized understanding that no oxygen was allowed in the smoking area, residents were required to keep their cigarettes and lighters at the nurse's station, and the new digitated smoking times and supervision. <BR/>On 04/03/2023 at 7:12 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an accurate MDS was completed for 6 of 12 residents (Residents #9, 25, 33, 50, 94, and 97) reviewed for MDS assessment accuracy.<BR/> The facility did not accurately code Resident #9's quarterly MDS assessment for assistance with eating and diuretic use.<BR/>The facility did not accurately code Resident # 25's annual MDS assessment for antipsychotic medication use. <BR/>The facility did not accurately code Resident #33's annual MDS assessment for Pressure Ulcer and insulin use, opioid use, antidepressant use, antibiotic use, and antianxiety use.<BR/>The facility did not accurately code Resident #50's quarterly MDS assessment for assistance with eating and diuretic use, opioid use, antidepressant use, and anticoagulant use.<BR/>The facility did not accurately code Resident #94's quarterly MDS assessment for antipsychotic use.<BR/>The facility did not accurately code Resident #97's admission MDS assessment for antianxiety use and anticoagulant use.<BR/>This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. <BR/>Findings included:<BR/>1.A review of Resident #9's face sheet and physician's orders for August 2023 indicated Resident #9 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including heart failure, diabetes, bipolar disorder (a disorder associated with mood swings ranging from depressive lows to manic highs), anxiety disorder, and depressive episodes. <BR/>A review of Resident #9's physician's order dated August 2023 indicated she had an order dated 11/22/2021 to receive a diuretic, acetazolamide, 500 mg twice a day. <BR/>A review of Resident #9's May 2023 MAR indicated the resident had received acetazolamide as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #9's quarterly MDS (Section N410: medications received) dated 05/11/2023 indicated she had not received a diuretic during the observation period. The same MDS (Section G: Functional status) indicated the resident required limited assistance of one-person physical assist with eating.<BR/>A review of a care plan initiated on 11/22/2021 and last revised on 06/17/2022 indicated Resident #9 required set up assistance by staff to eat.<BR/>During an observations and interview on 08/14/23 at12:37 PM Resident #9 was eating her lunch without assistance and having no problems. She said the food was pretty good and she was having no issues with eating.<BR/>During an observations and interview on 08/15/23 at12:40 PM Resident #9 was eating her lunch without assistance and having no problems. She was dipping the zucchini sticks into her salad dressing and said it was really good and wished she had some more.<BR/>2. A review of Resident #25's face sheet and physician's orders for August 2023 indicated Resident #25 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including psychosis and schizoaffective disorder (mental disorders). <BR/>A review of Resident #25's physician's order dated 05/21/2022 indicated he was to receive an antipsychotic, Seroquel, 100 mg daily at bedtime and an order dated 02/16/2023 indicated he was to also receive Seroquel 50 mg daily in the morning. <BR/>A review of Resident #25's June 2023 MAR indicated the resident had received both the morning and evening doses of the antipsychotic, Seroquel, as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #25's Annual MDS (Section N: Antipsychotic Medication Review) dated 06/21/2023 indicated he had not received an antipsychotic medication during the observation period. This incorrect coding led to the rest of the Antipsychotic Medication Review section of the MDS not being completed. <BR/>During an interview on 08/14/2023 at 10:30 AM with the MDS Coordinator from a sister facility, she said the facility did not have a full time MDS Coordinator and that she was helping at this facility a couple of days a week. She said she was not the person who completed Resident # 25's annual MDS.<BR/>During an interview on 08/17/2023 at 11:20 AM with the sister facility's MDS Coordinator, she said Section N0450-A should have been coded as the resident having received an antipsychotic medication which would have also led to the rest of the assessment being completed.<BR/>3. A review of Resident #33's face sheet and physician's orders for August 2023 indicated Resident #33 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including diabetes, stage 4 pressure ulcer of sacral region, chronic pain, paraplegia (paralysis of the legs and lower body), depressive disorder, anxiety disorder, urinary tract infection, and high blood pressure. <BR/>A review of Resident #33's physician's order dated August 2023 indicated she had orders dated 01/05/2023 to receive an antianxiety medication, venlafaxine, 75 mg daily; orders dated 09/03/2021 to receive an antianxiety medication, clonazepam, 0.5 mg twice a day; orders dated 03/15/2022 to receive an antibiotic, Hiprex, 1,000 mg twice a day; orders dated 02/25/2023 to receive an opioid, oxycodone ER, 15 mg twice a day, orders to receive an insulin, Levemir, 80 units subcutaneously twice a day.<BR/>A review of Resident #33's July 2023 MAR indicated the resident had received venlafaxine, clonazepam, antibiotic, opioid, and insulin as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #33's Wound Assessment Profile dated 07/06/2023, 07/13/2023, 08/03/2023, and 08/10/2023 indicated the resident had a stage 4 pressure ulcer on the sacrum (an injury that extends through muscle, tendon or bone).<BR/>A review of Resident #33's annual MDS dated [DATE] (Section M: Skin Conditions) indicated she did not have one or more unhealed pressure ulcer/injuries and (Section N410: medications received) indicated she had not received insulin injections, antianxiety medications, antidepressant medications, antibiotics, and opioid medications.<BR/>4. A review of Resident #50's face sheet and physician's orders for August 2023 indicated Resident #50 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular, often rapid, heart rate that commonly causes poor blood flow), chronic obstructive pulmonary disease, diabetes, pain, major depressive disorder, and peripheral venous insufficiency (walls of the veins not working properly making it difficult for the blood to return to the heart). <BR/>A review of Resident #50's physician's order dated August 2023 indicated she had an order dated 04/20/2023 to receive a diuretic, furosemide, 40 mg daily; an order dated 04/20/2023 to receive hydrocodone-acetaminophen 10-325 mg twice a day; , an order dated 07/04/2023 to receive insulin, Glargine 35 units subcutaneously in the morning before breakfast and Glargine 35 units subcutaneously (insertion under te skin by injection) at bedtime; an order dated 07/20/23 to receive Novolog insulin sliding scale before meals and at bedtime, an order dated 04/20/2023 to receive an anticoagulant, rivaroxaban, 20 mg in the evening; and an order dated 04/20/2023 to receive an antidepressant, trazadone, 50 mg at bedtime. <BR/>A review of Resident #50's July 2023 MAR indicated the resident had received rivaroxaban, furosemide, trazadone, hydrocodone-acetaminophen, Glargine, and Novolog, as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #50's quarterly MDS (Section N410: medications received) dated 07/25/2023 indicated she had not received insulin injections, an antidepressant, an anticoagulant, a diuretic, and an opioid during the observation period. The same MDS (Section G: Functional status) indicated the resident required limited assistance of two-persons physical assist with eating.<BR/>A review of a care plan initiated on 11/30/2018 and last revised on 12/05/2018 indicated Resident #50 required assistance of one staff member to eat<BR/>During an observation and interview on 08/14/23 at 12:39 PM Resident #50 was eating her lunch without assistance. She was sitting upright in bed and eating her lunch. She said it wasn't too bad.<BR/>During an observation and interview on 08/15/23 at 12:55 PM Resident #50 was eating her lunch without assistance. She was sitting upright in bed and eating her lunch. She was nodding off a little while eating.<BR/>5. A review of Resident #94's face sheet and physician's orders for August 2023 indicated Resident #94 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including schizophrenia (mental disorder), epilepsy (seizure disorder), major depressive disorder, and alcohol use. <BR/>A review of Resident #94's physician's order dated August 2023 indicated she had an order dated 10/27/2022 to receive an antipsychotic, Seroquel, 300 mg at bedtime and an order dated 03/31/2023 to receive Seroquel 150 mg in the morning. <BR/>A review of Resident #94's April and May 2023 MARs indicated the resident had received Seroquel as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #94's quarterly MDS (Section N410: medications received) dated 05/04/2023 indicated she had received an antipsychotic during the observation period. (Section N450: Antipsychotic Medication Review) dated 05/04/2023 indicated she had not received an antipsychotic medication during the observation period. This incorrect coding led to the rest of the Antipsychotic Medication Review section of the MDS not being completed. <BR/>6. A review of Resident #97's face sheet and physician's orders for August 2023 indicated Resident #97 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including atrial fibrillation an irregular, often rapid, heart rate that commonly causes poor blood flow), anxiety disorder (amental health disorder characterized by feelings of worry or fear), high blood pressure, and pneumonia.<BR/>A review of Resident #97's physician's order dated August 2023 indicated she had an order dated 05/11/2023 to receive an antianxiety, clonazepam, 0.5 mg twice a day and an anticoagulant, enoxaparin injectable 30 mg/0.3 ml injected subcutaneously every morning. <BR/>A review of Resident #97's May 2023 MAR indicated the resident had received 6 of 7 doses of enoxaparin of the 7 doses as ordered by the physician and clonazepam 5 of the 7 doses as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #97's admission MDS (Section N410: medications received) dated 05/17/2023 indicated she had not received an antianxiety medication or an anticoagulant during the observation period. <BR/>During an interview on 08/16/2023 at 01:35 PM with the sister facility's MDS Coordinator, she said she had been helping with the MDS since about June 2023. She said the RAI manual was used as the guideline for performing the MDS assessment. She said the policy would be to follow the RAI.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine and emergency dental care for 2 of 7 (Resident #1 and Resident #2) residents reviewed for dental services. <BR/>The facility failed to provide emergency dental services for Resident #1 after complaints of mouth pain, orders for dental referrals were received, and being prescribed antibiotics for a mouth infection.<BR/>The facility failed to provide dental services for Resident #2's broken teeth.<BR/>This failure could affect residents by placing them at risk for oral complications and diminished quality of life. <BR/>Findings included:<BR/>1. Record review of the face sheet dated 11/2/23 indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including COPD, diabetes, schizoid personality disorder (a condition in which people avoid social activities and interacting with others), and hypertension (elevated blood pressure)<BR/>Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 12 and was moderately cognitively impaired. The MDS indicated Resident #1 did not have any mouth or facial pain, discomfort, or difficulty swallowing. <BR/>Record review of the care plan last revised on 11/2/23 indicated Resident #1 had oral/dental health problems related to unhealthy teeth, dental pain.<BR/>Record review of the physician orders dated 11/2/23 indicated Resident #1 had an order for a dental consult due to complaints of tooth pain impacting ability to chew starting 8/17/23. The physician orders indicate Resident #1 had orders for Anbesol Maximum Strength Mouth/Throat Gel 1 application orally every 6 hours as needed for tooth pain starting 8/7/23, Mouth Rinse Mouth/Throat Liquid 10ml by mouth twice a day for mouth ulcers starting 9/26/23, Hydrocodone-Acetaminophen (used to treat pain) oral tablet 10-325mg 1 tablet every 4 hours as needed starting 8/21/23, and Hydrocodone-Acetaminophen oral tablet 10-325mg 1 tablet 3 times a day starting 8/7/23. <BR/>Record review of the nursing progress note dated 8/17/23 at 1:47 p.m. indicated Resident #1 had a swallowed study done. The progress noted indicated Resident #1's diet was changed to mechanical ground meat and crushed meds as needed. The progress note indicated Resident #1 received a dental referral for a dentist to evaluate and treat. <BR/>Record review of the nursing progress note dated 8/21/23 at 1:58 p.m. indicated the nurse reported to the SW that Resident #1 would like to see the dentist. The progress note indicated the SW went to Resident #1's room to talk to him regarding seeing the mobile dentist.<BR/>Record review of the nursing progress note dated 8/23/23 at 11:13 a.m. indicated the SW was working to have Resident #1 on the list for the mobile dentist's next visit to the facility. The progress noted indicated Resident #1 complained of tooth and gum pain. The progress note indicated the physician was notified of the resident's complaints of tooth and gum pain. The progress note indicated the physician gave an order for Doxycycline (antibiotic) 100mg by mouth twice a day for 5 days. <BR/>Record review of the nursing progress note dated 9/7/23 at 1:01 p.m. indicated Resident #1 was assessed by the physician and received an order for a dentistry referral. The progress note indicated the referral was put in the SW's box. <BR/>Record review of the nursing progress noted dated 9/14/23 at 10:37 p.m. indicated Resident #1 received an order for Doxycycline 100mg twice a day for 5 days for possible tooth infection. <BR/>During an interview on 11/1/23 at 12:21 p.m. Resident #1 said he has bad teeth and had not seen a dentist. Resident #1 said he did not have insurance. Resident #1 said he received ground textured food which was not good for his teeth. Resident #1 said he did not know why he was taken off the pureed diet . <BR/>During an interview on 11/1/23 at 1:05 p.m. DON said she had been trying to get Resident #1 in to see a dentist but everyone she had reached out to either did not take his insurance or was not accepting new patients at the time. The DON said she did not have documentation of what dentists were called, when they were called, or why they could not accept Resident #1 as a patient . The DON said the mobile dental contract had been signed in August 2023, but the contract was not sent to the corporate BOM until the end of September. The DON said they had not received a response from the corporate BOM. The DON said she started at the facility in May 2023 and mobile dental had not been at the facility since she started. The DON said she was unaware of any other residents having dental issues at this time. The DON said Resident #1's diet had been changed from mech soft to pureed at his request and after the first day of pureed and realizing he would not get certain foods he requested his diet be changed back to mech soft. The DON said Resident #1 was seen by the facility physician on 10/31/23 and received orders for a scan of his mouth. The DON said Resident #1 had reported he had been told in the past he may have cancer of his tongue. <BR/>During an interview on 11/1/23 at 1:34 p.m. the previous SW said he was employed at the facility from May to September 2023. The SW said he had been in charge of getting contracted services. The SW said when he started the facility did not have any contract for dental services. The SW said he had contacted local dentists to try to get Resident #1 seen but could not find a dentist that would accept Medicaid. The SW said he was told by the DON the new mobile dentistry company was supposed to come to the facility on 9/21/23. The SW said the DON had set up the date as he was out of the facility at the time.<BR/>During an interview on 11/2/23 at 11:22 a.m. LVN A said Resident #1 complained of his teeth. LVN A said she had made Resident #1 a dentist appointment, but they had called and cancelled due to insurance. LVN A said she was not sure who she made the appointment with but would check her nursing notes.<BR/>During an interview on 11/2/23 at 1:20 pm the DON said the facility was not sure of the extent of what was going on with Resident #1's mouth. The DON said sometimes Resident #1 said the issues was with his teeth, other times he would say his mouth issues were with his tongue, and other times he would say he had ulcers in his mouth causing the issues. The DON said the facility had received an order on 11/1/23 for Resident #1 to have a CT (computer tomography) scan (a diagnostic imaging exam that uses x-ray technology to produce images of the inside of the body) of his head and neck soft tissue to rule out issues with Resident #1's tongue. The DON said if the issues was teeth related a dentist would need to treat Resident #1. The DON said she had not checked to see if there was a low-income dentist locally and was unsure if the previous SW had checked into low-income dentistry. The DON said she had not thought about reaching out to dental schools to see if Resident #1 could be seen there. The DON said it was important to get Resident #1 into a dentist to find out what was going on with his mouth. <BR/>2. Record review of the face sheet dated 11/2/23 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including morbid obesity, diabetes, muscle weakness, hypotension (decreased blood pressure), sickle cell disease (a group of disorders that cause red blood cells to become misshapen and breakdown), major depressive disorder, and muscle spasms. <BR/>Record review of the MDS dated [DATE] indicated Resident #2 usually understood other and was usually understood by others. The MDS indicated Resident #2 had a BIMS of 15 and was cognitively intact. The MDS indicated Resident #2 did not have any obvious or likely cavity or broken natural teeth. <BR/>Record review of the care plan last revised on 4/22/22 indicated Resident #2 had oral/dental health problems related to compromised functional ability.<BR/>Record review of a social services progress note dated 10/17/18 at 4:39 p.m. indicated Resident 32 had a dental screen performed and received a dental referral. The progress note indicated the SW had faxed the dental referral.<BR/>Record review of a social services progress note dated 3/26/19 at 2:28 p.m. indicated the SW had scanned a mobile dental referral for Resident #2. <BR/>During an interview on 11/2/23 at 10:20 a.m. Resident #2 said she needed to see the dentist. Resident #2 said she had broken teeth that needed to be pulled. Resident #2 said she reported the broken teeth to the previous SW. Resident #2 said she had a dentist appointment scheduled before COVID hit in 2020 and she did not get to go to the appointment due to the COVID pandemic. Resident #2 said she had not been to the dentist since before the beginning of COVID in 2020. Resident #2 said her broken teeth sometimes caused issues with her eating. Resident #2 said at least 1-2 times a month her mouth would be too sore to eat certain foods. <BR/>During an observation on 11/2/23 at 11:00 a.m. Resident #2 had a broken tooth on the left upper jaw. Surveyor was unable to get a good observation of the right side of the resident's mouth. <BR/>During an interview on 11/2/23 at 11:29 a.m. the DON said she was not aware Resident #2 had any issues with her teeth. The DON said the previous SW should have reported to her Resident #2's teeth issues and documented them. The DON said she would have expected Resident #2 to have had a dental appointment by now if the issues started prior to COVID in 2020<BR/>Record review of the facility's Dental Services policy last revised on 6/2022 indicated, It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease dental radiographs as needed dental cleaning, fillings (new and repair), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedure, e.g., taking impressions for dentures and fitting dentures. Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 5 residents (Resident #1 and Resident #2) reviewed for resident rights. <BR/>The facility did not ensure Resident #1 and Resident #2's catheter bag (urine reservoir bag) had a privacy bag in place. <BR/>This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.<BR/>The findings included:<BR/>Record review of the face sheet for Resident #1 indicated he was re-admitted to the facility on [DATE] with diagnoses including high blood pressure, COPD (chronic obstructive pulmonary disease is a group of lung diseases that block airflow and make it difficult to breathe), heart disease, history of heart attack, and history of stroke. <BR/>Record review of the MDS dated [DATE] indicated Resident #1 sometimes understood others and rarely/never made himself understood. Resident #1 displayed no symptoms of inattention, disorganized thinking or altered level of consciousness. The MDS indicated Resident #1 had no behavior of rejecting care, required limited assistance with dressing and personal hygiene. The MDS indicated Resident #1was totally dependent on staff for eating, toilet use, and bathing. The MDS indicated Resident #1 had an indwelling catheter and was always incontinent of bowel.<BR/>Record review of the baseline care plan for Resident #1 dated 9/6/23 indicated he was to be provided catheter care as indicated. <BR/>During an observation on 9/21/23 at 12:50 p.m., Resident #1 sat in his wheelchair in front of the nursing station. His foley catheter drainage bag hung on the side of the wheelchair at the level of his waist. The catheter reservoir bag was uncovered. There was no dignity bag in place. Yellow urine was visible in the reservoir bag. MA B sat at the nursing station across from Resident #1. CNA C and CNA D were also in the area of the nursing station. <BR/>During an interview on 9/21/23 at 1:02 p.m., MA B said catheter reservoir bags should have a dignity bag in place in order to preserve there dignity. <BR/>During an interview on 9/21/23 at 1:07 p.m., CNA C said catheter reservoir bags should have a dignity bag in place to give them privacy and dignity. <BR/>During an interview on 9/21/23 at 1:10 p.m., CNA D said catheter reservoir bags should have a dignity bag in place. CNA D said it was important for residents with catheters to have a bag over their catheter reservoir bag because without one (dignity bag/cover) the resident could be embarrassed. <BR/>During an interview on 9/22/23 at 11:20 a.m., LVN A said it was the nurse's and nurse aides responsibility to ensure a dignity bag/cover was in place over resident's catheter bags. LVN A said there was no set time to check for dignity bags/covers and indicated it should be checked for at some point during the shift. LVN A said dignity bags/cover should be in place to ensure resident privacy and dignity. <BR/>2. Record review of the face sheet for Resident #2 indicated she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, morbid obesity, lymphedema (Swelling in an arm or leg caused by a lymphatic system blockage. The condition is caused by a blockage in the lymphatic system, part of the immune and circulatory systems), high blood pressure, heart failure, and COPD (chronic obstructive pulmonary disease is a group of lung diseases that block airflow and make it difficult to breathe). <BR/>Record review of the MDS dated [DATE] indicated Resident #2 understood others and made herself understood, and was cognitively intact (BIMS of 14). The MDS indicated Resident #2 had no behavior of rejecting care, required limited assistance with dressing and toilet use. The MDS indicated she required supervision only with eating and personal hygiene. The MDS indicated Resident #2 required extensive assistance with bed mobility and toilet use. The MDS indicated Resident #1 had an indwelling catheter and was always incontinent of bowel. <BR/>Record review of the care plan for revised on 8/16/23 indicated Resident #2 had a foley catheter. The care plan interventions included, change the catheter and drainage bag based on clinical indications such as infection, obstruction, or when the closed system is compromised; foley catheter care every shift and as needed, ensure privacy bag (is in place) for urinary drainage bag at all times while in bed, while walking or in wheelchair every shift. <BR/>During an observation and interview on 9/22/23 at 11:45 a.m., Resident #2 laid in her bed. Her catheter reservoir bag hung on her bedframe. The catheter reservoir bag was uncovered. There was no dignity bag in place. Yellow urine was visible in the reservoir bag.<BR/>During an observation on 9/22/23 at 1:00 p.m., Resident #2 laid in her bed. Her catheter reservoir bag hung on her bedframe. The catheter reservoir bag was uncovered. There was no dignity bag in place. Yellow urine was visible in the reservoir bag.<BR/>During an interview on 9/22/23 at 1:02 p.m., LVN F said dignity bags/cover should be placed over Resident #2's catheter reservoir bag to ensure resident privacy and dignity. <BR/>During an observation and interview on 9/22/23 at 4:23 p.m., Resident #2 laid in her bed. Her catheter reservoir bag hung on her bedframe. The catheter reservoir bag was uncovered. There was no dignity bag in place. Yellow urine was visible in the reservoir bag.<BR/>During an interview on 9/22/23 at 4:27 p.m., CNA G said residents should have covers over there catheter reservoir bags to maintain dignity. <BR/>During an interview on 9/22/23 at 4:28 p.m., LVN H said she assumed the care for Resident #2 after LVN F left for the day. LVN H said LVN F had not mentioned her catheter reservoir bag did not have a dignity bag in place. LVN H said there was no set time to check for dignity bags/covers and indicated it should be checked for at some point during the shift. LVN H said dignity bags/cover should be in place to ensure resident privacy and dignity especially in the event of a visitor. <BR/>During an interview on 9/22/23 at 5:00 p.m., the DON said Resident #1 and Resident #2 had both recently returned from the hospital. The DON said this was why they did not have dignity bags in place. She explained that all the facility catheter [NAME] bags had a dignity cover in place. The DON said the nursing staff should have ensured the dignity bag/cover was placed when they (Resident #1 and Resident #2) returned from the hospital. <BR/>During an interview on 9/22/23 at 5:20 p.m., the Administrator said he expected staff to ensure dignity bags were in place for residents that required catheters. The Administrator indicated catheter bags not being covered with dignity bag/cover was a dignity issue. The Administrator said there was no specific system in place to oversee staff in regard to the placement of dignity bags but indicated the lack of dignity bag should have been caught during administrative rounds. The Administrator said he would re-educate staff to ensure dignity bags were in place and department heads checked for the issue during there rounds. <BR/>Record review of the facility policy and procedure titled, Catheter Care dated July of 2022 stated, Policy: It is the policy of this facility to ensure residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .(2) Privacy bags will be available and catheter drainage bags will be covered at all times while in use .

**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 had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and pain for 1 of 7 (Resident #2) residents reviewed for urinary catheters. <BR/>The facility did not ensure Resident #2's urinary catheter (a tube inserted into the bladder to drain urine) bag was not lying in the floor .<BR/>This failure could place residents at risk for urinary catheter bags busting by being stepped on or wheeled over by a wheelchair allowing bacteria into the catheter tubing, pain, and infection.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 4/3/24 indicated Resident #2 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including muscle weakness, dementia, overactive bladder, chronic kidney disease, hypertension (elevated blood pressure), and lack of coordination.<BR/>Record review of the MDS dated [DATE] indicated Resident #2 was understood others and was usually understood by others. The MDS indicated Resident #2 had a BIMS of 15 and was cognitively intact. The MDS indicated Resident #2 had an indwelling catheter (urinary catheter that is left in place) and was always incontinent of urine. <BR/>Record review of the care plan revised on 2/7/24 indicated Resident #2 had impaired cognitive function/dementia or impaired thought processes related to dementia.<BR/>During an observation on 4/2/24 at 1:36 p.m. Resident #2's urinary catheter bag was lying on floor. <BR/>During an observation and interview on 4/3/24 at 9:34 a.m. Resident #2's urinary catheter drain bag was lying in the floor. Resident #2 said she did not put the catheter drain bag in the floor. Resident #2 said she could not reach the catheter drain bag to hang it on the bed where she liked it. Resident #2 said a staff member stepped on her catheter drain bag yesterday when it was in the floor and busted it. Resident #2 said staff replace the busted catheter drain bag and mopped the urine out of the floor. <BR/>During an interview on 4/3/24 at 12:33 p.m. the ADON said a foley catheter drain bag should be positioned below the abdomen unless otherwise requested by the resident. The ADON said a foley catheter drain bag should not ever be in the floor. The ADON said the importance of ensuring a foley catheter drain bag was not in the floor was for infection control. The ADON said there were approximately 3 residents in the facility she thought would put their foley catheter drain bag in the floor. The ADON said one of those residents was Resident #2.<BR/>During an interview on 4/3/24 at 1:00 p.m. CNA G said she usually worked the 200 hall. CNA G said urinary catheter drain bags should be below the waist of the resident with the tubing straight without kinks. CNA G said urinary catheter drain bags should not be in the floor. CNA G said the importance of catheter drain bags not being in the floor was for sanitary purposes and to ensure they do not get busted by being stepped on or rolled over with a wheelchair. CNA G said she was not aware of any residents who would place their foley catheter drain bag in the floor.<BR/>During an interview on 4/3/24 at 1:31 p.m. the DON said she expected a urinary catheter drain bag to be positioned below the level of the bladder. The DON said a urinary catheter drain bag should not be in the floor. The DON said the importance of a foley catheter drain bag not being in the floor was infection control.<BR/>During an interview on 4/3/24 at 1:33 p.m. the Administrator said she expected a foley catheter drain bag to be covered, anchored, and not in the floor. The Administrator said the importance of a foley catheter drain bag not being in the floor was infection control. <BR/>Record review of the facility's Indwelling Catheter Use and Removal policy dated 7/2020 indicated, It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice .Additional care practices include .c. Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter; and d. Securement of the catheter facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the bladder .<BR/>Record review of the facility's Infection Prevention and Control Program policy dated 3/2022 indicated, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the appropriate treatment and services to prevent complications was provided for 1 of 2 residents reviewed for feeding tube management. (Resident #3)<BR/>The facility did not ensure Resident #3 had his dressing removed/changed around his gastrostomy tube site after his return from the hospital and did not assess the site as ordered. <BR/>These failures could place residents with gastrostomy tubes at risk for skin irritation, insertion site infections and associated complications.<BR/>Findings included: <BR/>Record review of the face sheet for Resident #3 indicated he was re-admitted to the facility on [DATE] with diagnoses cellulitis (common, potentially serious bacterial skin infection) of the right leg, high blood pressure, heart failure, type 2 diabetes, morbid obesity, history of stroke, kidney cancer, and stage 3 chronic kidney disease. <BR/>Record review of the MDS dated [DATE] indicated Resident #3 understood others and made himself understood. The MDS indicated Resident #3 had no behavior of rejecting care. The MDS indicated Resident #3 required limited assistance with bed mobility, and transfers. The MDS indicated he required extensive assistance with dressing and bathing. The MDS indicated he required supervision with locomotion in his wheelchair, eating and personal hygiene. The MDS indicated Resident #3 was frequently incontinent of bladder and always incontinent of bowel. The MDS indicated Resident #3 had feeding tube during the 7 day look back period and received 51 percent or more of his calories through tube feeding as well as 501 ml (milliliters) of fluid or more of fluid intake. <BR/>Record review of the care plan dated 8/8/23 indicated Resident #3 required tube feeding. The care plan interventions included provide local care to G-tube (gastrostomy tube) site as ordered and monitor for signs and symptoms of infection. <BR/>Record review of the active physician order with a start date of 5/19/23 indicated Resident #3 was to have g-tube site care every shift and as needed. <BR/>Record review of the MAR/TAR for Resident #3 for September 2023 indicated the G-tube site had been provided site care every shift from 9/14/23 to 9/21/23. LVN A had signed the MAR/TAR electronically on 9/18/23, 9/19/23 and 9/20/23 on the day shift. RN I had signed the MAR/TAR electronically on 8/18/23, 9/19/23, 9/20/23 and 9/21/23. <BR/>During an observation and interview on 9/21/23 at 12:40 p.m., Resident #3 laid in his bed. There was an undated dressing over his G-tube site. The tape around the dressing was rolling up and had a scattered areas of black substance adhered to the tape. Resident #3 said no one had removed the dressing over the site since he returned from the hospital on Thursday (9/14/23). <BR/>During an interview on 9/21/23 at 12:45 p.m., CNA C said she had taken care of Resident #3 regularly since he returned from the hospital. CNA C said there had not been a date on the dressing since she had taken care of him from his return from the hospital. CNA C said she did not think the dressing had been changed. <BR/>During an interview on 9/21/23 at 1:00 p.m., LVN A said she was not sure how often G-tube dressings were to be changed. LVN A said she assumed it would be as ordered. LVN A said G-tube sights were to be assessed daily. <BR/>During an interview on 9/22/23 at 4:00 p.m., RN I said she took care of Resident #3 yesterday (9/21/23) on the 2-10pm shift and received report from LVN A. RN I said she had noticed the undated dressing late on her shift yesterday. RN I said the dressing looked worn and appeared it had been there for a while. RN I said she could not say for sure that dressing had not been changed since he had returned from the hospital but said he (Resident #3) reported to her that no one had changed the dressing since he had gotten back from the hospital on Thursday (9/14/23). RN I said she checked his orders and did not see a specific order regarding the g-tube site dressing change. RN I said she notified the on-coming nurse that an order needed to be obtained so the dressing could be changed. RN I said she did sign the EMAR/TAR indicating site care had been performed. RN I said she felt without more specific instructions site care meant assessing the area. RN I said she assessed the area by looking at the skin around the dressing but had not removed the dressing. <BR/>During an interview on 9/22/23 at 5:00 p.m., the DON said the G-tube site should have assessed for signs and symptoms of infection. The DON said it was not acceptable for dressing to have not been removed and the site assessed since Resident #3's return from the hospital. The DON said she felt the order was too vague and would ensure the orders for G-tube site assessment, and dressing changes were more specific in the future. <BR/>During an interview on 9/22/23 at 5:20 p.m., the Administrator said he expected staff to follow policy and procedure regarding G-tube site care, assessment and dressing changes. <BR/>A follow up interview with LVN A was attempted on 9/22/23 regarding the MAR/TAR sign off that the G-tube site had been provided care but was not obtained. <BR/>The facility policy and procedure titled Care and Treatment of Feeding Tubes, dated July of 2022 stated, Policy: it is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice with interventions to prevent complications to the extent possible .(3) The resident's plan of care will address the use of feeding tube, including strategies to prevent complications .(6) In accordance with facility protocol licensed nurses will monitor and check that the feeding tube is in the right location .(b) The enteral retention device will be checked daily to assure it is properly approximated to the abdominal wall and that the surrounding skin is intact. (7) Direction for staff on how to provide the following care will be provided: .(c) Examination and cleaning of the insertion site in order to identify, lessen, or resolve possible skin irritation and local infection .

Based on interview and record review, the facility failed to implement their written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents for 1 of 7 new hire staff reviewed for criminal history checks. (Staff B)<BR/>The facility employed Staff B who was not eligible for hire and retained the employee from hire on 5/19/23 through to 7/13/23.<BR/>This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.<BR/>Findings included:<BR/>Record review of the facility staff roster, undated indicated Staff B was hired on 5/19/23 and listed as CNA in training.<BR/>Record review of criminal history conviction name search history printed on 5/31/23 indicated search date of 5/23/23 for Staff B had 1 hit.<BR/>Record review criminal history conviction name search dated 7/12/23 for Staff B indicated the criminal history review documented an offense that made Staff B ineligible for hire. <BR/>Record review of undated and untitled document listing offense penal codes provided by the HR Clerk on 7/14/23 indicated staff B was determined to not be employable under Health and Safety Code (HSC) &sect;250.003(a)(1).<BR/>Record Review of Staff B's employment application says he was hired as a Kitchen Aide/Hospitality Aide. <BR/>Record review of general duties/schedule for Hospitality Helper indicated: Pass out ice and water on North, South and East Wings. Ice and water will be pass out one time on 6:00 - 2:00 pm, and 2:00 - 10:00 shift. Each Ice cart and Ice chest will be clean every Monday, Wednesday, and Friday. <BR/>Record review of Staff B's time sheet indicated the following:<BR/>*5/1/23 to 5/31/23 indicated Staff B worked a total of 76.77 hours;<BR/>*6/1/23 to 6/30/23 indicated Staff B worked a total of 238.27 hours;<BR/>*7/1/23 to 7/31/23 indicated Staff B worked a total of 90.28 hours and his last date of employment was 7/13/23.<BR/>Record review of Staff B's personnel file did not include documentation or date of his termination. <BR/>Record review of email thread from the HR Clerk to the Regional Director of HR dated 5/22/23 indicated we don't have enough funds to run backgrounds and I am desperately needing these people ran .Dishwasher Staff B . On 5/23/23, the Regional Director of HR emailed the HR Clerk .Let me know when you received them, please so I can shred the ones I have .<BR/>Record review of a petty cash voucher dated 5/30/31(5/30/23) and receipt indicated on 5/30/23 at 6:22 pm a $500 prepaid debit card was purchased for a total of 504.95 to be used for Criminal history check/gas for van.<BR/>Record review indicated Safe Surveys were completed on 07/14/23 and the facility continued training on eligibility for hire. The facility also completed additional background checks on all current employees to verify that all were eligible to work. <BR/>During an interview on 7/14/23 at 1:47 p.m., the HR Clerk said she had been the HR Clerk for three years. She said criminal history checks were done on all staff upon hire and annually. The HR Clerk said around the time Staff B was hired on 5/19/23, the facility was in-between Administrators, the previous Administrator was leaving, and the current Administrator was just starting. So a few new hires background checks were possibly missed. The HR Clerk said the background checks cost about three dollars each and she used a debit card to purchase the background checks. She said most of the times, she would use the previous Administrator's debit card or she would use her personal debit card to pay for the criminal history checks. She said when the previous Administrator left, the current Administrator did not want his personal card used for purchasing criminal history checks. So she did not know what to do. The HR Clerk said she was advised to reach out to corporate and that was when she reached out via email to the Regional Director of HR on 5/22/23 to assist with getting background checks. She said the Regional Director of HR ran the background checks on 5/23/23 and faxed the results, but she never received the fax. She stated the Regional Director of HR gave her the verbal approval to proceed with hiring Staff B.<BR/>During an interview on 7/14/23 at 2:02 p.m., Regional Director of HR said the HR Clerk had reached out to her via email on 5/22/23 requesting assistance with getting background checks on a few staff. She said she personally did Staff B's background checks and faxed over the results to the HR Clerk. She said she was not aware the HR Clerk did not receive the fax and shredded the paperwork. The Regional Director of HR said she provided the HR Clerk a printout verifying she ran a search on Staff B on 5/23/23. She said she gave the HR Clerk verbal approval to hire Staff B because she reviewed his criminal history and there were no issues. <BR/>During an interview on 7/14/23 at 3:38 p.m., the HR Clerk said Staff B was hired prior to his background checks being done. She said Staff B was hired as a Dishwasher, he worked two days 5/19/23 and on 5/20/23 as dishwasher and effective 5/22/22 to current he worked as the assigned smoke break staff and whenever it was not a smoke break, Staff B worked as Hospitality Aide and passed ice. The HR Clerk said she personally would not have hired Staff B due to his background charges. The HR Clerk said her first-time seeing Staff B's criminal history was on 7/13/23 when she ran it herself, she said Staff B was not eligible for hire until 2024. The HR Clerk said she followed the list penal codes she provided State Investigator, when determining if a person was eligible for hire. The HR Clerk said she told the Administrator on 7/13/23 about Staff B's criminal history and she said he told her since the Regional Director of HR gave her approval not to worry about it since Staff B had already been hired and working.<BR/>During an interview on 7/14/23 at 3:46 p.m., Administrator said he was the Abuse Coordinator and started on 05/08/23, as the Administrator. He said all staff were to have background checks done before hire and those were done by the HR Clerk. <BR/>During an interview on 8/2/2023 at 9:00 a.m., the HR Clerk said the current Administrator purchased a $500 Visa prepaid card at the end of May 2023 that is used to pay for Criminal background checks and the corporate office set up a line of credit at the agency to complete background checks. The card was set up to notify the Administrator when the balance is low. The HR Clerk said Staff B was terminated on 7/13/23. The HR Clerk said before a person was hired, their criminal history must be completed, clear, and completed annually after hire. She said the facility had completed in-services since May 2023 related to background checks being ran prior to hire and that continued training on eligibility was being completed. She said she and the department heads had been in-serviced on HR policies by the Corporate HR. The in-services included the Policy on Hiring and Firing of employees, and that criminal history checks are to be done prior to hiring an employee. She said Staff B was hired as a Hospitality Aide/Kitchen Aide.<BR/>During an interview on 8/2/2023 at 9:30 a.m., the DON said that Staff B was hired as a hospitality helper/Kitchen Aide and would issue cigarettes to residents when out for smoking breaks or pass ice. She said Staff B did not provide any 1-on-1 care to residents and was not in a closed room with any residents.<BR/>During an interview on 8/2/2023 at 11:00 a.m. the Administrator said he was not aware Staff B was not eligible for hire due to barrable charges because Staff B was hired before he became the Administrator. He said he established a new process that he will review all criminal history checks of potential new hires prior to sending them to the hiring managers. He said he also purchased a pre-paid Visa card for HR to use when running a criminal history. He said when he found out that Staff B was not eligible for hire, he was terminated effective 07/13/23. The Administrator said the policy on criminal history eligibility was discussed in morning meetings and QA/QAPI.<BR/>Record review of Background Investigation policy dated January 2023 indicated .Job reference checks, drug screenings, licensure verifications and criminal conviction record checks are conducted on all personnel making application for employment with this company .1) The Human Resource department will conduct all applicable background investigation(s) on each individual making application for employment with this company an on any current employee if such background investigation is appropriate for position for which the individual has applied .4)If the background investigation(s) disclose any material misrepresentation or omissions by the applicant or employment on the application form or reveal information indicating that the individual many not be appropriate for hire, the company will investigate the matter further. Upon completion of such investigation, if the company determines that the applicant's or employee's background makes him/her unsuitable for the position he/she is seeking, the applicant will not be employed, or if already employed will be terminated .<BR/>Record review abuse policy dated 6/2022 indicated .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of residential property .1.Screening: A)Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1)Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, student affiliated with academic institutions, volunteers, and consultants. 2)Screenings may be conducted by the facility itself, third party agency or academic institution. 3)The facility will maintain documentation of proof that the screening occurred .

Based on interview and record review, the facility failed to implement their written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents for 1 of 7 new hire staff reviewed for criminal history checks. (Staff B)<BR/>The facility failed to follow the A/N/E policy and procedure with regard to failing to screen applicants prior to hire.<BR/>This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.<BR/>Findings included:<BR/>Record review of the facility staff roster, undated indicated Staff B was hired on 5/19/23 and listed as CNA in training.<BR/>Record review of criminal history conviction name search history printed on 5/31/23 indicated search date of 5/23/23 for Staff B had 1 hit.<BR/>Record review criminal history conviction name search dated 7/12/23 for Staff B indicated the criminal history review documented an offense that made Staff B ineligible for hire. <BR/>Record review of undated and untitled document listing offense penal codes provided by the HR Clerk on 7/14/23 indicated staff B was determined to not be employable under Health and Safety Code (HSC) &sect;250.003(a)(1).<BR/>Record Review of Staff B's employment application says he was hired as a Kitchen Aide/Hospitality Aide. <BR/>Record review of general duties/schedule for Hospitality Helper indicated: Pass out ice and water on North, South and East Wings. Ice and water will be pass out one time on 6:00 - 2:00 pm, and 2:00 - 10:00 shift. Each Ice cart and Ice chest will be clean every Monday, Wednesday, and Friday. <BR/>Record review of Staff B's time sheet indicated the following:<BR/>*5/1/23 to 5/31/23 indicated Staff B worked a total of 76.77 hours;<BR/>*6/1/23 to 6/30/23 indicated Staff B worked a total of 238.27 hours;<BR/>*7/1/23 to 7/31/23 indicated Staff B worked a total of 90.28 hours and his last date of employment was 7/13/23.<BR/>Record review of Staff B's personnel file did not include documentation or date of his termination. <BR/>Record review of email thread from the HR Clerk to the Regional Director of HR dated 5/22/23 indicated we don't have enough funds to run backgrounds and I am desperately needing these people ran .Dishwasher Staff B . On 5/23/23, the Regional Director of HR emailed the HR Clerk .Let me know when you received them, please so I can shred the ones I have .<BR/>Record review of a petty cash voucher dated 5/30/31(5/30/23) and receipt indicated on 5/30/23 at 6:22 pm a $500 prepaid debit card was purchased for a total of 504.95 to be used for Criminal history check/gas for van.<BR/>Record review indicated Safe Surveys were completed on 07/14/23 and the facility continued training on eligibility for hire. The facility also completed additional background checks on all current employees to verify that all were eligible to work. <BR/>During an interview on 7/14/23 at 1:47 p.m., the HR Clerk said she had been the HR Clerk for three years. She said criminal history checks were done on all staff upon hire and annually. The HR Clerk said around the time Staff B was hired on 5/19/23, the facility was in-between Administrators, the previous Administrator was leaving, and the current Administrator was just starting. So a few new hires background checks were possibly missed. The HR Clerk said the background checks cost about three dollars each and she used a debit card to purchase the background checks. She said most of the times, she would use the previous Administrator's debit card or she would use her personal debit card to pay for the criminal history checks. She said when the previous Administrator left, the current Administrator did not want his personal card used for purchasing criminal history checks. So she did not know what to do. The HR Clerk said she was advised to reach out to corporate and that was when she reached out via email to the Regional Director of HR on 5/22/23 to assist with getting background checks. She said the Regional Director of HR ran the background checks on 5/23/23 and faxed the results, but she never received the fax. She stated the Regional Director of HR gave her the verbal approval to proceed with hiring Staff B.<BR/>During an interview on 7/14/23 at 2:02 p.m., Regional Director of HR said the HR Clerk had reached out to her via email on 5/22/23 requesting assistance with getting background checks on a few staff. She said she personally did Staff B's background checks and faxed over the results to the HR Clerk. She said she was not aware the HR Clerk did not receive the fax and shredded the paperwork. The Regional Director of HR said she provided the HR Clerk a printout verifying she ran a search on Staff B on 5/23/23. She said she gave the HR Clerk verbal approval to hire Staff B because she reviewed his criminal history and there were no issues. <BR/>During an interview on 7/14/23 at 3:38 p.m., the HR Clerk said Staff B was hired prior to his background checks being done. She said Staff B was hired as a Dishwasher, he worked two days 5/19/23 and on 5/20/23 as dishwasher and effective 5/22/22 to current he worked as the assigned smoke break staff and whenever it was not a smoke break, Staff B worked as Hospitality Aide and passed ice. The HR Clerk said she personally would not have hired Staff B due to his background charges. The HR Clerk said her first-time seeing Staff B's criminal history was on 7/13/23 when she ran it herself, she said Staff B was not eligible for hire until 2024. The HR Clerk said she followed the list penal codes she provided State Investigator, when determining if a person was eligible for hire. The HR Clerk said she told the Administrator on 7/13/23 about Staff B's criminal history and she said he told her since the Regional Director of HR gave her approval not to worry about it since Staff B had already been hired and working.<BR/>During an interview on 7/14/23 at 3:46 p.m., Administrator said he was the Abuse Coordinator and started on 05/08/23, as the Administrator. He said all staff were to have background checks done before hire and those were done by the HR Clerk. <BR/>During an interview on 8/2/2023 at 9:00 a.m., the HR Clerk said the current Administrator purchased a $500 Visa prepaid card at the end of May 2023 that is used to pay for Criminal background checks and the corporate office set up a line of credit at the agency to complete background checks. The card was set up to notify the Administrator when the balance is low. The HR Clerk said Staff B was terminated on 7/13/23. The HR Clerk said before a person was hired, their criminal history must be completed, clear, and completed annually after hire. She said the facility had completed in-services since May 2023 related to background checks being ran prior to hire and that continued training on eligibility was being completed. She said she and the department heads had been in-serviced on HR policies by the Corporate HR. The in-services included the Policy on Hiring and Firing of employees, and that criminal history checks are to be done prior to hiring an employee. She said Staff B was hired as a Hospitality Aide/Kitchen Aide.<BR/>During an interview on 8/2/2023 at 9:30 a.m., the DON said that Staff B was hired as a hospitality helper/Kitchen Aide and would issue cigarettes to residents when out for smoking breaks or pass ice. She said Staff B did not provide any 1-on-1 care to residents and was not in a closed room with any residents.<BR/>During an interview on 8/2/2023 at 11:00 a.m. the Administrator said he was not aware Staff B was not eligible for hire due to barrable charges because Staff B was hired before he became the Administrator. He said he established a new process that he will review all criminal history checks of potential new hires prior to sending them to the hiring managers. He said he also purchased a pre-paid Visa card for HR to use when running a criminal history. He said when he found out that Staff B was not eligible for hire, he was terminated effective 07/13/23. The Administrator said the policy on criminal history eligibility was discussed in morning meetings and QA/QAPI.<BR/>Record review of Background Investigation policy dated January 2023 indicated .Job reference checks, drug screenings, licensure verifications and criminal conviction record checks are conducted on all personnel making application for employment with this company .1) The Human Resource department will conduct all applicable background investigation(s) on each individual making application for employment with this company an on any current employee if such background investigation is appropriate for position for which the individual has applied .4)If the background investigation(s) disclose any material misrepresentation or omissions by the applicant or employment on the application form or reveal information indicating that the individual many not be appropriate for hire, the company will investigate the matter further. Upon completion of such investigation, if the company determines that the applicant's or employee's background makes him/her unsuitable for the position he/she is seeking, the applicant will not be employed, or if already employed will be terminated .<BR/>Record review abuse policy dated 6/2022 indicated .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of residential property .1.Screening: A)Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1)Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, student affiliated with academic institutions, volunteers, and consultants. 2)Screenings may be conducted by the facility itself, third party agency or academic institution. 3)The facility will maintain documentation of proof that the screening occurred .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 7 (Resident #1) residents reviewed for quality of care.<BR/>1.The facility failed to provide wound care to Resident #1's right lower extremity stump (the remaining part of the right leg after amputation) as ordered resulting in infection and surgical debridement (the removal of damaged tissues from a wound) to rule out osteomyelitis (inflammation of the bone caused by infection).<BR/>2.The facility failed to report redness to Resident #1's abdomen to the Nurse Practitioner or Wound Care Physician resulting in hospitalization related to cellulitis (bacterial skin infection) and panniculitis (inflammation of the subcutaneous fat) requiring intravenous (IV) antibiotics.<BR/>3.The facility failed to document wound care assessments per facility policy.<BR/>This failure resulted in an identification of an Immediate Jeopardy (IJ) at 2:35 p.m. on 4/2/24. While the IJ was removed on 4/3/24, the facility remained out of compliance with a scope identified as patterned and a severity of no actual harm with a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>These failures could result in residents with venous stasis ulcer of not having their treatments performed as ordered, wounds becoming infected wounds, and decreased wound healing.<BR/>Findings Included:<BR/>1. Record review of the face sheet dated 4/3/24 indicated Resident #1 was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including panniculitis, morbid obesity, diabetes, acquired absence of right leg below the knee, localized edema (swelling), and congestive heart failure (chronic condition in which the heart does not pump blood as well as it should).<BR/>Record review of the physician orders dated 4/3/24 indicated Resident #1 had an order to cleanse right below the knee amputation with normal saline, pat dry, apply calcium alginate (highly absorptive, non-occlusive dressing made of soft, non-woven calcium alginate fibers), collagen (wound dressing derived from collagen used to absorb exudate (fluids excreted by a wound), and cover with a dry dressing daily and as needed starting on 2/5/24. The physician orders indicated Resident #1 had an order for lymphedema (swelling caused by a lymphatic system blockage) wound of left abdomen skin prep daily starting 4/2/24. <BR/>Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 15 and was cognitively intact. The MDS indicated Resident #1 had a surgical wound and moisture associated skin damage.<BR/>Record review of the care plan revised 4/3/24 indicated Resident #1 had actual impairment to skin integrity: unstageable [wound] to the right leg with interventions including cleanse wound, apply medications and dressings as ordered. The care plan indicated Resident #1 had an infection of the wound. The care plan indicated Resident #1 had panniculitis . The care plan indicated had potential impairment to skin integrity of the lower abdomen and skin folds related to morbid obesity/incontinence. Resident had wound to right leg with treatment continued.<BR/>Record review of the TAR dated 2/1/24 through 2/29/24 indicated Resident #1's treatment to cleanse right below the knee amputation with normal saline, pat dry, apply calcium alginate, collagen and cover with a dry dressing daily and as needed was only performed on 2/7/24, 2/8/24, 2/10/24, 2/12/24, 2/13/24, 2/15/24, 2/16/24, 2/17/24, 2/22/24, 2/26/24, 2/27/24, 2/28/24, and 2/29/24. <BR/>Record review of the TAR dated 3/1/24 through 3/31/24 indicated Resident #1's treatment to cleanse right below the knee amputation with normal saline, pat dry, apply calcium alginate, collagen and cover with a dry dressing daily and as needed was only performed on 3/1/24, 3/3/24, 3/10/24, 3/11/24, 3/30/24, and 3/31/24.<BR/>Record review of the skin assessment dated [DATE] indicated Resident #1 had a right lower leg wound infection measuring 1.5cm x 0.3cm x 0.2cm. The skin assessment indicated Resident #1 had a wound to the right leg with treatment in place. <BR/>Record review of the skin assessment dated [DATE] indicated Resident #1 had a right lower leg wound infection measuring 1.5cm x 0.3cm x 0.2cm. The skin assessment indicated Resident #1 had a wound to the right leg with treatment in place. The skin assessment indicated Resident #1 had redness to left lateral side of abdomen with barrier cream (a product applied to the skin to help maintain the skins physical barrier, providing protection from irritants and preventing the skin from drying out) applied and Resident #1 was instructed to change positions every 2 hours. <BR/>Record review of the skin assessment dated [DATE] indicated Resident #1 had a wound to the right leg with treatment in place. The skin assessment indicated Resident #1 had redness to left lateral side of abdomen with barrier cream applied and Resident #1 was instructed to change positions every 2 hours. <BR/>Record review of the skin assessment dated [DATE] indicated Resident #1 had a wound to the right leg with treatment in place. The skin assessment indicated Resident #1 had redness to left lateral side of abdomen with barrier cream applied and Resident #1 was instructed to change positions every 2 hours. <BR/>Record review of wound assessments indicated Resident #1 did not have a wound assessment performed by the facility from 2/1/24 through 3/13/24 when Resident #1 was transferred to the hospital.<BR/>Record review of the Wound Care Physician's note dated 2/12/24 indicated Resident #1 had a right leg wound measuring 1cm x 0.3cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound was healing as evidenced by 0% decrease in surface area within the wound bed. <BR/>Record review of the Wound Care Physician's note dated 2/19/24 indicated Resident #1 had a right leg wound measuring 1cm x 0.3cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound was at goal.<BR/>Record review of the Wound Care Physician's note dated 2/26/24 indicated Resident #1 had a right leg wound measuring 2cm x 1.4cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound had exacerbated due to more edema in the leg. <BR/>Record review of the Wound Care Physician's note dated 3/4/24 indicated Resident #1 had a right leg wound measuring 2cm x 1.4cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound was at goal.<BR/>Record review of the Wound Care Physician's note dated 3/11/24 indicated Resident #1 had a right leg wound measuring 2cm x 1.4cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound was at goal.<BR/>Record review of the nursing progress note dated 3/11/24 indicated Resident #1 received an order for Doxycycline (antibiotic) 100mg twice a day for 7 days related to right stump wound. <BR/>Record review of the nursing progress note dated 3/13/24 indicated Resident #1 noted with change in condition including not feeling well, body aches, chills, fever, and right leg pain and swelling. The nursing progress note indicated a new order was received to send Resident #1 to the emergency department for evaluation and treatment. <BR/>Record review of the nursing progress note dated 3/27/24 indicated Resident #1 returned to the facility.<BR/>Record review of the hospital paperwork for hospital admission dated 3/13/24 through 3/27/24 indicated Resident #1 was admitted to the hospital with a primary diagnosis of acute panniculitis. The hospital paperwork indicated Resident #1 had discharge diagnoses including acute panniculitis, bacteremia (viable bacteria in the blood), and osteomyelitis of right tibia. The hospital paperwork indicated Resident #1 was admitted to the hospital with fever, chills and brought to emergency room for he was found to have an elevated white cell count of 17,200 (normal range 4,500 to 11,000) and large left-sided cellulitis involving his entire left abdominal wall pannus (excess skin and fat that hangs down from the abdomen). The hospital paperwork indicated Resident #1 was started on broad-spectrum IV antibiotics and based cellulitis spread from left flank to across his left midline. The hospital paperwork indicated Resident #1 had some evidence of wounds in his left abdominal wall. The hospital paperwork indicated Resident #1 had a right below-knee amputation stump ulcer with x-ray revealing osteomyelitis. The hospital paperwork indicated after right below the knee stump debridement on 03/21/2024 there was not any evidence of bone involvement.<BR/>During an interview on 3/28/24 at 1:26 p.m. Resident #1 said there had been staffing issues with treatment nurses. Resident #1 said his wound care had not been done as scheduled. Resident #1 said he had just returned from the hospital due to infection to wound and cellulitis to abdomen. Resident #1 said he had surgery on his below the knee amputation while in the hospital to determine in the infection was in the bone. Resident #1 said the infection had not made it to the bone and was only in the soft tissue. Resident #1 said he had not been receiving proper wound care prior to being hospitalized .<BR/>During an interview on 4/2/24 at 9:59 a.m. LVN A said she was familiar with Resident #1. LVN A said Resident #1's wound care was performed daily. LVN A said LVN F or LVN E were responsible for performing Resident #1's wound care. LVN A said the nurses were responsible for completing skin assessments. LVN A said she did not know if the increased redness to Resident #1's abdomen had been reported. LVN A said all wound treatments from the wound care physician were recommendations. LVN A said she would have to find out if the wound care physician recommendations were implemented or needed to be approved by the resident's primary care physician. LVN A said Resident #1 had a skin assessment dated [DATE] which indicated redness to left lateral abdomen.<BR/>During an interview on 4/2/24 at 10:14 a.m. the Wound Care Physician said he was familiar with Resident #1. The Wound Care Physician said Resident #1 had lots of lymphedema (swelling, most often in an arm or leg, caused by lymphatic system blockage) in his right stump. The Wound Care Physician said the facility had not had a treatment nurse in months. The Wound Care Physician said it was not ideal for dressing changes that were ordered daily not to be performed. The Wound Care Physician said it was not out of the realm for a dressing change ordered daily and not being performed daily to lead to infection. The Wound Care Physician said he was not informed of redness or increased redness to Resident #1's abdomen but the facility may have informed his primary care physician. The Wound Care Physician said wound treatments in his notes were recommendations. The Wound Care Physician said he saw residents at the facility weekly. The Wound Care Physician said he could not say if lymphedema treatment recommendation not being performed would lead to worsening lymphedema or infection. <BR/>During an interview on 4/2/24 at 10:21 a.m. the Nurse Practitioner said she was familiar with Resident #1. The Nurse Practitioner said she had not had any reports from the facility regarding Resident #1 having redness or increased redness to his abdomen. The Nurse Practitioner said most facilities notify them of changes in skin conditions or treatment orders, but this facility did not. The Nurse Practitioner said communication from this facility was lacking. The Nurse Practitioner said wound care treatments not performed as ordered could possibly lead to infection, but the surveyor would need to refer to the Wound Care Doctor. <BR/>During an interview on 4/2/24 at 12:23 p.m. LVN B said charge nurses were responsible for wound care and skin assessments at this time. LVN B said the last training she had received at the facility regarding skin assessments, wound documentation, or wound care policies was a couple of months ago. LVN B said the TAR indicated whether wound care had been performed. LVN B said if it was not charted in the TAR wound care was performed you could look at the date on the dressing. LVN B said if it was further back than one day and was not charted in the TAR wound care was performed it could not be proved it was performed. LVN B said skin assessment should be completed weekly.<BR/>Record review of the facility's Documentation of Wound Treatments policy dated 7/2022 indicated, The facility completes accurate documentation of the wound assessments and treatments, including response to treatments, change in condition, and changes in treatment. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates .Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift. Additional documentation shall include but is not limited to .e. Notification to physician and/or responsible party regarding wound or treatment changes.<BR/>The Administrator was notified on 4/2/24 at 2:48 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 4/2/24 at 2:56 p.m.<BR/>The facility's Plan of Removal was accepted on 4/3/24 at 9:40 a.m. and included:<BR/>Plan of Removal<BR/>1. <BR/>Immediate actions<BR/>The Medical Director and Resident #1's Primary Care Physician were notified by the Assistant Director of Nursing on 04/02/2024. <BR/>A full skin sweep was completed on all residents on 03/27-28/2024 by the Assistant Director of Nursing and the Director of Nursing. All residents admitted or readmitted from 03/27/2024 forward were reviewed to ensure for head-to-toe skin and wound assessments were completed appropriately. <BR/>Any admitted or readmitted residents from 03/27/2024 forward that were identified to not have skin assessments were assessed immediately on 04/02/2024.<BR/>An omissions report was pulled from 03/27/2024 forward and all omissions were addressed by the Director of Nursing. This was completed on 04/02/2024 and all staff were trained on how to pull the omissions report and directed to check it daily prior to the end of their shift to ensure no treatments are missed going forward. The omissions report identified staff who had not completed their treatments as ordered. <BR/>Resident #1 was immediately provided a head-to-toe skin assessment by the Director of Nursing and treatment was provided according to the Physician's orders for all areas on 04/02/2024. <BR/>2. <BR/>Education (provided by DON, ADON or Designee)<BR/>The Regional Director of Clinical Services in-serviced the Director of Nursing and Assistant Director of Nursing on all of the below in-services on 04/02/2024.<BR/>All nurses were in-serviced by the Director of Nursing/Assistant Director of Nursing on appropriately completing skin assessments and notifying the Physician of all newly identified skin issues in a timely manner on 04/02/2024. Each nurse will be in-serviced prior to returning to shift. This will be completed by 04/03/2024 and nurses will not return to shift without the in-service. The Director of Nursing and Assistant Director of Nursing are responsible for ensuring each nurse completes their skin assessments.<BR/>All nurses were in-serviced by the Director of Nursing/Assistant Director of Nursing on Policy and Procedure for Pressure Injury Prevention and Skin and Wound Care Management on 04/02/2024. This in-service will be completed by 04/03/2024 and nurses will not return to shift without the in-service. This in-service includes appropriately completing skin assessments, information on pressure and injury prevention, treatment for non-pressure injuries, the importance of wound care management and following the treatment orders. <BR/>All nurses were in-serviced by the Director of Nursing/Assistant Director of Nursing on pulling an omission's report prior to the end of each shift and correcting any absence of documentation on 04/02/2024. The Omission report would show any order on the TAR that was not completed during the scheduled shift. This in-service will be completed by 04/03/2024 and nurses will not return to shift without the in-service. <BR/>All nurses were in-serviced by the Director of Nursing/Assistant Director of Nursing on pulling and signing all MARs and TARs prior to the end of their shift on 04/02/2024. This in-service will be completed by 04/03/2024 and nurses will not return to shift without the in-service. If a nurse is unable to complete an assessment or wound care during their shift, they will notify the Director of Nurses and Assistant Director of nurses prior to leaving their shift. The oncoming shift will be notified during report that an assessment or treatment was not completed. <BR/>3. <BR/>Medical Director - The Medical Director has been notified of the Immediate Jeopardy.<BR/>4. <BR/>QAPI Committee Review - An interim QAPI committee meeting was completed on 04/02/2024. <BR/>5. <BR/>Plan of removal date: 04/02/2024<BR/>On 4/3/24 it was onfirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review on 4/3/24 of 3 of 3 new admissions or re-admission from 3/27/24 through 4/3/24 indicated all admissions had skin assessments performed and wound assessments performed if applicable.<BR/>Record review of a random sample of 16 of 66 residents on 4/3/24 indicated all sampled residents had skin assessments performed between 3/27/24 and 4/2/24.<BR/>Record review of the QAPI sign-in sheet indicated the facility had an ad-hoc QAPI meeting on 4/2/24 regarding wound treatments, skin and wound assessments, physician notification, and omission report. The QAPI sign-in sheet indicated all appropriate members of the IDT team were present for the QAPI meeting.<BR/>During interviews with staff (LVN C, LVN D, LVN E, LVN B, and the ADON) on 4/3/24 between 11:00 a.m. and 12:19 p.m. staff were able to explain importance of ensuring TARs and MARs were signed off, how to pull an omission audit to check to make sure all TARs and MARs had been signed off and treatments had been completed, how often skin and wound assessments should be performed, the importance of reporting changes in skin conditions to the PCP or wound care doctor, and interventions to prevent pressure ulcers including offloading, turning and repositioning every 2 hours, pressure relieving cushions in a resident's wheelchair, and bathing to aide in circulation.<BR/>On 4/3/24 at 12:21 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance the facility remained out of compliance with a scope identified as patterned and a severity of no actual harm with a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**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 3 residents (Resident #1) reviewed for smoking.<BR/>The facility failed to ensure Resident #1 was provided supervision when he smoked. Resident #1 had a history of attempting to smoke while wearing his oxygen tank (secured to the back of his motorized wheelchair). On 03/26/2023, a lit cigarette was discarded on the ground and ignited his oxygen tubing and catheter bag that was laying at the bottom of his motorized wheelchair. <BR/>An Immediate Jeopardy (IJ) was identified on 04/01/2023 at 3:20 PM. While the IJ was removed on 04/03/2023 at 7:12 PM, the facility remained out of compliance at no actual harm because the facility needed to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents at risk of harm, severe injury, and possible death to residents who wear oxygen and were inadequately assessed for smoking safely unsupervised. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet, dated 04/02/2023, revealed Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia (occurs when disease of the heart or lungs leads to failure to maintain adequate blood oxygen levels), cognitive communication deficit (difficulty with thinking and how someone uses language), and paraplegia (impairment in motor (movement) or sensory (feeling) function of the lower extremities). <BR/>Record review of the order summary report, dated 04/01/2023, revealed Resident #1 had an order, which started on 03/18/2023, for Oxygen continuously via nasal cannula . <BR/>Record review of Resident #1's comprehensive MDS assessment, dated 03/24/2023, revealed it had not been completed. <BR/>Record review of the comprehensive care plan, initiated on 03/20/2023, revealed Resident #1 had altered respiratory status and difficulty breathing. The interventions included oxygen at 2 LPM via NC every shift. The comprehensive care plan further revealed a smoking care plan was initiated on 03/26/2023 after Resident #1 ignited his oxygen tubing on the smoking patio. The intervention included Resident is deemed unsafe smoker, he smoked with oxygen tank in place after being educated to leave oxygen concentrator at nurses' station when going out to smoke.<BR/>Record review of the occupational therapy treatment encounter note, dated 03/22/2023, revealed Resident #1 was educated on the safety concerns including the oxygen tank attached to his motorized wheelchair and not being allowed in the smoking courtyard. <BR/>Record review of the nursing progress note, dated 03/22/2023 at 2:35 PM, revealed Resident #1 was repeatedly going outside in the common smoking area to smoke while oxygen was connected. The progress notes further revealed the charge nurse, ADON, and DON provided education and Resident #1 agreed not to smoke while using oxygen.<BR/>Record review of the smoking assessment, effective date 03/22/2023, revealed Resident #1 had a history of smoking-related problems that would be hazardous to self or others. The smoking assessment revealed Resident went to smoking area in power chair with his oxygen tank. The tank was removed, and resident educated. The smoking assessment revealed Resident #1 was able to keep his lighter and cigarettes and was safe to smoke unsupervised. The assessment was signed by the DON on 03/27/2023. <BR/>Record review of the nursing progress note, dated 03/25/2023 at 11:47 PM, revealed Resident #1 was provided additional education regarding removing his oxygen tank prior to going outside to smoke. <BR/>Record review of the nursing progress note, dated 03/26/2023 at 3:45 PM, revealed Resident #1 had been off the hall for about an hour visiting another resident. Resident #1 went out to smoking area, and per resident witnesses' Resident #1 removed his nasal cannula and laid it on his foley catheter bag and proceeded to take out a cigarette and light it. While smoking, Resident #1 dropped his cigarette on top of oxygen tubing that was on ground. The oxygen tubing and foley catheter caught fire. A resident in the area grabbed the fire extinguisher and quickly put out the fire. There were no visible injuries, 911 was called, the doctor was notified, and a message with call back number was left for family.<BR/>Record review of the incident report, dated 03/26/2023 at 3:30 PM, revealed Resident #1 was outside smoking with oxygen tank on, per witnesses' he took the nasal cannula off and placed it on the ground on his foley tubing prior to lighting the cigarette. He dropped his cigarette and the oxygen tubing ignited burning the oxygen tubing and foley tubing. Another resident immediately got the fire extinguisher and put out fire, and someone else hollered for nurse. Charge nurse went into smoking area and noted white substance all over resident. Nurse observed resident sitting in his power chair, holding the power cord to chair, and burnt oxygen tubing. The incident report further revealed immediate action taken was 911 was called, fire extinguisher was used, resident transported to ER to rule out any injury. Oxygen tank was turned off and removed from chair. Resident returned to nurses' station for eval.<BR/>Record review of the Smoking Policy In-service, initiated on 03/26/2023, revealed staff were in-serviced on the smoking policy that was implemented in 06/2022 which indicated oxygen was prohibited in the smoking area. The in-service further revealed 7. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether supervision is required for smoking, or if resident is safe to smoke at all. 8. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan. The in-service further revealed 13. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff.<BR/>Record review of the Supervised Smoking Schedule, undated, revealed instructions that included: Do not throw cigarettes on the ground, use the ashtrays. No cigarettes, cigars, lighters or matches (any lighting instrument) in a resident's room or on your person at any time. The schedule further revealed the smoking times as follows:<BR/>6:00 AM - 6:15 AM supervised by the staff on duty<BR/>9:00 AM - 9:15 AM supervised by the staff on duty<BR/>12:45 PM - 1:00 PM supervised by the staff on duty<BR/>4:00 PM - 4:15 PM supervised by the staff on duty<BR/>7:00 PM - 7:15 PM supervised by the staff on duty<BR/>10:00 PM - 10:15 PM supervised by the staff on duty<BR/>During an interview on 04/01/2023 at 9:07 AM, LVN D stated the residents were able to take themselves out to the smoking area and smoke if they were able to smoke unsupervised. LVN D stated there were currently no designated smoking times in place and residents could go out whenever. LVN D stated the residents were able to keep their cigarettes and lighters. <BR/>During an observation on 04/01/2023 at 9:05 AM, four residents (Resident's #2, #5, #6, and #7) were outside in the smoking courtyard. Residents #2, #5, #6, and #7 had their own cigarettes and lighters. <BR/>During an interview 04/01/2023 at 9:10 AM, Resident #2 stated she was the person who used the fire extinguisher to put the fire out on 03/26/2023. Resident #2 stated it was windy the day of the incident and Resident #1 was sitting in his motorized wheelchair against the wall. Resident #2 stated Resident #1 had taken his nasal cannula out of his nose and placed it on top of his catheter bag. Resident #2 stated Resident #1 was not right in the head and had come out several times with his oxygen tank on the back of his motorized wheelchair. Resident #2 stated the nurses would have normally turned the oxygen tank off, but it was on the day of the incident. Resident #2 stated another resident had dropped his cigarette on the ground and the wind blew it toward the nasal cannula and the tubing ignited causing a fire. Resident #2 stated she immediately grabbed the fire extinguisher and put out the fire. Resident #2 stated she did not believe there were any injuries to Resident #1. <BR/>During an interview on 04/01/2023 at 9:16 AM, Resident #5 stated the facility staff told them during the past week that the residents were not allowed to smoke without supervision anymore. Resident #5 stated the staff members had not supervised them this morning, but she was under the impression it was to have started. Resident #5 stated the facility told the residents who smoked they would also have to give up their cigarettes and lighters and could only smoke during the designated smoking times for only 15 minutes. Resident #5 stated the staff had not taken her cigarettes or lighter and had not provided supervision at this time. <BR/>During an interview on 04/01/2023 at 9:47 AM, LVN C stated on the morning of the incident on 03/26/2023 and the day prior on 03/25/2023 she had talked to Resident #1 several times about going outside with his oxygen on. LVN C stated Resident #1 had gone to another hall to visit another resident. LVN C stated Resident #1 entered the smoking area after leaving the other resident's room. LVN C stated a CNA had come to tell her he was outside with oxygen on. LVN C stated RN F had beat her to the smoking area and the fire was already extinguished. LVN C stated paramedics had been called so Resident #1 could have been checked out. LVN C stated he had some redness to his bilateral lower extremities, but they looked like that prior to the incident. LVN C stated to her knowledge, he took his nasal cannula off and placed it at the bottom of his motorized wheelchair where it caught fire. LVN C stated he had no injuries. LVN C stated some residents required supervision and some did not dependent on their smoking assessment. LVN C stated the facility had no set times for residents who were able to smoke unsupervised. LVN C stated the facility did an in-service stating residents had to be supervised while smoking and should have designated times but was usure when it started. LVN C stated it should have been implemented by today. <BR/>During an observation on 04/01/2023 at 9:54 AM, four residents were outside smoking with no staff supervision. <BR/>During an interview on 04/01/2023 at 9:58 AM, Resident #3 stated she did not smoke but liked to sit outside. Resident #3 stated she witnessed the incident that happened on 03/26/2023 with Resident #1. Resident #3 stated Resident #1 was confused and would often become naked by taking his gown off. Resident #3 stated Resident #1 had taken his oxygen off and placed it on his catheter bag. Resident #3 stated Resident #1 threw his lit cigarette on the ground, and he started yelling he was on fire. Resident #3 stated the flames were going and another resident grabbed the fire extinguisher and put out the fire. Resident #3 stated a different resident hollered for a nurse. Resident #3 stated the fire department arrived at the facility and told her Everyone could have been blown to pieces. <BR/>During an interview on 04/01/2023 at 10:18 PM, the DON stated on 03/26/2023 Resident #1 had taken his oxygen tank attached to his motorized wheelchair out into the smoking area. The DON stated it was discovered during the investigation that Resident #1 was not actually smoking but another resident was smoking beside him and dropped his cigarette on the ground. The DON said the cigarette rolled toward Resident #1's motorized wheelchair where his oxygen tubing was laying on his catheter bag and ignited. The DON stated another resident put out the fire using the fire extinguisher and Resident #1 was sent to the emergency room as a precaution. The DON stated when Resident #1 returned to the facility he was re-assessed as an unsafe smoker and his smoking materials were taken. The DON stated Resident #1 had one prior incident on 03/22/2023 where he was found outside with his oxygen tank on. The DON stated herself, the ADON, the nurse, and therapy provided Resident #1 with education regarding taking his oxygen tank into the smoking area. The DON stated he was deemed a safe smoker at that time because he was able to verbalize understanding of the smoking policy. The DON stated the corporate office had changed the smoking policy and she had in-serviced the residents and the staff. The DON stated the supervised smoking at designated times was supposed to have been implemented on Monday, 04/03/2023. <BR/>During an observation and interview on 04/01/2023 at 12:35 PM, Resident #1 was sitting up in his hospital bed. Resident #1 looked frail and unkempt as evidenced by the hospital gown falling off his bony shoulders and his hair was disheveled and falling into his face. Resident #1 was wearing a nasal cannula and was struggling to breath during the interview. Resident #1 stated he remembered the incident that occurred on 03/26/2023. Resident #1 stated he was not smoking but another resident was sitting beside him and was smoking. Resident #1 stated the other resident dropped his cigarette and about 5 minutes later his nasal cannula and foley catheter tubing caught on fire. Resident #1 stated it was a small flame and he was not injured. Resident #1 stated the facility made him go to the hospital and he believed they made a mountain out of a molehill. Resident #1 stated he knew all about safety and for significant damage to have been done, it would have needed to happen in an enclosed space. Resident #1 stated he normally went into the smoking area with his oxygen tank, but the staff would turn off the oxygen or he would himself. <BR/>During an interview on 04/01/2023 at 1:22 PM, CNA B stated she worked the hall were Resident #1 resided and had taken care of him. CNA B stated Resident #1 wanted to do what he wanted to when he wanted to do it. CNA B stated Resident #1 had behaviors, but it seemed like they were getting better. CNA B stated she observed Resident #1 outside in the smoking area on multiple occasions with his oxygen tank on the back of his motorized wheelchair. CNA B stated Resident #1 was an unsupervised smoker, and she believed the nurses were turning the oxygen off. CNA B stated all the nurses were aware Resident #1 was going outside with his oxygen tank on. CNA B stated she was provided an in-service on the new smoking policy and stated all residents were going to be supervised while smoking and only allowed to smoke at designated times. <BR/>During an interview on 04/01/2023 at 1:41 PM, MA E stated she worked on the hall were Resident #1 resided. MA E stated Resident #1 was told things and he would forget them. <BR/>During an interview on 04/01/2023 at 2:29 PM, COTA R stated 03/22/2023 was the first day Resident #1 was out of the bed. COTA R stated she was performing a safe motorized wheelchair assessment on Resident #1 when he mentioned he wanted to go outside for a cigarette. COTA R stated she provided education on safety to Resident #1 and instructed him it was not appropriate to go outside with his oxygen tank hooked on the back of his motorized wheelchair. COTA R stated she informed the nurse he was asking for a cigarette. COTA R stated Resident #1 was later found outside with his oxygen tank on his motorized wheelchair. <BR/>Record review of the Resident Smoking policy, updated in 03/2023, revealed 7. Residents who smoke will be assessed, using the Resident Safe Smoking Assessment, to determine the level of supervision the resident requires. 8. All residents who smoke will be allowed to smoke in designated smoking areas (weather permitting), at designated times with supervision, and in accordance with his/her care plan. The policy further revealed 13. Smoking materials of residents who smoke will be maintained by nursing staff.<BR/>The Administrator was notified on 04/01/2023 at 3:52 PM that an immediate jeopardy situation was identified due to the above failures. The Administrator and the DON was provided the immediate jeopardy template on 04/01/2023 at 3:59 PM. <BR/>During an interview on 04/02/2023 at 10:55 AM, the DON stated before the incident on 03/26/2023, the facility assessed residents for safe smoking, the need for supervision, and whether residents were able to keep their smoking materials by performing a smoking assessment. The DON stated it had been the policy from the time she started at the facility. The DON stated there was no set person to complete the smoking assessment. The DON stated often the MDS nurse, the charge nurse, or herself would have completed the smoking assessments. The DON stated this was monitored during daily clinical meetings and if the assessment was not completed, she would do it. The DON stated Resident #1 had a BIMS score of 14, which indicated no cognitive impairment and was able to verbalize understanding of the smoking policy. <BR/>The facility's plan of removal was accepted on 04/03/2023 at 2:56 PM and included the following:<BR/>The facility failed to provide supervision to Resident #1 who required oxygen and smoked. All Smoking assessments and Care plans were reviewed for residents who smoke, and changes were made as necessary on 3/26/2023 by the director of nurses. Residents who smoke were reviewed for care plan and if a care plan was not noted, a care plan was completed. On 3/31/2023 residents who smoked and used oxygen were asked to attend a care plan meeting so that the care plan could be updated to reflect that they used oxygen and understood that they could not go outside to smoke with oxygen. Every resident who smokes verified they understood that they were not allowed go outside to smoke with oxygen. <BR/>Resident #1 was assessed and transferred to ER 3/26/2023 at approximately 3:45 PM to evaluate and treat as necessary. The Resident returned 3/26/2023 at approximately 9:00 PM with no new orders and with no injuries reported by the ER. <BR/>The facility smoking policy was updated on 3/31/2023 and at that time DON/ADON began in-servicing facility staff on the policy changes. <BR/>Facility policy was updated by corporate office to provide scheduled supervised smoking times for all residents who smoke on 3/31/2023.<BR/>Assigned smoking times are supervised as follows: <BR/>6:00am to 6:15am - Charge Nurse on North Wing will assign staff member to take residents smoking paraphernalia out to smoke area and allow residents to smoke while being supervised. <BR/>9:00am - 915am - Activity Director or her designee will supervise M-F, Housekeeping staff member on duty will supervise during this time on Sat - Sun.<BR/>12:45pm - 1:00pm - Social Services will supervise during this time frame and housekeeping staff member will supervise on Sat - Sun.<BR/>4:00pm - 4:15pm - North Wing Charge Nurse will assign Aide/C.N.A.<BR/>7:00pm- 715: pm - South Wing Charge Nurse will assign Aide/C.N.A.<BR/>10:00 pm - 10:15pm - East Wing Charge nurse will assign Aide/C.N.A. <BR/>DON, ADON, and the wound care nurse in-serviced all staff regarding the new smoking policy and the supervised smoking requirements. This will be monitored by the Administrator, DON and ADON. Smoking policy will be covered during orientation for new hires. All staff currently on duty were in-serviced at 11:00 AM on 4/3/2023.<BR/>Any staff members not available for in-service will be in-serviced prior to returning to shift. <BR/>All resident smokers were invited to a meeting on 3/31/2023 conducted by Social Worker and Administrator. Each resident in attendance was provided a copy of the changes. The Smoking policy is part of the admission agreement, and the revised policy will be placed in admission packet immediately. Not all residents who smoke showed up for the meeting. For those who did not attend, the ADON went to each resident on 4/2/2023 at 2:00PM to educate them on the new smoking policy to ensure they understood. Also, the residents were reminded that they must turn in all cigarettes and lighters to the nurse. <BR/>The new smoking policy was updated on 3/31/2023 to reflect that oxygen tanks are not allowed in the smoking area. <BR/> The person assigned to supervise smoking will ensure there are no oxygen tanks in the smoking area. <BR/>Policy related to supervision during smoking times has been implemented and is in place. The new smoking policy implementation explanation started 3/31/23 with all residents who smoke. The new smoking policy implementation was completed on 4/2/2023 for all residents who smoke.<BR/>All residents who smoke were asked again on 4/3/2023 at 11:00 AM to turn in cigarettes and lighters to the charge nurse for storage. Staff in-serviced again regarding the new smoking policy to ensure everyone understood on 4/03/2023 at 12:00PM.<BR/>On 04/03/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>During an observation on 04/03/2023 at 4:25 PM, 13 residents were outside smoking supervised by CNA B. <BR/>During resident interviews on 04/03/2023 between 4:33 PM - 5:09 PM, Resident's #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 were able to verbalize understanding of the new smoking policy, which included supervised smoking and designated smoking times, verbalize understanding of not going into the smoking area with oxygen, and verified all cigarettes and lighters were turned into the facility staff. <BR/>Record review of the comprehensive care plan for Resident's #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, and #27 revealed they had been reviewed and revised as necessary. <BR/>Record review of the smoking assessments for Resident's #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #17, #18, #19, #20, #22, #23, #24, #25, #26, and #27 revealed they had been reviewed and revised as necessary. <BR/>Record review of the new smoking policy in-service provided to staff, dated 03/31/2023, 04/01/2023, and 04/02/2023, revealed 42 staff members had signed and dated the read and understood the new smoking policy, which included oxygen was not allowed in the smoking area, residents were required to keep their cigarettes and lighters at the nurse's station, and designated smoking times and supervision. <BR/>During interview on 04/03/2023 between 4:25 PM and 6:28 PM, the following staff members, LVN K, MA L, LVN M, CNA N, CNA O, CNA P, CNA B, LVN D, CNA Q, and the ADON were interviewed and verbalized understanding that no oxygen was allowed in the smoking area, residents were required to keep their cigarettes and lighters at the nurse's station, and the new digitated smoking times and supervision. <BR/>On 04/03/2023 at 7:12 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 3 resident (Resident #1) reviewed for smoking.<BR/>The facility failed to ensure Resident #1 was compliant with the facility's smoking policy and failed to implement the smoking policy to ensure residents did not bring oxygen into the smoking area. <BR/>This failure could place residents at risk of an unsafe smoking environment.<BR/>The findings included:<BR/>Record review of Resident #1's face sheet, dated 04/02/2023, revealed Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia (occurs when disease of the heart or lungs leads to failure to maintain adequate blood oxygen levels), cognitive communication deficit (difficulty with thinking and how someone uses language), and paraplegia (impairment in motor (movement) or sensory (feeling) function of the lower extremities). <BR/>Record review of the order summary report, dated 04/01/2023, revealed Resident #1 had an order, which started on 03/18/2023, for Oxygen continuously via nasal cannula . <BR/>Record review of Resident #1's comprehensive MDS assessment, dated 03/24/2023, revealed it had not been completed. <BR/>Record review of the comprehensive care plan, initiated on 03/20/2023, revealed Resident #1 had altered respiratory status and difficulty breathing. The interventions included oxygen at 2 LPM via NC every shift. The comprehensive care plan further revealed a smoking care plan was initiated on 03/26/2023 after Resident #1 ignited his oxygen tubing on the smoking patio. The intervention included Resident is deemed unsafe smoker, he smoked with oxygen tank in place after being educated to leave oxygen concentrator at nurses' station when going out to smoke.<BR/>Record review of the occupational therapy treatment encounter note, dated 03/22/2023, revealed Resident #1 was educated on the safety concerns including the oxygen tank attached to his motorized wheelchair and not being allowed in the smoking courtyard. <BR/>Record review of the nursing progress note, dated 03/22/2023 at 2:35 PM, revealed Resident #1 was repeatedly going outside in the common smoking area to smoke while oxygen was connected. The progress notes further revealed the charge nurse, ADON, and DON provided education and Resident #1 agreed not to smoke while using oxygen.<BR/>Record review of the smoking assessment, effective date 03/22/2023, revealed Resident #1 had a history of smoking-related problems that would be hazardous to self or others. The smoking assessment revealed Resident went to smoking area in power chair with his oxygen tank. The tank was removed, and resident educated. The smoking assessment revealed Resident #1 was able to keep his lighter and cigarettes and was safe to smoke unsupervised. The assessment was signed by the DON on 03/27/2023. <BR/>Record review of the nursing progress note, dated 03/25/2023 at 11:47 PM, revealed Resident #1 was provided additional education regarding removing his oxygen tank prior to going outside to smoke. <BR/>Record review of the nursing progress note, dated 03/26/2023 at 3:45 PM, revealed Resident #1 was witnessed in the smoking area with his oxygen tank on his motorized wheelchair. <BR/>Record review of the incident report, dated 03/26/2023 at 3:30 PM, revealed Resident #1 was witnessed outside in the smoking area with his oxygen tank on his motorized wheelchair. <BR/>Record review of the Smoking Policy In-service, initiated on 03/26/2023, revealed staff were in-serviced on the smoking policy that was implemented in 06/2022 which indicated oxygen was prohibited in the smoking area.<BR/>During an interview 04/01/2023 at 9:10 AM, Resident #2 stated she witnessed Resident #1 in the smoking area with his oxygen tank on.<BR/>During an interview on 04/01/2023 at 9:47 AM, LVN C stated on the morning of the incident on 03/26/2023 and the day prior on 03/25/2023 she had talked to Resident #1 several times about going outside with his oxygen on. LVN C stated a CNA had come to tell her he was outside with oxygen on.<BR/>During an interview on 04/01/2023 at 9:58 AM, Resident #3 stated Resident #1 was witnessed outside in the smoking area with his oxygen tank on the back of his motorized wheelchair. <BR/>During an observation and interview on 04/01/2023 at 12:35 PM, Resident #1 was sitting up in his hospital bed. Resident #1 looked frail and unkempt as evidenced by the hospital gown falling off his bony shoulders and his hair was disheveled and falling into his face. Resident #1 was wearing a nasal cannula and was struggling to breath during the interview. Resident #1 stated he normally went into the smoking area with his oxygen tank, but the staff would turn off the oxygen or he would himself.<BR/>During an interview on 04/01/2023 at 1:22 PM, CNA B stated she observed Resident #1 outside in the smoking area on multiple occasions with his oxygen tank on the back of his motorized wheelchair. CNA B stated Resident #1 was an unsupervised smoker, and she believed the nurses were turning the oxygen off. CNA B stated all the nurses were aware Resident #1 was going outside with his oxygen tank on.<BR/>During an interview on 04/01/2023 at 2:29 PM, COTA R stated she provided education on safety to Resident #1 and instructed him it was not appropriate to go outside with his oxygen tank hooked on the back of his motorized wheelchair. COTA R stated Resident #1 was later found outside with his oxygen tank on his motorized wheelchair.<BR/>During an interview on 04/02/2023 at 10:55 AM, the DON stated she expected staff to ensure no oxygen tanks were allowed outside. The DON stated either housekeeping or maintenance was responsible for ensuring the facility had a safe smoking environment. The DON stated it was important because she did not want a fire to happen. <BR/>During an interview on 04/02/2023 at 11:41 PM, the Administrator stated he expected the facility staff to ensure the smoking environment was safe. The Administrator stated oxygen tanks should not have been brought into the smoking area. The Administrator stated it should have been monitored by housekeeping staff, maintenance, or any staff that observed it. The Administrator stated it was important to avoid a fire.<BR/>Record review of the Resident Smoking policy, updated in 03/2023, revealed 2. Safety measures for the designated smoking area will include, but no limited to e. Prohibition of oxygen use in the smoking area.

**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 had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and pain for 1 of 7 (Resident #2) residents reviewed for urinary catheters. <BR/>The facility did not ensure Resident #2's urinary catheter (a tube inserted into the bladder to drain urine) bag was not lying in the floor .<BR/>This failure could place residents at risk for urinary catheter bags busting by being stepped on or wheeled over by a wheelchair allowing bacteria into the catheter tubing, pain, and infection.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 4/3/24 indicated Resident #2 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including muscle weakness, dementia, overactive bladder, chronic kidney disease, hypertension (elevated blood pressure), and lack of coordination.<BR/>Record review of the MDS dated [DATE] indicated Resident #2 was understood others and was usually understood by others. The MDS indicated Resident #2 had a BIMS of 15 and was cognitively intact. The MDS indicated Resident #2 had an indwelling catheter (urinary catheter that is left in place) and was always incontinent of urine. <BR/>Record review of the care plan revised on 2/7/24 indicated Resident #2 had impaired cognitive function/dementia or impaired thought processes related to dementia.<BR/>During an observation on 4/2/24 at 1:36 p.m. Resident #2's urinary catheter bag was lying on floor. <BR/>During an observation and interview on 4/3/24 at 9:34 a.m. Resident #2's urinary catheter drain bag was lying in the floor. Resident #2 said she did not put the catheter drain bag in the floor. Resident #2 said she could not reach the catheter drain bag to hang it on the bed where she liked it. Resident #2 said a staff member stepped on her catheter drain bag yesterday when it was in the floor and busted it. Resident #2 said staff replace the busted catheter drain bag and mopped the urine out of the floor. <BR/>During an interview on 4/3/24 at 12:33 p.m. the ADON said a foley catheter drain bag should be positioned below the abdomen unless otherwise requested by the resident. The ADON said a foley catheter drain bag should not ever be in the floor. The ADON said the importance of ensuring a foley catheter drain bag was not in the floor was for infection control. The ADON said there were approximately 3 residents in the facility she thought would put their foley catheter drain bag in the floor. The ADON said one of those residents was Resident #2.<BR/>During an interview on 4/3/24 at 1:00 p.m. CNA G said she usually worked the 200 hall. CNA G said urinary catheter drain bags should be below the waist of the resident with the tubing straight without kinks. CNA G said urinary catheter drain bags should not be in the floor. CNA G said the importance of catheter drain bags not being in the floor was for sanitary purposes and to ensure they do not get busted by being stepped on or rolled over with a wheelchair. CNA G said she was not aware of any residents who would place their foley catheter drain bag in the floor.<BR/>During an interview on 4/3/24 at 1:31 p.m. the DON said she expected a urinary catheter drain bag to be positioned below the level of the bladder. The DON said a urinary catheter drain bag should not be in the floor. The DON said the importance of a foley catheter drain bag not being in the floor was infection control.<BR/>During an interview on 4/3/24 at 1:33 p.m. the Administrator said she expected a foley catheter drain bag to be covered, anchored, and not in the floor. The Administrator said the importance of a foley catheter drain bag not being in the floor was infection control. <BR/>Record review of the facility's Indwelling Catheter Use and Removal policy dated 7/2020 indicated, It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice .Additional care practices include .c. Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter; and d. Securement of the catheter facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the bladder .<BR/>Record review of the facility's Infection Prevention and Control Program policy dated 3/2022 indicated, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use, for two of eight residents (Resident's #42 and#86) reviewed for antibiotic use.<BR/>1.) <BR/>Resident #42 was ordered Augmentin tablet 875-125 mg by mouth twice a day for upper respiratory infection on 04/10/2022 without an end date and was not on the Infection Control Tracking and Trending review. <BR/>2.) <BR/>Resident #86 was ordered Augmentin tablet 875-125 mg by mouth twice a day for infection control on 05/25/2022 without an end date and was not on the Infection Control Tracking and Trending review. <BR/>This failure could place residents with infections at risk for unnecessary antibiotic use and increased infections that are resistant to antibiotics. <BR/>Findings included:<BR/>Record review of the Antibiotic Stewardship Policy dated 06/2022 indicated it is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The policy explanation and compliance guidelines indicated .4. The program includes antibiotic use protocol and a system to monitor antibiotic use .v. all prescriptions for antibiotic shall specify the dose, duration, and indication for use.<BR/>1. Record review of Resident #42's face sheet dated 06/28/2000, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and most recent readmission on [DATE]. Her diagnoses included pneumonia, anemia, chronic obstructive pulmonary disease, stroke, weakness, and cognitive communication deficit.<BR/>Review of Resident #42's Minimum Data Set (MDS) dated [DATE], revealed she was cognitively intact and had been on an antibiotic for seven out of seven days during the observation period.<BR/>Resident #42's order summary report, revealed she had a physician order dated 04/10/2022 for Augmentin tablet 875-125 mg give one tablet by mouth two times a day for upper respiratory infection. There was no end date documented.<BR/>According to Resident #42's care plan initiated on 04/10/2022 and revised on 06/28/2022, revealed the resident had a respiratory infection and interventions included:<BR/>1.) <BR/>Antibiotic therapy as ordered by the physician<BR/>2.) <BR/>Augmentin 875/125 mg by mouth twice a day<BR/>3.) <BR/>Document response to the treatment<BR/>4.) <BR/>Emphasize good handwashing techniques to all direct care staff<BR/>According the Resident #42's medication administration records, the resident received Augment 875-125 mg one tablet by mouth twice a day at 9:00 AM and 5:00 PM daily from 5:00 PM on Sunday 04/10/2022 until 06/28/2022 at 5:40 PM when the physician order was discontinued.<BR/>Review of the facility's infection control data log from 01/01/2022 until 06/27/2022 did not document Resident #42's upper respiratory infection or antibiotic therapy.<BR/>During an observation and interview on 06/27/2022 at 9:33 AM, Resident #42 was resting in her bed, had oxygen at 2 liter per nasal cannula, and denied any concerns. She said she had breathing issues but staff cared for her well. Resident #42 said she did not know what specific treatments she was on for her breathing issues but said the staff knew and took care of her.<BR/>During an interview on 06/28/2022 at 12:15 PM, LVN C said she was Resident #42's charge nurse. LVN C said she thought Resident #42 was over her upper respiratory infection but was not sure.<BR/>During an interview on 06/28/2022 at 1:34 PM, the DON said she was responsible for overseeing the infection control log and antibiotic stewardship, which included tracking and monitoring all infections that required antibiotics. The DON said all antibiotics must have an appropriate diagnosis and included duration of use. The DON said all new orders, including new orders for antibiotics, were reviewed by her and the interdisciplinary team daily to ensure all orders were appropriately implemented but said she did not have Resident #42's antibiotic order documented on the infection control log, the antibiotic did not have a duration, and she did not find a care plan for Resident #42's antibiotic but these should have been completed by her.<BR/>During an interview on 06/29/2022 at 8:45 AM, the DON said she missed the review of Resident #42's antibiotic order without a stop date and the resident was on the antibiotic longer than was appropriate. The DON said she notified Resident #42's physician and responsible party of the medication error and initiated a staff in-service and audit of the antibiotic stewardship process.<BR/>During an interview on 06/29/2022 at 9:03 AM, the Administrator said he was not aware Resident #42 did not have an appropriate antibiotic administration order carried out until surveyor intervention. The Administrator said the DON was responsible for reviewing residents' new physician orders with the interdisciplinary team during daily morning meetings but did not recall if a review of Resident #42's antibiotic order was reviewed but it should have been monitored and documented on the infection control log.<BR/>2. According to Resident #86's face sheet dated 06/28/2022, she was a [AGE] year-old female admitted to the facility on [DATE] and with diagnoses that included intracranial injury with loss of consciousness (head injury), fracture left ilium (pelvic), and lumbosacral (lower back) fracture.<BR/>Review of Resident #86's Minimum Data Set (MDS) dated [DATE], revealed she was cognitively intact.<BR/>According to Resident #86's order summary report, she had a physician order dated 05/25/2022 for Augmentin tablet 875-125 mg give one tablet by mouth two times a day for infection control. There was no end date documented.<BR/>A review of Resident #86's care plans from admission date of 04/26/2022 through 06/27/2022 did not reveal a care plan for infection, or her antibiotic was completed.<BR/>According the Resident #86's medication administration records, the resident received Augment 875-125 mg one tablet by mouth twice a day at 8:00 AM and 4:00 PM daily from 4:00 PM on Wednesday 05/25/2022 until 06/28/2022 at 2:27 PM when the physician order was discontinued.<BR/>Review of the facility's infection control data log from 01/01/2022 until 06/27/2022 did not document Resident #86's infection diagnosis or antibiotic therapy.<BR/>During an observation and interview on 06/27/2022 at 9:41 AM, Resident #86 was sitting up in her wheelchair and denied concerns.<BR/>During an interview on 06/28/2022 at 11:11 AM, Medication Aide D said she administered Resident #86's antibiotic as ordered for diagnosis, infection control but did not think that was an appropriate diagnosis. Medication Aide D said she did not see an end date documented so thought it might be to prophylactic to prevent future infections.<BR/>During an interview on 06/28/2022 at 1:34 PM, the DON said she was responsible for overseeing the infection control log and antibiotic stewardship, which included tracking and monitoring all infections that required antibiotics. The DON said all antibiotics must have an appropriate diagnosis and included duration of use. The DON said all new orders, including new orders for antibiotics, were reviewed by her and the interdisciplinary team daily to ensure all orders were appropriately implemented but said she did not have Resident #86's antibiotic order documented on the infection control log, the antibiotic did not have a duration, did not have an appropriate diagnosis, and she did not find a care plan for Resident #86's antibiotic but these should have been completed by her.<BR/>During an interview on 06/28/2022 at 3:40 PM, LVN B said she was Resident #86's charge nurse and said she did not know why Resident #86 required an antibiotic and thought she was fine. LVN B said a resident had to have a specific reason to have an antibiotic. LVN B said the ADON, and DON were responsible to monitor the facility's infection control processes.<BR/>During an interview on 06/28/2022 at 3:53 PM, Resident #86 said she was on the antibiotic way too long. Resident #86 said she tried to tell them (staff) that I was on it (Augmentin) too long, but they (staff) would not listen. Resident #86 said she developed a rash under her breasts, but it resolved with antifungal treatment. Resident #86 said the physician prescribed the antibiotic when she had a sore throat and fever on 05/25/2022 but it resolved the next day.<BR/>During an interview on 06/29/2022 at 8:45 AM, the DON said she missed the review of Resident #86's antibiotic order without a stop date and the resident was on the antibiotic longer than was appropriate. The DON said she notified Resident #86's physician and responsible party of the medication error and initiated a staff in-service and audit of the antibiotic stewardship process.<BR/>During an interview on 06/29/2022 at 9:03 AM, the Administrator said he was not aware Resident #86 did not have an appropriate antibiotic administration order carried out until surveyor intervention. The Administrator said the DON was responsible for reviewing residents' new physician orders with the interdisciplinary team during daily morning meetings but did not recall if a review of Resident #86's antibiotic order was reviewed but it should have been monitored and documented on the infection control log.<BR/>Record review of the CDC's Core Elements of Antibiotic Stewardship for Nursing Homes accessed on 05/04/22 at https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-b-508.pdf Completeness of antibiotic prescribing documentation. Ongoing audits of antibiotic prescriptions for completeness of documentation, regardless of whether the antibiotic was initiated in the nursing home or at a transferring facility, should verify that the antibiotic prescribing elements have been addressed and recorded. These elements include: dose, (including route), duration (i.e., start date, end date and planned days of therapy), and indication (i.e., rationale and treatment site) for every course of antibiotics

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 12 residents (Resident #1, Resident #2, and Resident #4) reviewed for infection control. <BR/>1. The facility failed to ensure a resident COVID-19 outbreak that included one hospitalization, Resident #4, was reported to state regulatory authority.<BR/>2. The facility failed to ensure the OTA G, CNA D, and PT R maintained proper donning of facemasks for source control in the hallway and within 3 feet of Resident #1 and Resident #2 during a COVID-19 outbreak.<BR/>These failures could place residents at risk for development and spread of infection.<BR/>Findings include:<BR/>1. Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old female with an initial admission date of 12/05/2022. Resident #4 had diagnoses which included atrial fibrillation (irregular heartbeat), iron deficiency anemia secondary to blood loss (chronic) (decreased iron in the body due to excess bleeding), COVID-19, acute kidney failure, and chronic kidney disease, stage 4 (severe).<BR/>Record review of Resident #4's annual MDS, dated [DATE], reflected she had a BIMS score of 12, which indicated moderate cognitive impairment.<BR/>Record review of Resident #4's Care Plan, revised 01/02/2024, reflected she was at risk for signs and symptoms of COVID-19 and tested positive on 01/02/2024 with interventions to include: following facility protocol for COVID-19 screening/precautions and educate staff of COVID-19 signs and symptoms and precautions<BR/>Record review of the COVID-19 Log, dated 1/9/2024, and undated, Floorplan reflected Resident #4 tested positive for COVID-19 on 01/02/2024. The COVID-19 Log reflected 40 total COVID-19 positive residents and 5 positive staff since 12/30/2023. <BR/>Record review of Resident #4's Progress Notes, dated from 12/16/2023 through 01/07/2023, reflected multiple COVID-19 positive staff worked with Resident #4 to include LVN B, ADON, and LVN C. Progress Notes reflected Resident #4 was sent to the hospital on [DATE] per physician's orders following a change in condition to include labored breathing, fever, and altered mental status.<BR/>Record review of Resident #4's hospital records, dated 01/09/2024, reflected resident was being discharged from the hospital on [DATE] to return to nursing facility and had a hospital diagnosis which included .acute hypoxic respiratory failure (not enough oxygen in blood) secondary to pneumonia and COVID.<BR/>During an observation and interview on 01/09/2024 at 9:12 a.m., signage was posted at the entry notifying visitors there were COVID-19 positive residents in the facility.<BR/>During an interview on 01/09/2024 at 9:15 a.m., the Administrator and DON stated the facility had a COVID-19 outbreak and the ADON and DON was the IP and the ADON was not at work at the time of the survey. The DON stated 3 staff and 30 residents were currently positive for COVID-19 at the facility. The DON stated the facility did not have a designated COVID-19 unit; however, the majority of positives were located Hall S, and the outbreak initiated from LVN B who tested positive during routine testing on 12/29/2023 at another nursing facility, she was employed. The DON said facemasks were required for all staff in the building and physical therapy services were provided in the room for COVID-19 positive residents. The DON stated there was one COVID-19 positive resident who was hospitalized , Resident #4, who remained in the hospital. The Administrator said he did not report positive COVID-19 residents to HHSC, Program Manager, or any other regulatory agency because it was the first time he had COVID-19 in a facility and could not access the computer reporting system. The Administrator said it was important to notify regulatory agencies of COVID-19 positive residents upon first COVID-19 positive resident per COVID-19 policy and he anticipated to submit a self-report of COVID-19 outbreak to HHSC by the end of the day.<BR/>Record review of the facility policy, titled COVID-19 Prevention, Response, and Reporting, dated 06/22, reflected the following:<BR/>Policy: <BR/>It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections, COVID-19 information will be reported through the proper channels as per federal, state, and/or local health authority guidance.<BR/>Policy Explanation and Compliance Guidelines:<BR/>1. <BR/>The Infection Preventionist will assess facility risk associated with COVID-19 through surveillance activities of COVID-19 infection in the community and illnesses present in the facility .<BR/>b. Threat detected - the facility will respond promptly and implement emergency and/or outbreak procedures.<BR/>2. Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: heart failure, dementia (cognitive disorder), cancer, vitamin D deficiency, hallucinations, cognitive communication deficit (difficulty with thinking and using language), schizoaffective disorder (mental health condition with symptoms of both schizophrenia and mood disorders), neurocognitive disorder, chronic kidney disease stage 3, epilepsy (seizure disorder), and metabolic encephalopathy (brain dysfunction).<BR/>Record review of Resident #1's, undated, Care Plan reflected he had diabetes mellitus, was unaware of safety needs, and had an ADL self-care performance deficit requiring 1-2 staff assistance and had a skin infection with interventions to include: follow facility policy and procedures for line listing, summarizing, and reporting infections <BR/>Record review of Resident #1's quarterly MDS, dated [DATE], reflected he had a BIMS score of 12, which indicated moderate cognitive impairment.<BR/>During an observation and interview on 01/09/2024 at 10:00 a.m., the OTA G was providing physical therapy services and talking within 3 feet of Resident #1 who sat in his wheelchair in the physical therapy room. The OTA G had a facemask on that did not cover his nose and mouth and the resident was not wearing a facemask. The OTA G said he should be wearing a facemask while in the building within proximity to residents. The DOR, she said she oversaw proper PPE donning of facemasks and she did not know why the PT did not have his facemask donned properly while he was in close proximity with residents, and it may be due to the resident not being able to understand him and the DOR said she would address the concern. The DOR said the facility provided training on PPE donning and doffing during the current COVID-19 outbreak and it was important to properly don PPE to prevent the spread of infection for all residents at the facility. The DOR said her staff had not tested positive for COVID-19 and that therapy is provided in rooms for COVID-19 positive residents.<BR/>During an observation and interview on 01/09/2024 at 10:16 a.m., CNA D walked out of the shower room into the hallway directly across from the COVID-19 positive resident room with their door open and grabbed linen from the hallway storage rack. The CNA had no facemask donned in the hallway and said she was taking care of a positive COVID-19 resident today and indicated the room with isolation precaution signage and the PPE container directly across from the shower room where she had exited. The CNA said she was required to wear a facemask in the building and did not know why she did not have one on and facemasks were available at the nurse's station. The CNA said she received training on infection control and proper donning/doffing and said it was important to wear a facemask to prevent the spread of infection for all residents. The CNA D returned to the shower room with no facemask donned and donned a facemask at the nursing station to cover her nose and mouth. <BR/>During an interview on 01/09/2024 at 10:23 a.m., LVN A said CNA D was required to wear a facemask in the hallway and when showering residents and she had not noticed any staff not wearing their facemask. LVN A said she received training on PPE donning/doffing and said she would stop and remind staff to wear their facemask if she saw staff in the hallway without a facemask. LVN A said all charge nurses, the ADON, and the DON were responsible for ensuring facemasks were donned properly. LVN A said all residents were at risk for the spread of COVID-19 if facemasks were not properly donned, and it was important for staff to wear their facemasks to prevent the spread of infection. LVN A said she worked on Hall S that had the majority of COVID-19 positive residents on 01/07/2024 and that she had approximately 7 positive residents. <BR/>Record review of Resident #2's, undated, face sheet, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: asthma (lung disease), family history of HIV (Human Immunodeficiency Virus) (virus that attacks the body's immune system), disorder invol<BR/>ving the immune mechanism, and type 2 diabetes mellitus with diabetic neuropathy (nerve damage).<BR/>Record review of Resident #2's, undated, Care Plan reflected he was at risk for signs and symptoms of COVID-19 and he was unable to wear a mask due to needing his mouth to navigate his wheelchair with interventions to include: educate staff, resident, family, and visitors of COVID-19 signs and symptoms and precautions, and follow facility protocol for COVID-19 screening/precautions.<BR/>Record review of Resident #2's MDS section in electronic health record, revealed admission MDS had not been completed since his recent admission on [DATE].<BR/>During an observation and interview on 01/09/2024 at 11:00 a.m., the PT R was ambulating in the hallway with Resident #2. The PT was wearing a facemask that did not cover his nose and mouth while talking and ambulating in the hallway within 3 feet of Resident #2. Resident #2 did not have a facemask donned and they ambulated from Hall S, with the majority of reported COVID-19 positive residents. The PT R said he was supposed to wear his facemask when interacting with residents. The PT R said he was not sure if he was supposed to wear a face mask at all times in the facility and they provided training on infection control donning and doffing during the current COVID-19 outbreak. The PT R donned his facemask and covered his nose and mouth. The PT R said it was important to wear his mask while in close proximity of residents to prevent the risk of spreading infection to residents in the facility.<BR/>During an observation and interview on 01/09/2023 at 11:05 a.m., the Housekeeper had a facemask donned and said staff were required to wear facemasks in the hallways and in close proximity of residents and improper donning could put all residents at risk for getting sick. The Housekeeper said it was important to wear the facemasks properly to prevent the spread of infection.<BR/>During an interview on 01/09/2024 at 12:29 p.m., the DON and Administrator said the charge nurses, the ADON, and herself were ultimately responsible for ensuring proper PPE donning/doffing. The DON said staff were required to wear their masks when they were in a patient area or in the hallway. The DON said she ensured residents wore facemasks by doing daily reminders to encourage residents to wear them. The DON said there was no set schedule for monitoring of proper donning and doffing of PPE. The DON said she would continue to ensure compliance by frequent monitoring rounds to see if they were following protocols. The DON said if a staff member was observed without a facemask donned the employee would be stopped and provided education to review the importance for staff to wear their facemasks in order to prevent the risk of spreading infection. <BR/>During a telephone interview on 01/09/2024 at 12:39 p.m., the Attending Physician said he was aware of the COVID-19 outbreak at the facility and had a COVID-19 protocol for any resident that tested positive to include medication and staff must wear a mask in the facility if exposed to COVID-19 to prevent the spread of infection. <BR/>Record review of the facility policy, titled Infection Surveillance, dated 07/2022, reflected the following:<BR/>Policy:<BR/>A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. <BR/>Definitions:<BR/> .'Process measure' is a mechanism for evaluating specific steps in a process that lead, either positively or negatively, to a particular outcome metric. Also known as performance monitoring, a process measure is used to evaluate whether infection prevention and control practices are being followed .<BR/>Policy Explanation and Compliance Guidelines:<BR/>1. <BR/>The Infection Preventionist serves as the leader in surveillance activities . and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required .<BR/>Review of CDC Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19)Pandemic at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#SARS-CoV-2-metrics revealed the following:<BR/> .Source control is recommended for individuals in healthcare settings who:<BR/>Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or<BR/>Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure.<BR/>Source control is recommended more broadly as described in CDC's Core IPC Practices in the following circumstances:<BR/>By those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over (e.g., no new cases of SARS-CoV-2 infection have been identified for 14 days); or<BR/>Facility-wide or, based on a facility risk assessment, targeted toward higher risk areas (e.g., emergency departments, urgent care) or patient populations (e.g., when caring for patients with moderate to severe immunocompromise) during periods of higher levels of community SARS-CoV-2 or other respiratory virus transmission (See Appendix)<BR/>Have otherwise had source control recommended by public health authorities (e.g., in guidance for the community when COVID-19 hospital admission levels are high) .<BR/>Review of CDC's SARS-CoV-2 Community Transmission Level at https://covid.cdc.gov/covid-data-tracker/#maps_new-admissions-rate-county revealed Community Transmission Level was Low for the county.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an accurate MDS was completed for 6 of 12 residents (Residents #9, 25, 33, 50, 94, and 97) reviewed for MDS assessment accuracy.<BR/> The facility did not accurately code Resident #9's quarterly MDS assessment for assistance with eating and diuretic use.<BR/>The facility did not accurately code Resident # 25's annual MDS assessment for antipsychotic medication use. <BR/>The facility did not accurately code Resident #33's annual MDS assessment for Pressure Ulcer and insulin use, opioid use, antidepressant use, antibiotic use, and antianxiety use.<BR/>The facility did not accurately code Resident #50's quarterly MDS assessment for assistance with eating and diuretic use, opioid use, antidepressant use, and anticoagulant use.<BR/>The facility did not accurately code Resident #94's quarterly MDS assessment for antipsychotic use.<BR/>The facility did not accurately code Resident #97's admission MDS assessment for antianxiety use and anticoagulant use.<BR/>This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. <BR/>Findings included:<BR/>1.A review of Resident #9's face sheet and physician's orders for August 2023 indicated Resident #9 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including heart failure, diabetes, bipolar disorder (a disorder associated with mood swings ranging from depressive lows to manic highs), anxiety disorder, and depressive episodes. <BR/>A review of Resident #9's physician's order dated August 2023 indicated she had an order dated 11/22/2021 to receive a diuretic, acetazolamide, 500 mg twice a day. <BR/>A review of Resident #9's May 2023 MAR indicated the resident had received acetazolamide as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #9's quarterly MDS (Section N410: medications received) dated 05/11/2023 indicated she had not received a diuretic during the observation period. The same MDS (Section G: Functional status) indicated the resident required limited assistance of one-person physical assist with eating.<BR/>A review of a care plan initiated on 11/22/2021 and last revised on 06/17/2022 indicated Resident #9 required set up assistance by staff to eat.<BR/>During an observations and interview on 08/14/23 at12:37 PM Resident #9 was eating her lunch without assistance and having no problems. She said the food was pretty good and she was having no issues with eating.<BR/>During an observations and interview on 08/15/23 at12:40 PM Resident #9 was eating her lunch without assistance and having no problems. She was dipping the zucchini sticks into her salad dressing and said it was really good and wished she had some more.<BR/>2. A review of Resident #25's face sheet and physician's orders for August 2023 indicated Resident #25 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including psychosis and schizoaffective disorder (mental disorders). <BR/>A review of Resident #25's physician's order dated 05/21/2022 indicated he was to receive an antipsychotic, Seroquel, 100 mg daily at bedtime and an order dated 02/16/2023 indicated he was to also receive Seroquel 50 mg daily in the morning. <BR/>A review of Resident #25's June 2023 MAR indicated the resident had received both the morning and evening doses of the antipsychotic, Seroquel, as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #25's Annual MDS (Section N: Antipsychotic Medication Review) dated 06/21/2023 indicated he had not received an antipsychotic medication during the observation period. This incorrect coding led to the rest of the Antipsychotic Medication Review section of the MDS not being completed. <BR/>During an interview on 08/14/2023 at 10:30 AM with the MDS Coordinator from a sister facility, she said the facility did not have a full time MDS Coordinator and that she was helping at this facility a couple of days a week. She said she was not the person who completed Resident # 25's annual MDS.<BR/>During an interview on 08/17/2023 at 11:20 AM with the sister facility's MDS Coordinator, she said Section N0450-A should have been coded as the resident having received an antipsychotic medication which would have also led to the rest of the assessment being completed.<BR/>3. A review of Resident #33's face sheet and physician's orders for August 2023 indicated Resident #33 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including diabetes, stage 4 pressure ulcer of sacral region, chronic pain, paraplegia (paralysis of the legs and lower body), depressive disorder, anxiety disorder, urinary tract infection, and high blood pressure. <BR/>A review of Resident #33's physician's order dated August 2023 indicated she had orders dated 01/05/2023 to receive an antianxiety medication, venlafaxine, 75 mg daily; orders dated 09/03/2021 to receive an antianxiety medication, clonazepam, 0.5 mg twice a day; orders dated 03/15/2022 to receive an antibiotic, Hiprex, 1,000 mg twice a day; orders dated 02/25/2023 to receive an opioid, oxycodone ER, 15 mg twice a day, orders to receive an insulin, Levemir, 80 units subcutaneously twice a day.<BR/>A review of Resident #33's July 2023 MAR indicated the resident had received venlafaxine, clonazepam, antibiotic, opioid, and insulin as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #33's Wound Assessment Profile dated 07/06/2023, 07/13/2023, 08/03/2023, and 08/10/2023 indicated the resident had a stage 4 pressure ulcer on the sacrum (an injury that extends through muscle, tendon or bone).<BR/>A review of Resident #33's annual MDS dated [DATE] (Section M: Skin Conditions) indicated she did not have one or more unhealed pressure ulcer/injuries and (Section N410: medications received) indicated she had not received insulin injections, antianxiety medications, antidepressant medications, antibiotics, and opioid medications.<BR/>4. A review of Resident #50's face sheet and physician's orders for August 2023 indicated Resident #50 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular, often rapid, heart rate that commonly causes poor blood flow), chronic obstructive pulmonary disease, diabetes, pain, major depressive disorder, and peripheral venous insufficiency (walls of the veins not working properly making it difficult for the blood to return to the heart). <BR/>A review of Resident #50's physician's order dated August 2023 indicated she had an order dated 04/20/2023 to receive a diuretic, furosemide, 40 mg daily; an order dated 04/20/2023 to receive hydrocodone-acetaminophen 10-325 mg twice a day; , an order dated 07/04/2023 to receive insulin, Glargine 35 units subcutaneously in the morning before breakfast and Glargine 35 units subcutaneously (insertion under te skin by injection) at bedtime; an order dated 07/20/23 to receive Novolog insulin sliding scale before meals and at bedtime, an order dated 04/20/2023 to receive an anticoagulant, rivaroxaban, 20 mg in the evening; and an order dated 04/20/2023 to receive an antidepressant, trazadone, 50 mg at bedtime. <BR/>A review of Resident #50's July 2023 MAR indicated the resident had received rivaroxaban, furosemide, trazadone, hydrocodone-acetaminophen, Glargine, and Novolog, as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #50's quarterly MDS (Section N410: medications received) dated 07/25/2023 indicated she had not received insulin injections, an antidepressant, an anticoagulant, a diuretic, and an opioid during the observation period. The same MDS (Section G: Functional status) indicated the resident required limited assistance of two-persons physical assist with eating.<BR/>A review of a care plan initiated on 11/30/2018 and last revised on 12/05/2018 indicated Resident #50 required assistance of one staff member to eat<BR/>During an observation and interview on 08/14/23 at 12:39 PM Resident #50 was eating her lunch without assistance. She was sitting upright in bed and eating her lunch. She said it wasn't too bad.<BR/>During an observation and interview on 08/15/23 at 12:55 PM Resident #50 was eating her lunch without assistance. She was sitting upright in bed and eating her lunch. She was nodding off a little while eating.<BR/>5. A review of Resident #94's face sheet and physician's orders for August 2023 indicated Resident #94 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including schizophrenia (mental disorder), epilepsy (seizure disorder), major depressive disorder, and alcohol use. <BR/>A review of Resident #94's physician's order dated August 2023 indicated she had an order dated 10/27/2022 to receive an antipsychotic, Seroquel, 300 mg at bedtime and an order dated 03/31/2023 to receive Seroquel 150 mg in the morning. <BR/>A review of Resident #94's April and May 2023 MARs indicated the resident had received Seroquel as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #94's quarterly MDS (Section N410: medications received) dated 05/04/2023 indicated she had received an antipsychotic during the observation period. (Section N450: Antipsychotic Medication Review) dated 05/04/2023 indicated she had not received an antipsychotic medication during the observation period. This incorrect coding led to the rest of the Antipsychotic Medication Review section of the MDS not being completed. <BR/>6. A review of Resident #97's face sheet and physician's orders for August 2023 indicated Resident #97 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including atrial fibrillation an irregular, often rapid, heart rate that commonly causes poor blood flow), anxiety disorder (amental health disorder characterized by feelings of worry or fear), high blood pressure, and pneumonia.<BR/>A review of Resident #97's physician's order dated August 2023 indicated she had an order dated 05/11/2023 to receive an antianxiety, clonazepam, 0.5 mg twice a day and an anticoagulant, enoxaparin injectable 30 mg/0.3 ml injected subcutaneously every morning. <BR/>A review of Resident #97's May 2023 MAR indicated the resident had received 6 of 7 doses of enoxaparin of the 7 doses as ordered by the physician and clonazepam 5 of the 7 doses as ordered by the physician during the MDS assessment period. <BR/>A review of Resident #97's admission MDS (Section N410: medications received) dated 05/17/2023 indicated she had not received an antianxiety medication or an anticoagulant during the observation period. <BR/>During an interview on 08/16/2023 at 01:35 PM with the sister facility's MDS Coordinator, she said she had been helping with the MDS since about June 2023. She said the RAI manual was used as the guideline for performing the MDS assessment. She said the policy would be to follow the RAI.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a discharge was appropriately communicated and documented in the medical record for 1 of 4 discharged residents (Resident #1) reviewed for discharge requirements. <BR/>1. <BR/>The facility refused to re-admit Resident #1 from the hospital on 2/22/2024. <BR/>2. <BR/>Resident #1's clinical record had no physician documentation to address why the resident was being discharged , what needs of the resident the facility could not meet, and how the resident posed a danger to the existing resident population. <BR/>These failures could place residents at risk of not receiving the necessary care and services to meet their physical and psychological needs. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet dated 03/18/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Huntington's disease (an uncurable neurodegenerative disease that is mostly inherited), encephalopathy (disease that alters the brain), depression, and traumatic brain injury. <BR/>Record review of Resident #1's admission MDS assessment dated [DATE] indicated Resident #1 was usually able to be understood by others, usually able to understand others, had a BIMS of 03 which indicated Resident #1 had severe cognitive impairment. The MDS also indicated that he required limited assistance from 1 person for dressing and personal hygiene, supervision for bed mobility and toileting, and extensive assistance from 2 people with bathing. <BR/>Record review of Resident #1's Discharge summary dated [DATE] completed by the previous DON and unsigned by Resident #1's physician indicated Resident #1 was discharged from the facility while he continued to be in the hospital. <BR/>Record review of Resident #1's order summary report dated as of 03/18/2024 indicated he had orders as followed:<BR/>1. <BR/>I certify the resident Requires/Continues to require Long Term Nursing Care at this facility for the next 90 days dated 06/29/2023.<BR/>2. <BR/>Orders are reviewed and renewed every 30 days dated 06/29/2023.<BR/>3. <BR/>Resident may be transferred out to hospital for a higher level of care dated 02/18/24. <BR/>There was no discharge order noted. <BR/>Record review of Resident #1's care plan dated 07/14/23 and last revised on 03/14/24 did not include a discharge plan. <BR/>Record review of a care plan dated 07/14/23 and revised on 03/14/24 indicated Resident #1 had the potential for verbal aggression related to poor impulse control. Interventions included administer medications as ordered and monitor side effects, give resident choices about care, provide positive feedback for good behavior, and when resident becomes agitated intervene before situation escalates. <BR/>Record review of Resident #1's nurses notes dated 02/18/24 indicated Resident #1 had an episode of behaviors that included breaking facility furniture and hitting kitchen staff documented by LVN A at 09:02 AM prior to being transferred to the hospital. <BR/>Record review of Resident #1's electronic medical record indicated there was no note from the physician in his chart regarding his discharge or why he was not capable of returning to the facility as of 03/18/2024. <BR/>During an interview 03/18/24 at 1:50 PM, Resident #1 said he was the only person left in his family. Resident #1 said he did not remember the facility giving him any notice of being discharged and having to find somewhere else to go. Resident #1 said he was sorry for his outbursts, being mean to anyone, and the Bible said we were all imperfect. He said he would be good if he could go back to the facility because he had nowhere to go. <BR/>During an interview on 03/18/24 at 2:56 PM, an anonymous person said the facility dumped Resident #1 at the hospital and refused to take him back. The anonymous complainant said Resident #1 was not aggressive but did have behaviors to where he threw things and had episodes to where he would yell and curse, but he was able to return to the facility. They said Resident #1 had triggers to make him act out and could be re-directed at times. They said the facility should have re- assessed resident while at the hospital to determine if Resident #1 could return to the facility because that was considered dumping. They said Resident #1 had never hurt a staff member or other resident. The anonymous person said the facility placed the resident at risk for not finding any other facility placement and getting the care and services he required. <BR/>During an interview on 03/18/24 at 3:15 PM, the Administrator said Resident #1 was in the hospital the day she began at the facility on 02/19/24. The Administrator said she was made aware that Resident #1 had torn up the kitchen at the facility and broke glass as well. She said the physician was notified of Resident #1's behaviors indicated Resident #1 was a danger to himself and others. She said the previous interim administrator had made the decision to discharge Resident #1. The Administrator said 30-day notice was not given to Resident #1 because the discharge was considered an emergency. She said the hospital called her on 2/22/24 and she told them the facility would not be accepting the Resident #1 back to the facility due to his behaviors on 02/18/24. <BR/>During an interview on 03/18/24 at 5:24 PM, Resident #1's physician said there was nothing the facility could do with him at the time of discharge to the hospital on [DATE]. He said he did not have a note in the electronic medical record because the facility staff member (unsure of name) called him at night, and he instructed the facility to send Resident #1 to the hospital to be evaluated and stabilized. The physician said he would have expected the facility to re-evaluate Resident #1 for him to return to the facility. He said he believed Resident #1 could have been stabilized and returned to the facility, but he was unsure if the corporate office would accept him back because the facility was scared due to previous tags. The Physician said the facility placed Resident #1 at risk for other facilities not to accept him due to behaviors. <BR/>Record review of facility's Policy for Transfer and discharge date d June 2022 indicated:<BR/>It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances .<BR/>Policy Explanation and Compliance Guidelines:<BR/>1. <BR/>The facility will evaluate and determine the level of care needed for the resident prior to admission to the facility's ability to meet resident's needs. <BR/>2. <BR/>Once admitted , the resident has the right to remain in the facility unless their transfer or discharge meets one of the following specified exemptions:<BR/>a. <BR/>The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .<BR/> 12. Emergency Transfer/Discharges- initiated by the facility for medical reasons to an acute care setting such as a hospital, for immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified).<BR/>a. Obtain a physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis .<BR/>h. The Social Services Director, or designee, will provide copies of emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as list meets all requirements for content if such notices.<BR/>i. The resident will be permitted to return to the facility upon discharge from the acute care setting .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after the facility completed the resident's assessment for 2 of 2 residents reviewed for MDS assessments. (Resident #32 and 65)<BR/>The facility failed to transmit to the CMS system Resident #32 's discharge MDS assessment dated [DATE]. <BR/>The facility failed to transmit to the CMS system Resident #65 's discharge MDS assessment dated [DATE]. <BR/>This failure could place the residents at risk for not having the MDS assessment transmitted as required.<BR/>Findings included:<BR/>A review of Resident #65's face sheet dated 08/16/23 reflected a [AGE] year-old female. She was re-admitted to the facility on [DATE]. #65 was discharged on 4/12/2023 which reflected that the MDS record was over 120 days old.<BR/>A review of Resident #32's face sheet dated 08/16/23 reflected a [AGE] year-old female. She was admitted to the facility on [DATE]. Resident #32 was discharged on 4/13/23 which reflected that the MDS record was over 120 days old. Review of the electronic MDS tab for Resident #32 revealed the admission MDS was dated 03/17/2023. The admission MDS status reflected incomplete, assessment was never added to a batch, meaning the assessment had not been electronically transmitted to CMS<BR/>An interview with the MDS Nurse on 08/15/23 at 1:28 pm revealed she was responsible for ensuring the MDS was completed and transmitted. The MDS Nurse revealed the Admissions MDS should have been completed and transmitted by the 14th day. The MDS nurse revealed the annual MDS for Residents #32 and #65 had not been completed and transmitted. She stated the reason the MDS had not been completed and transmitted she said she was not the full time MDS Nurse and she was filling in until the facility obtained a full time MDS Nurse. She said she that the MDS had not been set up correctly in the system to be transmitted. When asked for a policy she said they just follow the Resident Assessment Instrument (RAI) guidelines.<BR/>An interview with the ADM on 08/15/23 at 2:12 pm revealed he was not aware Resident #65 and #32 MDS had not been completed and transmitted, he said he was not the administrator at that time and It was the responsibility of the MDS nurse to complete and transmit the MDS.<BR/>During an interview with the DON on 08/15/2023, she said the facility did not have a full time MDS Coordinator.

Based on observation, interview, and record review, the facility failed to post the daily nurse staffing data at the beginning of the shift, in a prominent place, and readily accessible to residents and visitors that included the facility name, the number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care for 4 of 4 days reviewed for nurse staffing data. <BR/>The facility failed to post the required nurse staffing information 08/14/2023, 08/15/2023, 08/16/2023, and 08/17/2023. <BR/>This failure could place residents and visitors at risk for not having access to nurse staffing information and census. <BR/>Findings included:<BR/>During observation on 08/14/2023 at 11:00 AM, the nurse staffing data for 08/14/2023 was not noted to be posted anywhere in the facility.<BR/>During observation on 08/15/2023 at 09:00 AM, the nurse staffing data for 08/15/2023 was not noted to be posted anywhere in the facility.<BR/>During observation on 08/16/2023 at 08:45 AM, the nurse staffing data for 08/16/2023 was not noted to be posted anywhere in the facility.<BR/>During observation on 08/17/2023 at 11:45 PM AM, the nurse staffing data for 08/17/2023 was not noted to be posted anywhere in the facility.<BR/>During interviews on 08/17/2023 at 12:10 PM with the DON and Staffing Coordinator, the DON said the Staffing Scheduler was responsible for ensuring the nurse staffing data was posted. <BR/>The Staffing Coordinator said she was sorry the staffing data was not posted and provided no reason why it was not. <BR/>A review of the facility's policy dated 07/2022 and titled Nurse Staffing Posting Information indicated:<BR/>1. The Nurse Staffing Sheet will be posted on a daily basis .<BR/> 2. The facility will post the Nurse Staffing Sheet at the beginning of each shift .and<BR/> 3.b. In a prominent place readily accessible to residents and visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review Level 1(PASRR) Screening for 2 of 5 residents reviewed for PASRR (Resident #36 and #57).<BR/>The facility failed to ensure Resident #36 had an accurate PASRR Level 1 Screening indicating a diagnosis of mental illness on 9/20/2021. <BR/>The facility failed to ensure Resident #57 had an accurate PASRR Level 1 Screening indicating a diagnosis of mental illness on 5/10/2023. <BR/>These failures could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 04/10/2024 indicated Resident #36 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder, depression, and seizures. <BR/>Record review of the significant change MDS assessment dated [DATE] indicated, Resident #36 had a BIMS score of 11 (eleven) indicating mildly impaired cognition. The MDS section for PASRR (A1500) indicated Resident #36 did not have a serious mental illness. The MDS Section I, Psychiatric/Mood Disorder, indicated Resident #36 had diagnoses of depression and bipolar disorder. Section N of the same MDS assessment indicated Resident #36 had received antidepressants and anxiolytic medications for 7 of 7 days of the assessment period. <BR/>Record review of the quarterly MDS assessment dated [DATE] indicated, Resident #36 had a BIMS score of 11 (eleven) indicating mildly impaired cognition. The MDS Section I, Psychiatric/Mood Disorder, indicated Resident #36 had diagnoses of depression and bipolar disorder. Section N of the same MDS assessment indicated Resident #36 had received antidepressants and anxiolytic medications for 7 of 7 days of the assessment period. <BR/>Record review of Resident #36's PASRR Level 1 Screening completed on 09/20/2021 indicated in section C0100 there was no evidence of this individual having mental illness.<BR/>2. Record review of a face sheet dated 04/10/2024 indicated Resident #57 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and anxiety disorder. <BR/>Record review of the admission MDS assessment dated [DATE] indicated, Resident #57 had a BIMS score of 03 (three) indicating severely impaired cognition. The MDS section for PASRR (A1500) indicated Resident #57 did not have a serious mental illness. The MDS Section I, Psychiatric/Mood Disorder, indicated Resident #57 had diagnoses of depression and bipolar disorder. Section N of the same MDS assessment indicated Resident #57 had not received antipsychotic or anxiolytic medications for 7 of 7 days of the assessment period.<BR/>Record review of the quarterly MDS assessment dated [DATE] indicated, Resident #57 had a BIMS score of 03 (three) indicating severely impaired cognition. The MDS Section I, Psychiatric/Mood Disorder, indicated Resident #57 had diagnoses of depression and bipolar disorder. Section N of the same MDS assessment indicated Resident #57 had not received antipsychotic or anxiolytic medications for 7 of 7 days of the assessment period. <BR/>Record review of Resident #57's PASRR Level 1 Screening completed on 06/14/2023 indicated in section C0100 there was no evidence of this individual having mental illness.<BR/>During an interview on 09/25/2024 at 3:25 PM, the MDS nurse said the MDS department was responsible for PASRR functions. She said the MDS nurse was assigned the task of reviewing the Level 1 PASRRs to ensure accuracy and appropriate follow-up actions. She said the person who would have reviewed Resident #36's PASRR I was no longer working at the facility. She said the LA should have been notified of the inaccurate PASRR Level I. The MDS nurse said the LA should have been notified of Resident #57s incorrect PASRR Level I also. The MDS Nurse said she understood the importance of PASRR Level 1 Screenings being accurate because the facility needed to make sure eligible residents were getting the correct resources.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical needs for 1 of 6 residents (Resident #3) reviewed for care plans. <BR/>The facility failed to ensure Resident #3's care plan was updated when she completed her vitamin C, multivitamin with minerals, and zinc (supplements for wound care). <BR/>This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life.<BR/>Findings Included: <BR/>1. Record review of the face sheet dated 3/25/25 indicated Resident #3 was admitted to the facility on [DATE] with diagnoses including pressure ulcer of the sacral region, dementia, and multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves).<BR/>Record review of the physician orders dated 3/25/25 indicated Resident #3 did not have an order for vitamin C, multivitamin with minerals, or zinc.<BR/>Record review of the MDS dated [DATE] indicated Resident #3 understood others and was understood by others. The MDS indicated Resident #3 had a BIMS score of 11 and was moderately cognitively impaired. The MDS indicated Resident #3 had I unhealed stage 4 pressure ulcer that was present on admission/entry or reentry. The MDS indicated Resident #3 was receiving nutrition or hydration intervention to manage skin problems. <BR/>Record review of the care plan last revised 10/28/24 indicted Resident #3 had actual impairment to skin integrity of stage 4 pressure injury to the coccyx (a small, triangular-shaped bone located at the bottom of the spine) with interventions including vitamin C 500mg twice a day, multivitamin with minerals, and zinc 50mg daily. <BR/>Record review of the nurse progress note dated 3/15/25 indicated Resident #3 was sent to the ER due to a critical low hemoglobin (a protein found in red blood cells that carries oxygen throughout the body).<BR/>During an observation and interview attempt on 3/21/25 at the hospital Resident #3 was unable to be observed or interviewed due to having the physician in the room examining her at the time of the state surveyor's visit.<BR/>During an interview on 3/25/25 at 11:43 a.m. the DON said the facility did not have a policy specific to physician orders.<BR/>During an interview on 3/25/25 at 2:01 p.m. the DON said the facility had a protocol for supplements such as vitamins and zinc for wound care. The DON said the facility's protocol was for a resident with a wound to be on supplements for 90 days and then the resident could be re-evaluated to determine if the supplements needed re-instated or not. The DON said the Treatment Nurse was responsible for updating care plans related to skin issues. The DON said once a supplement had been completed, she expected the care plan to be updated to reflect the resident was no longer on the supplement or for the supplement to be re-instated. The DON said the importance of updating care plans was for accuracy and to ensure the care plan matched each residents' needs. <BR/>During an interview on 3/25/25 at 2:15 p.m. the Administrator said she expected care plans to be updated quarterly and as needed. The Administrator said the importance of updating care plans was to communicate a resident's needs and to ensure any changes in the residents' needs were documented for staff to know how to properly care for each resident. <BR/>Record review of the facility's Comprehensive Care Plans policy dated 7/2022 indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe at minimum the following: .f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's culture identity, as indicated .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical needs for 1 of 6 residents (Resident #3) reviewed for care plans. <BR/>The facility failed to ensure Resident #3's care plan was updated when she completed her vitamin C, multivitamin with minerals, and zinc (supplements for wound care). <BR/>This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life.<BR/>Findings Included: <BR/>1. Record review of the face sheet dated 3/25/25 indicated Resident #3 was admitted to the facility on [DATE] with diagnoses including pressure ulcer of the sacral region, dementia, and multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves).<BR/>Record review of the physician orders dated 3/25/25 indicated Resident #3 did not have an order for vitamin C, multivitamin with minerals, or zinc.<BR/>Record review of the MDS dated [DATE] indicated Resident #3 understood others and was understood by others. The MDS indicated Resident #3 had a BIMS score of 11 and was moderately cognitively impaired. The MDS indicated Resident #3 had I unhealed stage 4 pressure ulcer that was present on admission/entry or reentry. The MDS indicated Resident #3 was receiving nutrition or hydration intervention to manage skin problems. <BR/>Record review of the care plan last revised 10/28/24 indicted Resident #3 had actual impairment to skin integrity of stage 4 pressure injury to the coccyx (a small, triangular-shaped bone located at the bottom of the spine) with interventions including vitamin C 500mg twice a day, multivitamin with minerals, and zinc 50mg daily. <BR/>Record review of the nurse progress note dated 3/15/25 indicated Resident #3 was sent to the ER due to a critical low hemoglobin (a protein found in red blood cells that carries oxygen throughout the body).<BR/>During an observation and interview attempt on 3/21/25 at the hospital Resident #3 was unable to be observed or interviewed due to having the physician in the room examining her at the time of the state surveyor's visit.<BR/>During an interview on 3/25/25 at 11:43 a.m. the DON said the facility did not have a policy specific to physician orders.<BR/>During an interview on 3/25/25 at 2:01 p.m. the DON said the facility had a protocol for supplements such as vitamins and zinc for wound care. The DON said the facility's protocol was for a resident with a wound to be on supplements for 90 days and then the resident could be re-evaluated to determine if the supplements needed re-instated or not. The DON said the Treatment Nurse was responsible for updating care plans related to skin issues. The DON said once a supplement had been completed, she expected the care plan to be updated to reflect the resident was no longer on the supplement or for the supplement to be re-instated. The DON said the importance of updating care plans was for accuracy and to ensure the care plan matched each residents' needs. <BR/>During an interview on 3/25/25 at 2:15 p.m. the Administrator said she expected care plans to be updated quarterly and as needed. The Administrator said the importance of updating care plans was to communicate a resident's needs and to ensure any changes in the residents' needs were documented for staff to know how to properly care for each resident. <BR/>Record review of the facility's Comprehensive Care Plans policy dated 7/2022 indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe at minimum the following: .f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's culture identity, as indicated .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical needs for 1 of 6 residents (Resident #3) reviewed for care plans. <BR/>The facility failed to ensure Resident #3's care plan was updated when she completed her vitamin C, multivitamin with minerals, and zinc (supplements for wound care). <BR/>This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life.<BR/>Findings Included: <BR/>1. Record review of the face sheet dated 3/25/25 indicated Resident #3 was admitted to the facility on [DATE] with diagnoses including pressure ulcer of the sacral region, dementia, and multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves).<BR/>Record review of the physician orders dated 3/25/25 indicated Resident #3 did not have an order for vitamin C, multivitamin with minerals, or zinc.<BR/>Record review of the MDS dated [DATE] indicated Resident #3 understood others and was understood by others. The MDS indicated Resident #3 had a BIMS score of 11 and was moderately cognitively impaired. The MDS indicated Resident #3 had I unhealed stage 4 pressure ulcer that was present on admission/entry or reentry. The MDS indicated Resident #3 was receiving nutrition or hydration intervention to manage skin problems. <BR/>Record review of the care plan last revised 10/28/24 indicted Resident #3 had actual impairment to skin integrity of stage 4 pressure injury to the coccyx (a small, triangular-shaped bone located at the bottom of the spine) with interventions including vitamin C 500mg twice a day, multivitamin with minerals, and zinc 50mg daily. <BR/>Record review of the nurse progress note dated 3/15/25 indicated Resident #3 was sent to the ER due to a critical low hemoglobin (a protein found in red blood cells that carries oxygen throughout the body).<BR/>During an observation and interview attempt on 3/21/25 at the hospital Resident #3 was unable to be observed or interviewed due to having the physician in the room examining her at the time of the state surveyor's visit.<BR/>During an interview on 3/25/25 at 11:43 a.m. the DON said the facility did not have a policy specific to physician orders.<BR/>During an interview on 3/25/25 at 2:01 p.m. the DON said the facility had a protocol for supplements such as vitamins and zinc for wound care. The DON said the facility's protocol was for a resident with a wound to be on supplements for 90 days and then the resident could be re-evaluated to determine if the supplements needed re-instated or not. The DON said the Treatment Nurse was responsible for updating care plans related to skin issues. The DON said once a supplement had been completed, she expected the care plan to be updated to reflect the resident was no longer on the supplement or for the supplement to be re-instated. The DON said the importance of updating care plans was for accuracy and to ensure the care plan matched each residents' needs. <BR/>During an interview on 3/25/25 at 2:15 p.m. the Administrator said she expected care plans to be updated quarterly and as needed. The Administrator said the importance of updating care plans was to communicate a resident's needs and to ensure any changes in the residents' needs were documented for staff to know how to properly care for each resident. <BR/>Record review of the facility's Comprehensive Care Plans policy dated 7/2022 indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe at minimum the following: .f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's culture identity, as indicated .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical needs for 1 of 6 residents (Resident #3) reviewed for care plans. <BR/>The facility failed to ensure Resident #3's care plan was updated when she completed her vitamin C, multivitamin with minerals, and zinc (supplements for wound care). <BR/>This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life.<BR/>Findings Included: <BR/>1. Record review of the face sheet dated 3/25/25 indicated Resident #3 was admitted to the facility on [DATE] with diagnoses including pressure ulcer of the sacral region, dementia, and multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves).<BR/>Record review of the physician orders dated 3/25/25 indicated Resident #3 did not have an order for vitamin C, multivitamin with minerals, or zinc.<BR/>Record review of the MDS dated [DATE] indicated Resident #3 understood others and was understood by others. The MDS indicated Resident #3 had a BIMS score of 11 and was moderately cognitively impaired. The MDS indicated Resident #3 had I unhealed stage 4 pressure ulcer that was present on admission/entry or reentry. The MDS indicated Resident #3 was receiving nutrition or hydration intervention to manage skin problems. <BR/>Record review of the care plan last revised 10/28/24 indicted Resident #3 had actual impairment to skin integrity of stage 4 pressure injury to the coccyx (a small, triangular-shaped bone located at the bottom of the spine) with interventions including vitamin C 500mg twice a day, multivitamin with minerals, and zinc 50mg daily. <BR/>Record review of the nurse progress note dated 3/15/25 indicated Resident #3 was sent to the ER due to a critical low hemoglobin (a protein found in red blood cells that carries oxygen throughout the body).<BR/>During an observation and interview attempt on 3/21/25 at the hospital Resident #3 was unable to be observed or interviewed due to having the physician in the room examining her at the time of the state surveyor's visit.<BR/>During an interview on 3/25/25 at 11:43 a.m. the DON said the facility did not have a policy specific to physician orders.<BR/>During an interview on 3/25/25 at 2:01 p.m. the DON said the facility had a protocol for supplements such as vitamins and zinc for wound care. The DON said the facility's protocol was for a resident with a wound to be on supplements for 90 days and then the resident could be re-evaluated to determine if the supplements needed re-instated or not. The DON said the Treatment Nurse was responsible for updating care plans related to skin issues. The DON said once a supplement had been completed, she expected the care plan to be updated to reflect the resident was no longer on the supplement or for the supplement to be re-instated. The DON said the importance of updating care plans was for accuracy and to ensure the care plan matched each residents' needs. <BR/>During an interview on 3/25/25 at 2:15 p.m. the Administrator said she expected care plans to be updated quarterly and as needed. The Administrator said the importance of updating care plans was to communicate a resident's needs and to ensure any changes in the residents' needs were documented for staff to know how to properly care for each resident. <BR/>Record review of the facility's Comprehensive Care Plans policy dated 7/2022 indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe at minimum the following: .f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's culture identity, as indicated .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on interview and record review the facility failed to maintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision for 1 of 1 grievance book reviewed for clinical records. <BR/>The facility failed to follow their policy and maintain the grievance records for a period of no less than 3 years from January 2020 to October 31, 2023.<BR/>This failure could place residents at risk for unresolved grievances which could lead to miscommunication, a delay in services or a potential decline in resident 's health.<BR/>Findings included:<BR/>Record review of facility's undated grievance binder revealed no documentation from January 2020 to October 31, 2023. <BR/>During an interview 12/15/23 at 3:48 p.m., the Administrator said someone from housekeeping tossed the previous grievance binder with all the grievances in the trash and he had to start over and made a new grievance binder and only had grievance records for November 2023.<BR/>During an interview on 12/18/23 at 12:20 p.m., the Housekeeping Supervisor said he did not remember the exact date, but the Administrator came to him regarding a missing grievance binder. The Housekeeping Supervisor said he asked the Administrator where was the grievance binder and he said the Administrator told him he sat the grievance binder on the trashcan in his office. The Housekeeping Supervisor said he asked the Administrator why he would place the grievance binder on top of a trashcan, because anyone would mistake it to be trash. The housekeeping supervisor said his housekeeping staff thought the grievance binder was trash and it was trashed and discarded in the onsite trash compactor (a self-contained, motorized device that compresses/crushes the garbage inside its bin).<BR/>During an interview 12/18/23 at 4:03 p.m., the Administrator said he was the Grievance Official. He said he normally kept the grievance binder on his bookshelf in his office, but he had recently used the binder and had not put it back at that time. The Administrator said he left the facility to go run an errand and sat the grievance binder on top of his office trashcan located underneath his office desk and planned on putting the grievance binder back onto his bookshelf whenever he returned. He said whenever he returned from his errands, he immediately realized the grievance binder was missing. The Administrator said he did not know how long the grievance records were to be maintained. <BR/>Record review of Resident and Family Grievances Policy dated 2023 indicated It is the policy of the facility to support each resident's and family member's rights to voice grievances without discrimination, reprisal or fear of discrimination .2)The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordination with state and federal agencies as necessary in light of specific allegations . 11) Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 1 of 3 residents (Resident #1) reviewed for comprehensive MDS assessment timing.<BR/>The facility failed to complete Resident #1's admission MDS assessment within 14 days of admission. <BR/>This failure could place residents at risk of not having their needs met.<BR/>The findings included:<BR/>Record review of Resident #1's face sheet, dated 04/02/2023, revealed Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia (occurs when disease of the heart or lungs leads to failure to maintain adequate blood oxygen levels), cognitive communication deficit (difficulty with thinking and how someone uses language), and paraplegia (impairment in motor (movement) or sensory (feeling) function of the lower extremities).<BR/>Record review of Resident #1's comprehensive MDS assessment, dated 03/24/2023, revealed it had not been completed. The MDS assessment should have been completed on 03/30/2023. The MDS assessment was 3 days late. <BR/>During an interview on 04/02/2023 at 11:21 AM, MDS Nurse G stated she was responsible for ensuring Resident #1's admission MDS assessment was completed. MDS Nurse G stated the MDS assessment was completed but it was not signed by the RN. MDS Nurse G stated it had not been closed yet. MDS Nurse G stated she had been sick and had requested more records, so she was unable to complete it. MDS Nurse G stated it should have been completed on 03/30/2023. MDS Nurse G stated it was important to complete comprehensive MDS assessments in a timely manner because it was an assessment and would help develop the care plan. <BR/>During an interview on 04/02/2023 at 11:33 AM, the DON stated MDS assessments should be completed within 14 days of admission. The DON stated she expected the MDS nurses to ensure MDS assessments were completed timely and was unsure why Resident #1's MDS was late. The DON stated completed MDS assessments timely was important, so the staff have a care plan to follow to take care of residents. <BR/>During an interview on 04/02/2023 at 11:41 AM, the Administrator stated he expected MDS assessments to be completed timely. The Administrator stated this was monitored by asking about MDS assessments daily in the morning meeting. The Administrator stated it was important because it was regulatory. <BR/>Review of the CMS RAI Version 3.0 Manual, dated October 2019, revealed, in Chapter 2, page 2-16, admission (Comprehensive): MDS Completion Date must be completed no later than 14th calendar day of the resident's admission (admission date + 13 calendar days)

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 smoking area reviewed.<BR/>The facility failed to ensure cigarette butts were disposed of appropriately, the red trash can, and ashtrays were kept free of trash, and the ashtrays were in safe functioning order. <BR/>These failures could place the residents at risk for injury and fire.<BR/>The findings included:<BR/>During an observation on 04/01/2023 at 9:05 AM, there were 15 red-tipped cigarette butts observed in the courtyard. There were 2 ashtrays, a stand-alone ashtray, and a tabletop ashtray. The stand-alone ashtray had several soda cans, a plastic food container, and several empty boxes of cigarettes with the plastic on them. The tabletop ash tray had the bottom rusted out and had attempted to have been taped back together with gray duct tape. There were 2 red trash cans. One red trash had several soda cans and an empty cigarette box with the plastic on it.<BR/>During an observation on 04/01/2023 at 9:54 AM, there were 15 red-tipped cigarette butts observed in the courtyard. There were 2 ashtrays, a stand-alone ashtray, and a tabletop ashtray. The stand-alone ashtray had several soda cans, a plastic food container, and several empty boxes of cigarettes with the plastic on them. The tabletop ash tray had the bottom rusted out and had attempted to have been taped back together with gray duct tape. There were 2 red trash cans. One red trash had several soda cans and an empty cigarette box with the plastic on it.<BR/>During an observation on 04/02/2023 at 9:55 AM, the stand-alone ashtray had several soda cans, a pair of gloves, and several empty boxes of cigarettes with the plastic on them. The tabletop ash tray had the bottom rusted out and had attempted to have been taped back together with gray duct tape. There were 2 red trash cans. One red trash had several soda cans, an empty chip package, and an empty cigarette box with the plastic on it. There were 11 red-tipped cigarette butts on the ground.<BR/>During an interview on 04/02/2023 at 10:31 AM, Housekeeper H stated he had worked at the facility for 7 years. Housekeeper H stated housekeeping staff was responsible for ensuring cigarette butts were not on the ground, trash was not in the ashtrays, and trash was not located in the red trashcans. Housekeeper H stated he tried to empty the ashtrays and sweep the cigarette butts up approximately 3 times a day. Housekeeper H stated the staff became busy and they do not always have a set schedule. Housekeeper H stated the last time he emptied the ashtrays and swept the ground was around 7:00 AM. Housekeeper H stated the tabletop ashtray had the bottom rusted out and duct tape applied for approximately 3 months. Housekeeper H stated it was important to make sure trash was not in the ashtrays, ashtrays were in good condition, and cigarette butts were not on the ground because it was a fire hazard. <BR/>During an interview on 04/02/2023 at 10:55 AM, the DON stated she expected staff to ensure no trash was found in the ashtrays, red trashcans, cigarette butts were discarded appropriately, and oxygen tanks were not allowed outside. The DON stated either housekeeping or maintenance was responsible for ensuring the facility had a safe smoking environment. The DON stated it was important because she did not want a fire to happen. <BR/>During an interview on 04/02/2023 at 11:41 PM, the Administrator stated he expected the facility staff to ensure the smoking environment was safe. The Administrator stated trash should not have been in the ashtrays, the red trash cans, cigarette butts should not have been on the ground and oxygen tanks should not have been brought into the smoking area. The Administrator stated it should have been monitored by housekeeping staff, maintenance, or any staff that observed it. The Administrator stated it was important to avoid a fire.<BR/>Record review of the Resident Smoking policy, updated in 03/2023, revealed This facility provides a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. The policy further revealed 2. Safety measures for the designated smoking area will include, but no limited to b. Provision of ashtrays made of noncombustible material and safe design. c. Accessible metal containers with self-closing covers into which ashtrays can be emptied.