Denton Village by PureHealth

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure the resident had the right to be free from neglect as defined in this subpart for one (Resident #1) of six residents reviewed for neglect. 1. On [DATE] LVN B failed to notify Resident #1's doctor or hospice provider after she checked Resident #1's BS level of 576; and on [DATE] and [DATE] LVN B failed to notify Resident #1's doctor or hospice provider after she checked Resident #1's BS levels over 600. 2. On [DATE] and [DATE] the facility failed to ensure Resident #1 was given his dayshift dose of his diabetic Metformin medications to prevent his BS level from getting higher and on [DATE] the facility failed to ensure Resident #1 received his dayshift dose of his potassium chloride medication. (There was no evidence provided that the facility contacted the pharmacy, doctor, hospice or obtained the medications from the E-kit or checked Resident #1's BS Levels). 3. On [DATE] RN A failed to check Resident #1's BS after Resident #1 fell to the floor and injured his head, it was unknown what his BS level was. Subsequently, Resident #1 was sent to the hospital [DATE] and was admitted for having a ground level fall, SAH (Subarachnoid hemorrhage- (Brain bleed), hypotension (low blood pressure) and BS level of 812 (very high). On [DATE] Resident #1 passed away. An Immediate Jeopardy (IJ) was identified on [DATE]. An IJ Template was provided to the facility on [DATE] at 5:00 pm. While the Immediate Jeopardy was removed on [DATE] at 5:57 pm, the facility remained out of compliance at a scope of pattern with a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place all diabetic residents at risk of not getting their medications which could cause increased BS levels to be untreated and result in nerve damage, eye disease, diabetic coma, or death. Findings included: Record review of Resident #1's Hospice Patient Fact report dated [DATE] revealed, Metformin ER 500 extended release 24 hr start date [DATE] (no end date). 500 mg take 1 tab by mouth twice daily at breakfast and dinner oral. Insulin glargine, human recombinant analog U-100 insulin 100 start date [DATE] (no end date). 100 unit/ml (3 ml) inject 6 units subcutaneous at dinnertime once a day subcutaneous. Reason for medication: Diabetes. Record review of Resident #1's admission MDS assessment dated [DATE] revealed an [AGE] year-old male who admitted [DATE] from home, had a BIMS score of 00 (Severe cognitive impairment) and active diagnoses that included debility and cardiorespiratory conditions. His diagnoses were heart failure, peripheral vascular disease (circulation disorder), renal insufficiency (Poor kidney function), acute chronic systolic (congestive) heart failure. He had repeated falls, and a cognitive communication deficit. He had no pain issues but had a fall in the last 2-6 months prior to admission and had a swallowing disorder. His weight was 155 pounds and was on a mechanically altered diet. He received five insulin injections in the past seven days, oxygen therapy and hospice care. Resident #1 had an overall goal for discharge and was established to return to the community with family. (He had no diabetic or seizure diagnoses). Record review of Resident #1's Care Plan dated [DATE] revealed he had a cognitive communication deficit, acute on chronic systolic (congestive) heart failure, stage 3 chronic kidney disease (Kidney function loss), peripheral vascular disease, risk for falls - repeated falls. On [DATE] he had a urinary tract infection, terminal prognosis, and was under hospice care. Further review revealed there was no care plan related to diabetes. Record review of Resident #1's [DATE] Physician's Orders dated [DATE] by Doctor F revealed, Insulin subcutaneous solution 100 unit/ml inject 8 unit subcutaneously at bedtime for diabetes (start [DATE] - stop [DATE]). Metformin oral tablet give 500 mg by mouth two times a day for diabetes (start [DATE] - stop [DATE]). Potassium Chloride extend release 10 MEQ give 1 tablet by mouth one time a day for potassium replacement (start [DATE]- [DATE]). (There was no physicians order to check his BS twice per day as Doctor ordered by NP Q). Record review of Resident #1's [DATE] MAR dated on [DATE] by MA I revealed, his 10 MEQ potassium chloride Extended release was not given and coded 9 other/see progress notes. On [DATE] and [DATE] his 500 mg metformin was not given and coded 9 other/see progress notes. Record review of Resident #1's Vitals Section for blood sugar dated [DATE] at 9:12 am by RN A revealed his BS level was 212. Further review revealed there was no other BS level readings in this section. Record review of Resident #1's Nurses note dated [DATE] at 7:31 pm by LVN B revealed, Insulin subcutaneous solution 100 unit/ml - inject 8 units subcutaneously at bedtime for diabetes. BS 576!! Further review revealed no documented evidence his doctor or hospice provider was notified of Resident #1's BS level. Record review of Resident #1's Nurses note dated [DATE] at 8:52 pm by LVN B revealed, Resident resting in bed with eyes closed with TV (television) on. No visible signs of distress noted. Took pt's blood sugar prior to administering of his HS insulin. Blood sugar came back above 600. Administered order for 8 units of long acting. No orders for sliding scale insulin. Bed in lowest position and call light within reach. Further review revealed no documented evidence his doctor or hospice provider was notified of Resident #1's BS level or that it had been rechecked that day. Record review of Resident #1's Nurses note dated [DATE] at 9:27 am by MA I revealed, Metformin oral tablet 500 mg - give 500 mg by mouth two times a day for diabetes not available nurse notified. And at 9:45 am Potassium chloride ER tablet extended release 10 MEQ - give 1 tablet by mouth one time a day for potassium replacement, not available nurse notified. Record review of Resident #1's Nurses note dated [DATE] at 8:03 pm by LVN B revealed, Insulin subcutaneous solution 100 unit/ml - Inject 8 unit subcutaneously at bedtime for Diabetes. Blood sugar reading was over 600. Further review revealed no documented evidence his doctor or hospice provider was notified of Resident #1's BS level or that it had been rechecked that day. Record review of Resident #1's Nurses note dated [DATE] at 12:14 pm by MA I revealed, Metformin oral tablet 500 mg - give 500 mg by mouth two times a day for diabetes, not available nurse notified. Record review of Resident #1's Nurses note: Change in Condition report dated [DATE] at 8:00 am by RN A revealed, Falls - BP 103/64 and Blood glucose: BS 212 - [DATE] at 9:21 am. Further review revealed there was not a current BS level documented on [DATE]. Record review of Resident #1's Incident report dated [DATE] at 8:00 am revealed by RN A, Called in by CNA that patient was on the floor bleeding. On assessment patient found on the floor with skin tear to forehead. Nurse ask what had happened and was told the patient got out of chair and try to walk and fell to the floor. Nurse ask patient andall [sic] he stated he needs water to drink. Thicken water given to patient and he calm down. Skin tear noted to forehead and arm. Will continue to monitor. Was the incident witnessed No, neuro checks, vitals, monitor frequently, floor mat, pressure apply to patient forehead [sic]. Record review of the Resident #1's Paramedic's Patient Care record dated [DATE] revealed, a call was made at 10:25 am and at 10:31 at the facility. At 10:33 am he had a hematoma and laceration / abrasion on left side of forehead and at 10:39 am his clinical impression was altered mental status and diabetic hyperglycemia. His chief complaint Fall - altered mental status - hyperglycemia. There was a blunt injury (medical and trauma) and at 10:40 am he was given saline IV therapy and at 10:41 am his blood glucose was high. He had a Glasgow coma score <= 13 (mild traumatic brain injury) and Resident #1 was transported to the emergency room hospital. Record review of Resident #1's Hospital records revealed he was admitted on [DATE] in critical condition for a ground level fall, (primary diagnosis) subarachnoid hemorrhage and hypotension. His glucose (BS) level was 812 (critically high), HPI [AGE] year-old male with advance dementia, diabetes, CAD s/p.A-fib on Eliquis, PAD, CAD, CKD3 presented on 10/29[2025] after a ground level fall was found to have subarachnoid hemorrhage (brain bleed) and uncontrolled blood sugars possibly in hyperosmolar hyperglycemic syndrome (Very high BS for a long period of time). Patient remined in persistent shock, likely cardiogenic. Record review of Resident #1's Hospital deceased Discharge summary dated [DATE] revealed his discharge diagnoses HHS (extremely high blood sugar level), T2DM (type 2 diabetes), Cardiogenic shock (inadequate blood flow to organs), SAH (brain bleed), Ground level fall, acute encephalopathy (sudden severe brain disorder), NSVT (irregular fast heartbeat), PVC's (extra early heartbeats) , Chronic AF (irregular heartbeat), CHF (heart not pumping blood regularly), AK (sun exposure skin lesions)on CKD (kidney damage). Time of death 7:38 pm. Interview on [DATE] at 2:23 pm, RN A stated Resident #1 was at this facility for a few days for a short stay while the FM had a procedure. She stated Resident #1 had no falls until the morning of [DATE] when they were getting the residents into the dining room for breakfast and during that time Resident #1 fell in the dining room. She stated she was not in the dining room and was gone for about 10 minutes at the time but heard Resident #1 got up from his wheelchair and fell. She stated a dietary aide was in the dining room and told her about it and when she went to the dining room she saw Resident #1 on the floor, then she assessed him. She stated he had a small skin tear that was 0.2 cm. long on his forehead that bled and did not notice any knots. She stated Resident #1 was able to talk and he shook his head and asked for some water; and she then she put pressure on his head and the bleeding stopped. She stated she gave Resident #1 some water and then took his vitals and was BS checked but did not document them anywhere that were normal and said she believed Resident #1 got up and tried to walk and fell. She stated Resident #1 was fine and ate his breakfast. She stated Resident #1 was able to feed himself with a spoon and they just had to watch him eat. She stated after that he was taken to his room and sometime later he started having a change. She stated she called the FM, but the FM did not answer, and hospice did not answer. She stated Doctor F was already at the facility and he went to check on Resident #1 and told her to call hospice and to see what the family wanted to do. She stated she called hospice again and the DON tried to call the FM and still was not able to talk to anyone. She stated she was told the FM was having a medical procedure and the reason why there was no response. She stated Resident #1 had not vomited or had signs of aspiration, but MR Nurse G said he had seizure like activity. She stated hospice Nurse E arrived one or two hours later. She stated she did Resident #1's incident report. She stated Resident #1 was not on a sliding scale and was given an insulin long-acting injection at bedtime. She stated Resident #1 had a lot of medications and said he had not missed getting them. She stated he was a one person assist and was able to pivot with transfers and he was A/O x 1 meaning his cognition was not good. She stated Resident #1 had floor mats on both sides of his bed and his bed was in the lowest position. Interview [DATE] at 3:17 pm, LVN B stated on [DATE] she received a report about Resident #1 being taken to the hospital because he had a fall during the morning shift. She stated Resident #1 was a diabetic who took Metformin and also took insulin long-acting injections at night. She stated she took Resident #1's BS level before giving his insulin at night which ran pretty high. She stated she told Resident #1's hospice nurse about his 600 BS levels but could not remember the hospice nurse's name or if the hospice doctor was contacted. She stated she spoke to one of the ADON's and overnight charge nurse about his high BS level but was unsure of their names. She stated Resident #1 did not have a sliding scale and believed she spoke to Doctor F about his 600 BS, was not sure when but thought Doctor F told her to refer to Resident #1's hospice provider. She stated she did not remember reaching out to the FM over the phone or in person about his high BS and could not remember if she spoke to the DON about his high BS. She stated hearing that Resident #1 went to the hospital and had a brain bleed. Interview on [DATE] at 4:19 pm, CNA C stated on [DATE] she did not see what happened because she was getting the residents into the dining room for breakfast. She stated she was not Resident #1's CNA but Dietary Aide D said, oh look he fell and when she turned around she saw Resident #1 on the floor on his side. She stated RN A came to assist him and he had a skin tear on his forehead that bled from falling and bumping his head on the floor. She stated RN A washed the spot and put gauze on it. She stated Resident #1 bled a small amount that had eventually stopped, and he was his normal self. She stated after RN A assessed Resident #1, she helped the nurse get him back into his wheelchair. She stated Resident #1 stayed in the dining room and ate his breakfast, which he ate pretty good. She stated hearing Resident #1 went to the hospital later that day. Interview on [DATE] at 5:49 pm, Hospice ED H stated everything was secondhand information and said he had no conversations from the facility nurse [DATE]. He stated he heard Resident #1 fell the morning of [DATE], that he was left unattended and he fell and hit his head and was sent to the hospital. He stated Resident #1 had a brain bleed. He stated there were no concerns with Resident 1 not getting his medications but heard his BS level was pretty high and assumed he did not get his insulin doses. He stated Resident #1's FM supplied his insulin and blood pressure medications, and some were from the facility's pharmacy. He stated not being aware of Resident #1 having a skin tear on his forehead after he fell but he got involved when he was transferred to the hospital. He stated the facility was responsible for doing his BS checks. He stated he had not spoken to the facility about Resident #1's stay. Interview on [DATE] at 5:15 pm, the DON stated Resident #1 admitted to the facility on respite care. He stated Resident #1 fell in the dining room the morning of [DATE] and was able to consume his meal and drink. He stated Resident #1's ST on his forehead was 2 cm x 0.5 cm. He stated after he ate, Resident #1 had a seizure, then he was taken to his room. He stated they were waiting for hospice to let them know if they could send him to the hospital and RN A said she had called the hospice provider twice, but they were not responding. He stated around 9:00 am, he went in Resident #1's room to assess him, and he was not responding, and they could not get the FM on the phone. He stated he tried to call the FM without a response. Then the hospice nurse arrived, and Resident #1 was taken to the hospital. He stated management talked about Resident #1's fall in the dining room but was not aware Resident #1 missed getting his Metformin on [DATE] and [DATE]. He stated when a resident's insulin was too high he expected the nurses to call the resident's doctor to see if medication could be given to get their BS down. He stated he was not aware Resident #1's BS was over 600 while he was at this facility. He stated their Admissions Director AA checked on Resident #1 at the hospital and found out he was deceased . Interview on [DATE] at 5:40 pm, LVN B stated when Resident #1 admitted , the FM said she would be out and not able to communicate and they needed to talk to hospice for any concerns. She stated she would be unavailable while she was gone for a medical procedure. Interview on [DATE] at 6:15 pm, the DON stated Resident #1 did not have any discontinued medications prior to his discharge and saw on his MAR he did not get his dayshift Metformin for two days. He stated he was not aware that MA I documented Resident #1's Metformin was unavailable and would have to talk to her about what happened. He stated he was unaware of Resident #1's 600 BS levels and missed diabetic medications and would have to address that with the nursing staff. He stated he would have to check with the pharmacy and E-Kit to see if the medication was given and not documented. He stated it was strange that Resident #1 received his night doses of his Metformin [DATE] and [DATE] but not the dayshift ones. He stated Resident #1's [DATE] SBAR assessment automatically showed his [DATE] BS level 200 and was not sure why the [DATE] BS was not used. He stated Resident #1's vitals were checked and had asked RN A was his BS checked, and she said yes but it was not documented. He stated for the days prior to discharging, Resident #1 had 600 BS readings, and the nurses should have notified the doctor or hospice to possibly send the resident to the hospital. He stated he thought it was kind of strange for the nurses not to follow through by calling Resident #1's doctor or hospice provider for orders and rechecking his BS levels. He stated Resident #1 received long-acting insulin at night with the use of pen injector but there was not an order for his insulin levels to be checked. He stated before Resident #1 went to the hospital RN A should have checked his BS level but failed to document it because if it was not documented it was not done. Interview on [DATE] at 9:20 am, Dietary Aide D stated she worked the morning of [DATE] when Resident #1 fell. She stated Resident #1 fell around 8:00 am and that breakfast had not started yet. She stated the staff were bringing the residents into the dining room. She stated she was putting drinks on the tables and there was a CNA standing at a table with her back to the residents sorting meal tickets. She stated Resident #1 was sitting in his wheelchair and then she heard a noise and Resident #1 said Ouch' after he slammed down to the floor so hard. She stated Resident #1 had an abrasion on his forehead that was bleeding. She stated RN A came to the dining room and cleaned him up. She stated there were other residents in the dining room. She stated his forehead was not bleeding a lot and the nurse was able to get it to stop bleeding, and Resident #1 ate his breakfast. She stated one resident asked why 911 was not called, and something was mentioned about hospice, and the nursing staff waited until after breakfast then took him to his room. Interview on [DATE] at 9:44 am, Hospice Nurse E stated she was on call and closest to Resident #1 when they received the call about Resident #1's fall. She stated she was not sure when she arrived because she did not have Resident #1's record on her to review. She stated whatever the time was she asked the staff why they were not called sooner. She stated RN A said Resident #1 fell and hit his head and had a seizure and when she arrived Resident #1 had a large bump on the left side of his forehead. She stated Resident #1's pupils were not responsive to light and his BP was not normal and low for him. She stated her main focus was Resident #1's internal bleeding because he was not responsive which meant he was bleeding on the inside of his brain. She stated Resident #1 had a brain bleed that the facility should have called them about sooner. She stated after she assessed Resident #1 she called the FM and was told to have Resident #1 sent to the hospital. She stated she spoke to RN A again for him to get transferred to the hospital and during the time she was there he did not vomit or seizure, but it was reported from the facility nurse he vomited and had a seizure before she arrived. She stated not being aware of his BS levels being 600 a few times since being at the facility. She stated when Resident #1 admitted to the hospital his BS level was 820 or 830 and was not sure why it was so high because he took diabetic medications at the facility. She stated hospice could order Resident #1's diabetic medications but did not manage it and that was the responsibility of the facility to do. She stated a sliding scale could have been initiated if they were notified of the BS issue. She stated missing one day dose of diabetic medication would definitely make a person's insulin go up. She stated Resident #1 was not getting sliding scale insulin at home because the FM did a lot of dietary management of his meals and drinks. Interview on [DATE] at 10:33 am, the FM stated Resident #1 admitted to the facility for respite care while they had a procedure and gave all of Resident #1's medications to the facility. They stated they were not told about Resident #1's 600 BS levels. They stated they received a call from Hospice Nurse E on [DATE] about Resident #1's complications from falling. They stated they told Hospice Nurse E to have Resident #1 sent to the hospital and the hospice nurse followed them to the hospital. They stated the hospital said his BS level was 840, she believed. They stated had Resident #1's BS been checked it would not have been that high and could not believe not one person noticed how high it was. They stated the Medical Examiner talked to them about Resident #1's fall and the condition of his body and his high BS. They stated they thought Resident #1 was being put in a good place and wondered how did he fall, why was he feeding himself and had so many questions. They stated they felt bad because they were not at the facility to have kept him from falling. They stated the day before [DATE] they had a video phone call with Resident #1, and he looked fine, but now he was deceased . They stated Hospice Nurse E said once she (Hospice Nurse E) arrived Resident #1 had started having a seizure and Hospice Nurse E suspected he had a brain bleed. They stated they did not have any missed calls from the facility. Interview on [DATE] at 10:58 am, Hospice Nurse J stated she was Resident #1's nurse who saw him twice and there were no reports of his BS level increasing. She stated he took diabetic medication but did not have sliding scale orders because his insulin levels were normal at home. Interview on [DATE] at 11:31 am, the Administrator stated Resident #1 fell [DATE] around 8:00 am and was a hospice patient. She stated their facility called his hospice provider and when they arrived he was sent to the hospital. She stated the facility notified Facility Doctor F immediately after Resident #1 fell from what she understood. She stated there were a few calls made to his hospice provider and hospice finally came out and evaluated Resident #1. She stated her staff assessed Resident #1 and notified Doctor F and they did everything they were supposed to do. She stated that she knew of Resident #1 did not go without any of his medications. She stated she was not aware Resident #1 had BS readings over 600 and did not receive his dayshift Metformin on [DATE] and [DATE] at the facility. She stated maybe he was given the Metformin from the E-kit and the staff did not document it. She stated the nurse might have pulled the diabetic medication out of the E-kit for Resident #1. She stated she was not aware the hospital said his BS was over 800 and stated he passed away two or three days after he discharged from the facility. She stated she did not investigate or report the incident to HHSC because of the new provider letter on reporting falls and deaths. Interview on [DATE] at 11:52 am, the DON stated he spoke to MA I who said she did not give Resident #1 two doses of his Metformin on [DATE] and [DATE] which was why she documented it was unavailable and notified the nurse, in the progress note. He stated MA I told him the Metformin was unavailable and thought the nurse may have reached out to the pharmacy or hospice provider. He stated not being sure how Resident #1 ran out of the Metformin that came with the resident and said he had one diabetic pill he took 1xd, Metformin 2xd and a long-acting insulin at bedtime. He stated Resident #1 did not have any type of diabetic monitors on him. He stated if the medication was still not available after two times MA I should have notified him or one of the ADONs to get the medication. He stated if Resident #1's BS levels were elevated LVN B should have called hospice since she was checking it. He stated LVN B said she was checking Resident #1's BS because she did not see anyone doing it and LVN B should have notified the hospice provider when Resident #1's BS was over 600. He stated he was not sure if LVN B called the doctor/NP about Resident #1's elevated BS levels but she should have notified his hospice provider to get further orders. He stated he did not see any documentation from the nurses notifying the hospice provider about Resident #1's elevated BS and what the hospice nurse said. He stated he saw concerns for the nurse's failure to document more thoroughly and give Resident #1 all of his Metformin. He stated there was a lot of confusion for getting more of his Metformin and that he should have been notified and his doctor and hospice and that did not happen. He stated if he had known Resident #1 was out of Metformin, he would have gotten it from their pharmacy. He stated two missed dosages could have a detrimental effect on a resident by increasing their BS even though he was taking two other diabetic medications. He stated he looked a lot at Resident #1's MARS and was not sure how he missed seeing Resident #1 did not get his Metformin. He stated he was not sure how the hospice provider policy was related to diabetic management and medication dispensing and would have to review it. He stated all the staff said Resident #1 stood up and fell and he said wanted some water. He stated because he was on hospice they notified hospice between 8:00 am and 9:00 am and talked to the answering service but not sure who RN A talked to. He stated being told the hospice provider was sending a nurse and after he received a report of Resident #1 having a seizure he thought about sending Resident #1 to the hospital, but did not know what hospice wanted to do. He stated not being aware Resident #1's BS was over 800 at the hospital but got word he had passed away from their Admissions Coordinator AA a few days after he discharged from the facility. He stated they did not know if the FM wanted him to go to the hospital and if Resident #1 were not on hospice he would have been sent right out to the hospital. Interview on [DATE] at 10:46 am, RN L stated when a resident had a 400 to 450 BS level they needed to contact the resident's provider. She stated normally residents taking diabetic medication had a sliding scale to give them a one-time order if their BS was too low or too high. She stated a 600 BS level was an emergency because that was way too high and needed immediate attention by calling the doctor. She stated high BS levels depended on the resident if they had some medical conditions or if they were on steroids that made their BS level so high. She stated if a resident's BS level was 600 she would first try to see what the resident's normal BS levels were and looked at their medical background then sought a treatment plan. She stated as a nurse they knew what they were supposed to do for high BS and if she did not hear from the doctor or hospice, she would see about getting the resident out to the hospital. She stated if a resident had a BS over 600 could depend on a lot and a resident could go into diabetic ketoacidosis (Acidic blood) and HHS (extremely high blood sugar levels). Interview on [DATE] at 10:55 am, MA M stated the nurses checked the diabetic residents' BS level. She stated when a resident ran out of medications she would first check everywhere and notify the nurse to see if it could be taken from the E-kit. She stated if the medication was not given she would document the medication was not available, notify the nurse if the medication was really not given. She stated if Metformin or blood pressure medications were not available it was very important for the nurse to get them from the E-kit and she would continue to notify the nurse that the medication was not available. She stated if the medication was not given after the second day would raise a concern and she would have to just continue to document the medication was unavailable, nurse notified. She stated she would press the issue with the nurse because Metformin was very important for the diabetic residents to received it and would ask if the nurse could she check the resident's blood sugar. She stated she would have to let Weekend Supervisor N know of the missing medication, if she were working weekends and if she worked during the week she would notify the DON. She stated the staff needed to control the resident's BS level with the medications prescribed. She stated a resident could go into a diabetic coma if their BS levels increased. She stated increased BS levels was emergent and needed to take control of this issue right away. Interview on [DATE] at 11:18 am, Weekend Supervisor N stated if a resident's diabetic medication were unavailable she would first check the E-kit or pharmacy and call family to assist. She stated Metformin was in their E-kit and on the outside of the E-kit, there was a list of what medications were in it. She stated if the medication was not in the E-kit she would get the medication from the pharmacy. She stated if a resident had a 600 BS level, she would first check to see if they had sliding scale insulin and if they did not she would call the doctor to get a doctor's order for a treatment. She stated she would of course assess the residents and monitor them and keep calling the doctor over and over again until the doctor was reached. She stated for a hospice resident she would follow the doctor's orders and if they did not have a sliding scale she would call hospice first and for no response she would call the resident's facility doctor. She stated she would notify the FM/RP about the 600 high BS if the resident was on hospice and would let the FM/RP know as well to get them to help with reaching out to hospice. She stated she would document everything in the resident's progress note for their attempts with whom she contacted at the hospice provider. She stated she would document why they were being contacted and who she spoke to and what the response was from the on-call office and hospice nurse. She stated once the hospice provider gave orders to treat she would document what the hospice provider said and made sure the orders were added to the orders for the next nurses to follow. She stated she would then follow through on the treatment plan and notify the next nurse what happened. She stated if there BS did not decrease it would be considered emergent, and she would call 911 and would definitely send the resident to the hospital then call the FM/RP and doctor or hospice provider. She stated if the resident did not get a treatment, they could go into diabetic ketoacidosis or a coma. She stated if a resident did not have medication she would document in the progress note and in the 24-hour report book and said if she noticed something needed to be taken care of that same day she would let the DON know about the situation. She stated she would follow the resident's sliding scale orders and administer the insulin needed for that BS level and would recheck their BS level a few minutes after giving it. She stated she would let the hospice nurse know about the 600 BS level and asked what did they need to do about it like giving a fast acting or smaller dose of insulin for example then rechecking the BS level 30 minutes later. She stated before sending a resident out she would do an assessment and check the resident's vitals including the BS and if they had a seizure she would review to

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure assessments accurately reflected the resident's status for one (Resident #27) of six residents reviewed for Accuracy of Assessments.<BR/>The facility failed to ensure Resident #27's Quarterly MDS Assessment accurately reflected that Resident #27 was on oxygen therapy.<BR/>This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.<BR/>Findings included:<BR/>Review of Resident #27's Face Sheet, dated 08/21/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Resident #27 was diagnosed with chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and pleural effusion (collection of fluid around the lungs).<BR/>Review of Resident #27's Quarterly MDS Assessment, dated 04/13/2024, reflected Resident #27 was cognitively intact with a BIMS score of 15. Resident #27's Quarterly MDS Assessment did not indicate that the resident was on oxygen therapy.<BR/>Review of Resident #27's Comprehensive Care Plan, dated 08/02/2024, reflected Resident #27 had oxygen therapy related to COPD and one of the interventions was oxygen therapy continuous. <BR/>Review of Resident #27's Physician Order, dated 07/27/2022, reflected O2 via nasal cannula 1-3L every shift.<BR/>Observation and interview with Resident #27 on 08/21/2024 at 9:37 AM revealed the resident was on her wheelchair, awake. She was on oxygen administration via nasal cannula at 2 to 3 liters per minute. According to Resident #27, she was on oxygen for years because sometimes she had a hard time breathing. <BR/>In an interview with the ADON on 08/22/2024 at 7:15 AM, the ADON stated if a resident was using oxygen, it should be reflected on the system to make sure all the needed respiratory care was given to the resident. She added there should be an accurate assessment to know how to care for the residents. The ADON said if there was no accurate assessment, there could be a misunderstanding about the care needed by the resident and the resident might not be able to get the treatment needed. She said she would coordinate with the DON and the MDS Nurse to address the issues.<BR/>In an interview with the DON on 08/22/2024 at 7:35 AM, the DON stated an accurate assessment was important so that the staff would know how to take care of the residents. He said the care plan of the residents would be based on the assessment. He said if a resident was using oxygen, it should be reflected on the medical diagnosis, physician orders, the MDS, and the care plan. He said if the residents were not properly assessed, the proper care and needs would not be met. The DON said the expectation was that the residents were properly assessed not only during admission but every day to see if there were changes in condition, any refusal of care, or a resident acting different than usual. He said he would collaborate with the MDS Nurse and the ADON to audit the MDS Assessments and make proper changes.<BR/>In an interview with the Administrator on 08/22/2024 at 7:53 AM, the Administrator stated the MDS should reflect the current condition of the resident. She said, by doing so, the needs of the residents would be addressed. She said she would coordinate with the DON to evaluate the situation, discuss it during quality assurance, and conduct in-services.<BR/>Observation and interview with MDS Nurse on 08/22/2024 at 8:16 AM, the MDS Nurse stated she was responsible in doing the MDS Assessment and the care plan. She said once the staff put in the initial order, it would take seven days before the MDS was triggered. She said the medical diagnosis, physician order, the MDS, and the care plan should be all in-line and should match to provide a clear overview of the resident's current condition. She turned on the computer and went to Resident #27's profile. The MDS nurse reviewed the date of the resident's order for oxygen. The resident's Physician order reflected that the order for oxygen was placed on the system last 07/27/2022. She then checked the resident's MDS and confirmed that the resident was not triggered for oxygen use. The MDS nurse said the MDS was used to make the care plan. She said if the MDS was not triggered, the care might be missed. She said she would make an audit to make sure the MDS would reflect the current condition of the residents.<BR/>Record review of facility policy, Resident Assessment (Comprehensive Assessment), LTC Rehab/Skilled & Long-Term Care: Therapy & Rehab revised 07/20/2023 revealed Purpose: To identify the resident's care needs . Procedure . during examination . any shortness of breath.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to, in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that were complete and accurately documented for one (Resident #1) of six residents reviewed for medical records. The facility failed to ensure Resident #1's face sheet and care plans were complete and accurate. Resident #1 was diagnosed with diabetes and took diabetic medications and he had no diabetes diagnosis on his facility's EMR records. This failure could place all residents at risk of inadequate care if all of their diagnoses were not included in the resident's EMR records, which could result in a decline in the resident's health and psych-social well-being. Findings included: Record review of Resident #1's Face Sheet dated 11/14/25 revealed an [AGE] year-old male who admitted [DATE] with diagnoses of Acute on chronic systolic (Congestive) heart failure, Peripheral vascular disease, stage 3 chronic kidney disease, repeated falls, and cognitive communicative deficit. (There was no diabetic diagnosis). Record review of Resident #1's Hospice Patient Fact report dated 10/17/25 revealed, Metformin ER 500 extended release 24 hr start date 04/25/25 (no end date). 500 mg take 1 tab by mouth twice daily at breakfast and dinner oral. Insulin glargine, human recombinant analog U-100 insulin 100 start date 07/16/25 (no end date). 100 unit/ml (3 ml) inject 6 units subcutaneous at dinnertime once a day subcutaneous. Reason for medication: Diabetes. Record review of Resident #1's admission MDS assessment dated [DATE] revealed an [AGE] year-old male who admitted [DATE] from home, had a BIMS score of 00 (Severe cognitive impairment) and active diagnoses that included debility and cardiorespiratory conditions. His diagnoses were heart failure, peripheral vascular disease (circulation disorder), renal insufficiency (Poor kidney function), acute chronic systolic (congestive) heart failure. He had repeated falls, and a cognitive communication deficit. He had no pain issues but had a fall in the last 2-6 months prior to admission and had a swallowing disorder. His weight was 155 pounds and was on a mechanically altered diet. He received five insulin injections in the past seven days, oxygen therapy and hospice care. Resident #1 had an overall goal for discharge and was established to return to the community with family. (He had no diabetic diagnosis). Record review of Resident #1's Care Plan dated 10/23/25 revealed he had a cognitive communication deficit, acute on chronic systolic (congestive) heart failure, stage 3 chronic kidney disease (Kidney function loss), peripheral vascular disease, risk for falls - repeated falls. On 10/24/25 he had a urinary tract infection, terminal prognosis, and was under hospice care. Further review revealed there was no care plan related to diabetes. Record review of Resident #1's October 2025 Physician's Orders dated 10/23/25 by Doctor F revealed, Insulin subcutaneous solution 100 unit/ml inject 8 unit subcutaneously at bedtime for diabetes (start 10/23/25 - stop 10/29/25). Metformin oral tablet give 500 mg by mouth two times a day for diabetes (start 10/23/25 - stop 10/29/25). Record review of Resident #1's October 2025 MAR revealed, Insulin Subcutaneous solution 100 unit/ml inject 8 unit subcutaneous at bedtime for diabetes and Metformin oral tablet 500 mg give 500 mg by mouth two times per day for diabetes (start 10/23/25 -10/29/25). Record review of Resident #1's Vitals Section for blood sugar dated 10/23/25 at 9:12 am by RN A revealed his BS level was 212. Further review revealed there was no other BS level readings in this section. Interviews on 11/18/25 at 4:20 pm, ADON Z stated the Admissions Director completed the resident's face sheets and the Regional MDS Coordinator K was responsible for completing the care plans. Interview on 11/18/25 at 4:46 pm, Regional MDS Coordinator K stated he was the Corporate MDS Coordinator and the former facility MDS Coordinator stopped working at this facility last month [October 2025]. He stated he was not aware of Resident #1's face sheets and Care Plans were inaccurate. He stated his role was to review the residents' documentation that reflected what the staff were documenting. He stated the IDT was responsible for reviewing and ensuring the residents' records were accurate and complete, He stated the DON reinforced that leadership had all the information for the residents and to report any issues that they needed to address. He stated he did not want to say what could happen to a resident if their medical records were not accurate and complete. Interview on 11/18/25 at 5:07 pm, the DON stated the MDS Coordinator was responsible for ensuring all the residents' diagnoses were on their face sheets. He stated he was not sure how that was missed and said not having all of the residents' diagnoses could cause a resident to get improper care or lack of care, which could run into several complications as the end result. Interview on 11/18/25 at 5:46 pm, the Administrator stated she was not sure why Resident #1's diagnoses were not on his face sheet and care plan because she was not a nurse to have been able to say that was missing. She stated the clinical leadership team was responsible for the accuracy of the residents' records and the hospice provider was responsible with ensuring they gave them accurate information. She stated the IDT was responsible for ensuring the resident's records were accurate. She stated she did not know how to answer the question on how it could affect the residents if their medical records were not accurate and correct, but they had a protocol they went by. On 11/18/25 at 5:35 pm the facility's medical record policy was requested and the Administrator stated she would provide it. On 11/19/25 at 2:18 pm the Administrator stated they did not have a one.

**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 care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #19) of thirteen residents reviewed for dignity.<BR/>The facility failed to treat Resident #19 with dignity and promote enhancement of her quality of life when the resident was not provided a privacy bag for her catheter bag.<BR/>This failure placed residents at risk of not having their right to a dignified existence maintained.<BR/>Findings included: <BR/>Review of Resident #19's Face Sheet, dated 08/21/2024, reflected that the resident was an [AGE] year-old female admitted on [DATE]. Resident #19 was diagnosed with neuromuscular dysfunction of bladder (the muscles and nerves that control the bladder do not work properly due to illness).<BR/>Review of Resident #19's Quarterly MDS Assessment, dated 07/13/2024, reflected Resident #19 was cognitively intact with a BIMS score of 13. The Quarterly MDS Assessment indicated that the resident had an indwelling catheter.<BR/>Review of Resident #19's Comprehensive Care Plan, dated 06/28/2024, reflected Resident #19 had an indwelling catheter related to neurogenic bladder (the normal bladder function is disrupted due to nerve damage) and one of the interventions was catheter care every shift.<BR/>Review of Resident #19's Physician Order, dated 11/07/2023, reflected CATHETER: Foley 18fr (French: unit used to indicate the size of the catheter) with 10 cc balloon to dependent drainage. Change catheter and drainage bag monthly on the 3rd, and prn one time a day every 1 month(s) starting on the 3rd for 1 day(s) related to NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED <BR/>AND as needed for patency.<BR/>Observation and interview with Resident #19 on 08/21/2024 at 6:30 AM revealed Resident #19 was in her bed, awake. Resident #19 had a catheter bag hanging at the railings below her bed. The urine inside catheter bag was observed visible from the hallway and upon entrance to the room. The catheter bag did not have a privacy bag. Resident #19 stated she had the catheter for the longest time because there was something wrong with her bladder. Resident #19 said she was not aware her catheter bag was exposed. Resident #19 said she did not know how long it had been exposed.<BR/>Observation on 08/21/2024 at 7:13 AM revealed Resident #19's catheter bag was still hanging on the railings below her bed. It still did not have a privacy bag. The content of the catheter bag was still visible from the hallway and upon entrance to the room.<BR/>In an interview with CNA C on 08/21/2024 at 7:15 AM, CNA C confirmed that Resident #19's catheter bag did not have a privacy bag. CNA C stated he saw it when he made his rounds, and he should have gotten a privacy bag as soon as he saw it. CNA C said the privacy bag was used so that the content of catheter bag wiould not be seen by other people. CNA C added that the privacy bag was used to prevent embarrassment. CNA C said he would get a privacy bag and put it on the railing below the bed. CNA C said the resident had a privacy bag on the wheelchair but then said there should also be a privacy bag when the resident was inside the room.<BR/>In an interview with LPN A on 08/22/2024 at 8:32 AM, LPN A stated the staff needed to make sure Foley bags were inside a privacy bag. LPN A said there should be a privacy bag for the catheter bag so that it will not be visible to other residents or visitors. She said without the privacy bag, the resident might be embarrassed, humiliated, or uncomfortable going out of the room. She said she did not notice the urine drainage bag was exposed the day before. She said she would make a round and check if the residents with catheter had their privacy bags. She said she was responsible in making sure the catheter bag had a privacy bag.<BR/>In an interview with the ADON on 08/22/2024 at 7:15 AM, the ADON stated all the residents should be treated with dignity. She said dignity could be in the form of pulling the privacy curtain while providing care or making sure nothing was exposed when transporting the residents. She said, for a resident with catheter, there should be privacy bag to maintain dignity. She said the expectation was for the staff to be mindful of the feelings of the residents with catheter. She said they would do an in-service pertaining to maintaining the residents' dignity.<BR/>In an interview with the DON on 08/22/2024 at 7:35 AM, the DON stated the catheter bag should have been placed inside a privacy bag to avoid embarrassment and humiliation. The DON said all the residents had the right for a dignified existence and not having a privacy bag was not one of them. She said all the staff, including her, were responsible in providing dignity to the residents with catheter. The DON said the expectation was for the staff to make sure the catheter bag had a privacy bag when the resident was inside or outside the room. She concluded that she would continually remind the staff the importance of dignity and privacy for residents with catheter through an in-service.<BR/>In an interview with the Administrator on 08/22/2024 at 7:53 AM, the Administrator stated her expectation was for all the staff to provide dignity to all the residents. She said a catheter bag without a privacy bag was a dignity issue because if the urine bag was visible from the hallway, it could cause embarrassment. She said he would coordinate with the DON concerning the privacy bag.<BR/>Review of facility policy, Resident Dignity - Rehab/Skilled Rehab/Skilled & Long Term Care: Therapy & Rehab revised 11/16/2023 revealed Purpose: To maintain dignity . Policy: The location will promote care . enhances each resident's dignity and respect in full recognition of his or her individuality . Procedure . l. Refraining from practices demeaning to residents such as keeping urinary catheter bags uncovered.

**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 for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for three (Resident #9, Resident #15, and Resident #106) of eight residents reviewed for Care Plans. <BR/>1. <BR/>The facility failed to ensure Resident #9 was care planned for indwelling Foley catheter.<BR/>2. <BR/>The facility failed to ensure Resident #15 were care planned for oxygen administration.<BR/>3. <BR/>The facility failed to ensure Resident #106 were care planned for oxygen administration.<BR/>These failures could place the residents at risk of not receiving the necessary care and services.<BR/>Findings included:<BR/>1. <BR/>Review of Resident #9's Face Sheet, dated 08/21/2024, revealed Resident #9 was a [AGE] year-old male who was admitted to the facility 07/22/2024. Relevant diagnoses included benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged and not cancerous) with lower urinary tract symptoms and chronic kidney disease. <BR/>Review of Resident #9 Quarterly MDS Assessment, dated 07/28/24, revealed Resident #9 was cognitively intact with a BIMS score of 15, an indwelling foley catheter, and was dependent on staff for toileting hygiene.<BR/>Review of Resident #9's Physician Order, dated 07/22/2024, revealed Catheter: 18 f (French: unit used to indicate the size of the catheter) with cc balloon to dependent drainage.<BR/>Review of Resident #9's Comprehensive Care Plan on 08/21/2024 reflected no care plan for indwelling catheter.<BR/>Observation on 08/21/2024 at 12:46 PM revealed Resident #9 had a foley catheter hanging on his wheelchair. It was in a privacy bag and not touching the floor. <BR/>2. <BR/>Review of Resident #15's Face Sheet, dated 08/20/2024, reflected that the resident was an [AGE] year-old male admitted on [DATE]. Resident #15 was diagnosed with chronic respiratory failure (condition where there is not enough oxygen in the body or too much carbon dioxide in the body) with hypoxia (insufficient amount of oxygen in the body).<BR/>Review of Resident #15's Quarterly MDS Assessment, dated 07/23/2024, reflected that Resident #15 was cognitively intact with a BIMS score of 15. Resident #15's Quarterly MDS Assessment indicated that the resident had oxygen therapy while a resident of the facility.<BR/>Review of Resident #15's Physician Order, dated 07/27/2022, reflected Oxygen via nasal cannula 1-4 liters per minute continuously and as needed for dyspnea (difficulty in breathing), hypoxia (low level of oxygen in the blood) or acute angina (chest pain). As needed for dyspnea, hypoxia, acute angina, AND every shift.<BR/>Review of Resident #15's Comprehensive Care Plan on 08/20/2024 reflected no care plan for oxygen therapy.<BR/>Observation on 08/20/2024 at 9:09 AM revealed Resident #15 was on his bed, asleep. It was observed that Resident #15 had oxygen administration via nasal cannula at 3 liters per minute. The nasal cannula was connected to an oxygen concentrator.<BR/>In an interview with Resident #15 on 08/20/2024 at 11:27 AM, Resident #15 stated he had been using oxygen for almost two years. He said he used the oxygen day and night.<BR/>3. <BR/>Review of Resident #106's Face Sheet, dated 08/21/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Resident #106 was diagnosed with pneumonia (inflammation and fluid in the lungs caused by a bacterial, viral, or fungal infection) and anxiety disorder.<BR/>Review of Resident #106's Quarterly MDS Assessment, dated 04/30/2024, reflected Resident #106 was cognitively intact with a BIMS score of 15. Resident #106's Quarterly MDS Assessment did not indicate that the resident was on oxygen therapy.<BR/>Review of Resident #106's Physician Order, dated 08/16/2024, reflected Oxygen at 2 LPM (per nasal cannula, face mask, facial tent) via O2 concentrator and/or tank at bedtime every night shift for SOB.<BR/>Review of Resident #106's Comprehensive Care Plan on 08/21/2024 reflected no care plan for oxygen therapy.<BR/>Observation and interview with Resident #106 on 08/20/2024 at 9:09 AM revealed that Resident #106 was on her bed, awake. It was observed that she had a nasal cannula connected to an oxygen concentrator. According to Resident #106, she would use the oxygen at night.<BR/>In an interview with the ADON on 08/22/2024 at 7:15 AM, the ADON stated it was important that residents had a care plan to fully provide the care and services the residents needed. The ADON said that for this case, there should be a care plan for the indwelling catheter and oxygen administration. She said without the care plan, there could be confusion on the care of the residents and their needs would not be addressed. She said she was responsible in making the care plan. She said the expectation was all the issue of the residents were care planned.<BR/>In an interview with the DON on 08/22/2024 at 7:35 AM, the DON stated every resident needed a comprehensive care plan to make sure the residents received the applicable and appropriate care needed. The DON said the care plan should be in place so that the staff providing care would be on the same page. The DON stated the care plan was important because it reflected the resident's needs. He said the care plan should be resident-centered and should show what specific care the resident needed. He said the expectation was for all residents to have a complete and detailed care plan. He said he would coordinate with the ADON and the MDS Nurse to audit the care plans of the resident. <BR/>In an interview with the Administrator on 08/22/2024 at 7:53 AM, the Administrator stated all the residents should have a care plan appropriate to their needs. She said without the care plan, the staff would not know the goals and the interventions needed by the residents. The Administrator concluded that the expectation was for the staff to ensure that the residents were care planned accordingly. She said she would coordinate with the DON and the MDS Nurse to make sure all the residents were care planned.<BR/>Observation and interview with MDS Nurse on 08/22/2024 at 8:16 AM, the MDS Nurse confirmed that Resident #9 did not have a care plan for the indwelling catheter. She also confirmed that Resident #15 and Resident #106 did not have a care plan for oxygen therapy. She stated she missed it and would add the care plan for the indwelling catheter and oxygen therapy. The MDS Nurse stated care plans were important to ensure the residents were getting the care needed. She said care plans served as guides on how the staff would take care of the residents. The MDS Nurse added that without the care plans, the staff could miss significant interventions needed by the residents. <BR/>Record review of facility's policy, Comprehension Care Plan and Care Conferences - Rehab/Skilled Rehab/Skilled & Long-Term Care: Therapy & Rehab revised 12/04/2023 revealed Purpose: to develop a person-centered care plan for each resident . Procedure . 5. Formulating the care Plan . a. The care plan is driven by identified resident issues/conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to ensure residents who were incontinent with bladder received appropriate treatment and services to prevent urinary tract infection for three (Resident #8, Resident #15, and Resident #21) of three residents reviewed for incontinent care. 1. The facility failed to ensure that CNA F performed the right technique during Resident #8's incontinent care on 09/18/2025. 2. The facility failed to ensure that CNA F performed the right technique during Resident #15's incontinent care on 09/18/2025. 3. The facility failed to ensure that CNA E performed the right technique during resident #21's incontinent care on 09/18/2025. This failure could place residents at risk for urinary tract infection. Findings included: 1. Record review of Resident #8's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with cystitis (inflammation of the bladder) with hematuria (blood in the urine) and kidney failure (kidneys stop working). Record review of Resident #8's Comprehensive MDS Assessment, dated 06/21/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated that the resident was frequently incontinent for bladder and bowel. Record review of Resident #8's Comprehensive Care Plan, dated 09/04/2025, reflected that the resident had incontinence and one of the interventions was to assist during toilet use or personal hygiene. An observation on 09/18/2025 at 12:58 PM revealed CNA F was about to do Resident #8's incontinent care. She washed her hands and put on a pair of gloves. She took a brief from a drawer and placed it on top of the resident's overbed table. She then took a towel from the drawer and wet it. She then pulled off the resident's pants and unfastened the brief. She cleaned the resident's perineal area (area between the legs) using the wet towel. She cleaned the top part of the resident's perineal area and then the sides of the perineal area. After cleaning the sides of the perineal area, she cleaned the middle portion of the perineal area with the same face towel that she used to clean the sides of the perineal area. She turned the resident and used the same towel to clean the resident's bottom. She cleaned the resident's bottom from back to front. After cleaning the resident's bottom, she took the brief from the resident's overbed table and placed it under the resident and fixed it. 2. Record review of Resident #15's Face Sheet, dated 09/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with a personal history of urinary tract infection. Record review of Resident #15's Comprehensive MDS Assessment, dated 08/21/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated that the resident was frequently incontinent for bladder and bowel. Record review of Resident #15's Comprehensive Care Plan, dated 09/12/2025, reflected that the resident had incontinence and one of the interventions was to assist during toilet use or personal hygiene. Observation on 09/19/2025 at 12:47 PM revealed CNA F was about to do Resident #15's incontinent care. She washed her hands and put on a pair of gloves. She took a brief and a towel from a drawer. She wet the towel. She took off the resident's pants, unfastened the brief, and pushed it in the middle of the legs. She then cleaned the resident's perineal area using the wet towel. She cleaned the top part of the resident's perineal area and then the sides of the perineal area. After cleaning the sides of the perineal area, she cleaned the middle portion of the perineal area with the same face towel that she used to clean the sides of the perineal area. She turned the resident and used the same towel to clean the resident's bottom. After cleaning the resident's bottom, she took the brief from the top of the drawer and placed it under the resident. She rolled back the resident and fixed the brief. In an interview on 09/18/2025 at 1:08 PM, CNA F stated the proper technique during incontinent care would be to use a wipe and then discard. She said if she was using wipes, it should be one stroke then discard. She said she should have used another face towel to clean the middle portion of the resident's perineal area. She said she was not aware she cleaned Resident #15's bottom from back to front. She said her actions could cause urinary tract infections. She said she should slow down and think while she was doing incontinent care to protect the residents from infections. 3. Record review of Resident #21's Face Sheet, dated 09/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic kidney disease. Record review of Resident #21's Quarterly MDS Assessment, dated 09/09/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident was incontinent for bladder and bowel. Record review of Resident #21's Comprehensive Care Plan, dated 07/17/2025, reflected the resident had ADL self-care performance and one of the interventions was to provide assist during toilet use and personal hygiene. Observation on 09/19/2025 at 10:39 AM revealed CNA E about to do Resident #21's incontinent care. He washed his hands and put a towel on the resident's overbed table. He took the box of gloves from the wall and wipes and put it on the overbed table. He cleaned the perineal (area between the thighs) area with a wipe. He cleaned the top portion of the perineal area then the sides of the perineal area. after cleaning the sides, he used the same wipe to clean the middle portion of the perineal area. He rolled the resident and cleaned the bottom. After cleaning the bottom, he rolled the soiled brief towards the middle and cleaned the resident's bottom. After cleaning the bottom, he rolled back the resident and cleaned again the resident's perineal area twice with a wet towel. He cleaned the sides again and then the middle portion of the perineal area. After cleaning the perineal area, he fixed the brief. In an interview on 09/18/2025 at 11:04 AM, CNA E stated the wipes that he used to clean the side of the front part should have been discarded and he should have used a new wipe when he cleaned the middle part He said the wipe used on the sides where already dirty and Resident #21 might get a urinary tract infection. In an interview on 09/19/2025 at 7:01 AM, the DON stated the staff cannot use wipes or face towels that were used to clean the sides of the perineal area to clean the middle portion of the perineal area. He said the unwanted microorganisms (organisms that is too small to be seen) from the sides could be introduced and could eventually cause UTI especially for women. He said even though the staff cleaned the middle portion using a front to back technique, if they used soiled wipes and soiled face towels, it was still wrong. He said what should have done was one stroke, discard. He said, in cleaning the bottom, it should be from front to back and not the other way around because the microorganisms from the anal area will go to perineal area. He said, the staff should use wipes and not face towels because first, they have supplies of wipes, and second the face towel could be abrasive. He said he was made aware by CNA E and CNA F about the issue, and they already had a one-on-one in-service. He said they were checked off for incontinent care, so he did not know what happened. He said the expectation was for the staff to do the proper technique when providing incontinent care. In an interview on 09/19/2025 at 7:33 AM, ADON A stated she was surprised when she heard about the issue during incontinent care because they just went over with the staff about pericare a few weeks ago. She said the aides did the procedure properly. She said the technique should have been, one wipe, discard. She said it was not acceptable to use the wipes used cleaning the sides of the perineal area and re-use to clean the middle part because the middle part was the one prone to female residents having UTI. She said cleaning the bottom was from front to back so as not to introduce microorganism to the perineal area. She said cleaning the bottom back to the front could also cause UTI. She said an in-service about incontinent care was already initiated and her expectation was for the staff to follow the proper technique when providing incontinent care. She said they would closely monitor the staff adherence to the procedure of incontinent care. In an interview on 09/19/2025 at 8:02 AM, the Administrator stated she was made aware about the issue during incontinent care. She said CNA E told her what happened. She said the aides had previous training so she did not know what happened. She said the expectation was for the staff to use one wipe at a time and to wipe the bottom from front to back. She said the DON already started an in-service about incontinent care. She said it seemed like a lot more training about pericare should be done. Record review of the facility's policy entitled Urinary Continence and Incontinence - Assessment and Management Strategy, Delivery, Performance revised 09/2024 reflected Policy Statement: 1. The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence . Policy Interpretation and Implementation . 2. Relevant information . f. additional information such as the type and frequency of physical assistance necessary for the resident. Policy and procedure for Incontinent Care was requested via email to the Administrator on 09/18/2025 at 12:09 PM and 09/19/2025 at 10:21 AM but was not provided prior to exit. Record review of the facility's Competency Assessment Peri Care 2018 MED-PASS, Inc. revised February 2018 reflected A) Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . For a female resident . b. Wash perineal area, wiping from front to back . (2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth . e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Residents #27 and Resident #106 ) of eight residents reviewed for Respiratory Care.<BR/>1. <BR/>The facility failed to ensure Resident #27's breathing mask used for nebulization was properly stored.<BR/>2. <BR/>The facility failed to ensure Resident #106's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored.<BR/>These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.<BR/>Findings included: <BR/>1. <BR/>Review of Resident #27's Face Sheet, dated 08/21/2024, reflected that the resident was an [AGE] year-old female admitted on [DATE]. Resident #27 was diagnosed with chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and pleural effusion (collection of fluid around the lungs).<BR/>Review of Resident #27's Quarterly MDS Assessment, dated 04/13/2024, reflected Resident #27 was cognitively intact with a BIMS score of 15. Resident #27's Quarterly MDS Assessment indicated that the resident had COPD.<BR/>Review of Resident #27's Comprehensive Care Plan, dated 08/02/2024, reflected Resident #27 had oxygen therapy related to COPD and one of the interventions was oxygen therapy continuous. <BR/>Review of Resident #27's Physician Order, dated 03/01/2024, reflected Arformoterol Tartrate Inhalation Nebulization Solution (Arformoterol Tartrate) 2 ml inhale orally via nebulizer two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE.<BR/>Observation and interview with Resident #27 on 08/21/2024 at 9:37 AM revealed the resident was on her wheelchair, awake. It was noted that Resident #27's nebulizer machine was observed sitting on top of the resident's side table. A breathing mask was connected to the nebulizer machine. The breathing mask was observed on the table. The breathing mask was not bagged. The part of the nebulizer mask that touched the face when in use was in contact with the table. Resident #27 said she had a breathing treatment twice a day because of her breathing problem. Resident #27 said the nurse would put a solution on the container connected to the mask, would turn it on, and would put the mask on her face. Resident #27 said she was not sure if the nurse was putting it in a bag, but she never saw a bag for her nebulizer mask.<BR/>Observation and interview with LPN D on 08/20/2024 at 11:57 AM, LPN D stated the breathing mask should not be exposed nor touching anything because it could cause cross contamination and infection. LPN D said the breathing mask should be bagged when not in use. LPN D went inside Resident #27's room and confirmed the breathing mask was on top of the table. LPN D said she did administer the resident's breathing treatment but was not able to put the mask in the plastic bag when the treatment was done. LPN D disconnected the breathing mask and said she would obtain a new one and would put it in a plastic bag. LPN D went to her cart, opened the last drawer, took a new breathing mask and a plastic bag out. LPN D went back to Resident #27's room, connected the new breathing mask and then placed it inside a plastic bag.<BR/>2. <BR/>Review of Resident #106's Face Sheet, dated 08/21/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Resident #106 was diagnosed with pneumonia (inflammation and fluid in the lungs caused by a bacterial, viral, or fungal infection) and anxiety disorder.<BR/>Review of Resident #106's Quarterly MDS Assessment, dated 04/30/2024, reflected Resident #106 was cognitively intact with a BIMS score of 15. Resident #106's Quarterly MDS Assessment did not indicate that the resident was on oxygen therapy.<BR/>Review of Resident #106's Comprehensive Care Plan on 08/21/2024 reflected no care plan for oxygen therapy.<BR/>Review of Resident #106's Physician Order, dated 08/16/2024, reflected Oxygen at 2 LPM) (per nasal cannula, face mask, facial tent) via O2 concentrator and/or tank at bedtime every night shift for SOB.<BR/>Observation and interview with Resident #106 on 08/20/2024 at 9:09 AM revealed that Resident #106 was on her bed, awake. It was observed that she had a nasal cannula that was coiled on the railings of the resident's bed. The nasal cannula was not bagged. She said she would use the nasal cannula once in a while. She said sometimes the nurse would put it on and off. She said she never saw a plastic bag for her nasal cannula. <BR/>Interview with RN E on 08/21/2024 at 10:41 AM, RN E stated the nasal cannula should not be coiled in the railing of bed because the railing of the bed was not clean. She said this could cause cross contamination and probable infection. She said coiling the tubing of the nasal cannula could also compromise the passage of oxygen on the tubing. She said she did not notice that the nasal cannula was not bagged. She said she would check on Resident 106's nasal cannula. She said she would also change it and put it in a bag.<BR/>In an interview with the ADON on 08/22/2024 at 7:15 AM, the ADON stated the breathing mask, and the nasal cannula should be bagged when the resident was not using it to prevent cross contamination and infection. She said the staff who took off the mask and the nasal cannula should put it in a bag. She said if the resident was the one taking it off, there should be a bag ready for them to put the mask in. She also said that the resident should be educated why the mask should be bagged. She said the expectation was for the staff to bag the breathing mask and the nasal cannula when not in use. She said she would coordinate with the DON to conduct an in-service pertaining to bagging the nasal cannula and the breathing mask when the residents were not using them. She said she would also make a round to check if the breathing masks and nasal cannula not in used were bagged.<BR/>In an interview with the DON on 08/22/2024 at 7:35 AM, the DON stated the breathing mask, and the nasal cannula should be bagged when not in use to keep it clean. The DON said the proper way of storing the breathing mask and the nasal cannula was to place them inside the plastic bag when the resident was done with the breathing treatment or when the resident was not using the nasal cannula. He said if those breathing apparatus were not bagged, were exposed, or touching surfaces that were not clean, then oxygen administration could be compromised. The DON said the staff, including him, were responsible in monitoring that the breathing mask and the nasal cannula were bagged when not in use. He said the expectation was the breathing mask and the nasal cannula would be stored properly. The DON said she would continually remind the staff to be diligent in making sure the procedures for respiratory care were followed. He said he would re-educate the staff providing respiratory care.<BR/>In an interview with the Administrator on 08/22/2024 at 7:53 AM, the Administrator stated everything used by the residents should be kept clean. She said the nasal cannula and the breathing mask should be stored properly to prevent respiratory infections. The Administrator said the expectation was for the staff to do their due diligence in order to provide the highest level of respiratory care. The Administrator said he would coordinate with the DON to address the issue.<BR/>Review of facility policy Oxygen Administration, Safety, Mask Types - R/S, LTC, Therapy & Rehab Rehab/Skilled & Long -Term Care: Therapy & Rehab revised 07/08/2024 revealed Purpose: To keep oxygen equipment clean and maintained in good condition . Procedure . Oxygen cylinder . 14. When oxygen is not in use, store cannula, face mask . plastic bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation ,interview and record reviews the facility failed to ensure informed consent prior to installation. The facility failed to ensure Resident #5, #9, #10, #11, #30, and #46 had physician orders for the pivot assist bars attached to the residents' bed. This failure could place residents at risk of having unnecessary equipment installed on their beds .Findings included: 1. Record review of Resident #5's Face Sheet, dated 09/18/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and Alzheimer's disease (cognitive decline). Record review of Resident #5's Comprehensive MDS Assessment, dated 08/15/25, reflected the resident had severe cognitive impairment with a BIMS score of 3. The Comprehensive MDS Assessment indicated that the resident had an active diagnosis of muscle weakness. Record review of Resident #5's Comprehensive Care Plan, dated 09/09/25, reflected the resident had a history of falls, with his last fall occurring on 08/31/25. The care plan did not include the pivot assist bars as an intervention. Record review of Resident #5's physician orders, dated 09/18/25, reflected no physician orders for the pivot assist bars. Observation on 09/17/2025 at 10:28 AM revealed Resident #5 had pivot assist bars on both sides of the bed. 2. Record review of Resident #9's Face Sheet, dated 09/18/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and history of falls. Record review of Resident #9's Comprehensive MDS Assessment, dated 07/02/25, reflected the resident had an intact cognitive response with a BIMS score of 14. The Comprehensive MDS Assessment indicated that the resident had an active diagnosis of repeated falls and muscle weakness. Record review of Resident #9's Comprehensive Care Plan, dated 07/18/25, reflected the resident had a history of falls, with his last fall occurring on 08/03/25. The care plan did not include the pivot assist bars as an intervention. Record review of Resident #9's physician orders, dated 09/18/25, reflected no physician orders for the pivot assist bars. Observation on 09/17/2025 at 11:25 AM revealed Resident #9 had pivot assist bars on both sides of the resident's bed 3. Record review of Resident #10's Face Sheet, dated 09/18/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with senile degeneration of brains. Record review of Resident #10's Comprehensive MDS Assessment, dated 07/27/25, reflected the resident had a moderate cognitive impairment with a BIMS score of 8. The Comprehensive MDS Assessment indicated that the resident had an active diagnosis of coronary artery disease (disease of the heart). Record review of Resident #10's Comprehensive Care Plan, dated 08/13/25, reflected the resident had a history of falls, but the care plan did not include the pivot assist bars as an intervention. Record review of Resident #10's physician orders, dated 09/18/25, reflected no physician orders for the pivot assist bars. Observation on 09/17/2025 at 10:35 AM revealed Resident #10 had pivot assist bars on both sides of the resident's bed. 4. Record review of Resident #11's Face Sheet, dated 09/18/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with a history of fall, and muscle weakness. Record review of Resident #11's Comprehensive MDS Assessment, dated 07/12/25, reflected the resident was moderately cognitively impaired with a BIMS score of 8. The Comprehensive MDS Assessment indicated that the resident had an active diagnosis of repeated falls and muscle weakness. Record review of Resident #11's Comprehensive Care Plan, dated 07/13/25, reflected the resident had a history of falls, but the care plan did not include the pivot assist bars as an intervention. Record review of Resident #11's physician orders, dated 09/18/25, reflected no physician orders for the pivot assist bars. Observation on 09/17/2025 at 11:06 AM revealed Resident #11 had pivot assist bars on both sides of the resident's bed. 5. Record review of Resident #30's Face Sheet, dated 09/18/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with a muscle weakness and the need of assistance for personal care. Record review of Resident #30's Comprehensive MDS Assessment, dated 07/02/25, reflected the resident had a moderate cognitive impairment with a BIMS score of 9. The Comprehensive MDS Assessment indicated that the resident had an active diagnosis of and muscle weakness. Record review of Resident #30's Comprehensive Care Plan, dated 07/13/25, reflected the resident had a history of falls, but the care plan did not include the pivot assist bars as an intervention. Record review of Resident #30's physician orders, dated 09/18/25, reflected no physician orders for the pivot assist bars. Observation on 09/17/2025 at 11:11 AM revealed Resident #30 had pivot assist bars on both sides of the resident's bed. 6. Record review of Resident #46's Face Sheet, dated 09/17/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #46 had diagnoses of muscles weakness. Record review of Resident #46's Quarterly MDS Assessment, dated 09/09/25, reflected Resident #46 had a moderate cognitive impairment with a BIMS score of 12. The Quarterly MDS Assessment reflected an active diagnosis of muscle weakness and osteoarthritis of both knees. Record review of Resident #46's Comprehensive Care Plan, dated 09/06/25, reflected the resident had a history of falls, but the care plan did not include the pivot assist bars as an intervention. Record review of Resident #46's physician orders, dated 09/18/25, reflected no physician orders for the pivot assist bars. Observation on 09/17/2025 at 10:51 AM revealed Resident #46 had pivot assist bars on both sides of the resident's bed. In an interview on 09/18/25 at 1:48 PM, LVN D, was told by the Surveyor of Resident #30 had pivot assist bars on both sides of his bed, but no physician orders were observed for the devices. She stated the resident did not have physician orders for the equipment. She stated the resident should have physician orders for the bars because it could be a form of restraint and safety hazards. In an interview on 09/18/25 at 2:15 PM, ADON A was told by the Surveyor of Resident #5, #9, #10, #11, #30, and #46 not having physician orders for the pivot assist bars on the beds. She stated the bed came with the bars on them. She stated the resident did use the bars to reposition themselves. She stated she did not think physician orders were needed for the bars. She stated she would follow up with the DON to see about getting physician orders for the equipment. In an interview on 09/19/25 at 11:08 AM, the DON was told by the Surveyor of Resident #5, #9, #10, #11, #30, and #46, not having physician orders for the pivot assist bars. He stated this was brought to his attention by ADON after the Surveyor brought it to ADON A's attention, and they were now completing bedrail assessments for the residents, care planning the use of the bedrails, and obtaining physician orders for the devices. He stated he was not sure of the risk for the resident because the bars had been on the beds for over six years, but they would ensure physician orders for the pivot assist bars were obtained going forward. The facility's policy RESTRAINTS dated 06/17 reflected, It is the policy of the facility to refuse to restrain residents for any cause. Should a resident have cause for need of a restraint, the physician will be notified immediately, and Texas state regulations will be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that two (Resident #19 and Resident #48) of five residents were provided medications and/or biologicals and pharmaceutical services to meet their needs.<BR/>The facility failed to ensure MA re-ordered medications in a timely manner for Resident #19 (Torsemide 20 mg) and Resident #48 (Solifenacin 5 mg). <BR/>This failure could place the residents at risk of not receiving medications as ordered by the physician.<BR/>Findings included: <BR/>Resident # 19<BR/>Review of Resident #19's Face Sheet, dated 08/21/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included cystitis (inflammation of the bladder) and acute kidney failure.<BR/>Review of Resident #19's Quarterly MDS Assessment, dated 06/13/2024, reflected resident was cognitively intact with a BIMS score of 13. The Quarterly MDS Assessment also indicated Resident #19 had an acute kidney failure.<BR/>Review of Resident #19's Comprehensive Care Plan, dated 06/28/2024, reflected resident was on diuretic therapy the intervention was monitor resident's condition related to use of torsemide.<BR/>Review of Resident #19's Physician Order for torsemide, dated 07/27/2023, reflected Torsemide Oral Tablet 20 MG (Torsemide) Give 0.5 tablet by mouth one time a day for edema.<BR/>Resident #48 <BR/>Review of Resident #48's Face Sheet, dated 08/21/2024, reflected that resident was a [AGE] year-old male admitted on [DATE]. Resident #48 was diagnosed with chronic kidney disease.<BR/>Review of Resident #48's Quarterly MDS Assessment, dated 07/26/2024, reflected resident had a severe impairment in cognition with a BIMS score of 06. The Quarterly MDS Assessment indicated Resident #48 was diagnosed with renal (pertaining to the kidney) failure.<BR/>Review of Resident #48's Care Plan on 08/21/2024 revealed no care plan for renal failure.<BR/>Review of Resident #48's Physician's Order for Solifenacin 5 mg reflected Solifenacin Succinate Oral Tablet 5 MG (Solifenacin Succinate). Give 5 mg by mouth one time a day for antispasmodic.<BR/>In an observation and interview with MA on 08/21/2024 at 6:30 AM revealed MA was preparing Resident #19's medication. MA said Resident #19 did not have a blister pack for torsemide. She said she would ask the nurse to get it from the e-kit. MA looked for the nurse and told her that she needed torsemide for Resident #19. MA continued to prepare Resident #19's medication and then gave it to Resident #19. MA then prepared Resident #48's medication. MA placed the last pill of Resident #48's Solifenacin. MA finished preparing the medications and gave it to Resident #48. She said she did not have another blister pack for Resident #48's Solifenacin. She said she would check her cart because it might be with the other resident's medication. While still looking for the medication, the nurse came and gave her Resident #19's torsemide that was placed in a small plastic cup. MA checked the name and milligrams of the medication, opened it, placed it in a small cup, and gave it to Resident #19. MA said the medication should be re-ordered as soon as the medications reach the last line. MA explained they could re-order medications through the system, through faxing, or by calling the pharmacy. MA said she would go ahead and re-order the medications. MA said she was responsible for re-ordering medication that were running low. MA stated she did notice that the medications were running low but was not able to re-order them. MA said if medications were not re-ordered on a timely manner, the residents might run out of medications and their present medical situations might worsen. MA stated she would check her medication carts and re-order the medications that were running low.<BR/>In an interview with LPN A on 08/21/2024 at 1:50 PM, LPN A confirmed that MA asked her to get Resident #19's torsemide from the e-kit. She said the e-kit would be for emergencies and new admissions and not for the medications that were not re-ordered in a timely manner. She said the medications should have been re-ordered when there were only four or five medications left in the blister card. She said things could happen and the pharmacy would not be able to deliver or refill the e-kit. She continued that if that happened, the residents would not have medications to take. She said adverse outcome could happen. She stated sometimes the computer would let you know that it was time to re-order certain medications so there would be no reason for not re-ordering on a timely manner.<BR/>In an interview with the ADON on 08/22/2024 at 7:15 AM, the ADON stated the staff should re-order the medications once the medications hit the last dark line of the blister pack. The ADON said the nurses and the MA were responsible in re-ordering medications once they were running low. The ADON said if the MA was busy, the nurses could re-order the medications. The ADON said if the medications were not re-ordered on a timely manner, there could be a possibility the residents would not have their medications. The ADON added without the medications the medical issues of the residents could worsen. The ADON said the expectation was for the staff to be diligent in re-ordering the medications to prevent missed medications. The ADON said the facility had an e-kit but said the e-kit should not be used because the medications were not re-ordered in a timely manner. The ADON said she would do an in-service for ordering and re-ordering the medications. <BR/>In an interview with the DON on 08/22/2024 at 7:35 AM, the DON stated medications should be re-ordered in a timely manner. The DON said anything could happen that could affect the delivery of the medications from the pharmacy. The DON said the staff must make sure they re-order the medications in a timely manner so the residents would have their needed medications all the time. The DON said the staff should not wait for the last minute to re-order the medications. The DON said if the residents did not get their medications, their medical issues may worsen. The DON said they would in-service the staff about re-ordering medications. The DON said whichever staff observed the medication was running low should have re-ordered it. The DON continued the staff only needed to click the re-supply button on the residents' profile, fax it to the pharmacy, or call the pharmacy. The DON concluded the expectation was for the staff to be diligent in re-ordering medications and said they would audit all the carts, MA's and nurses', to check which medications needed re-ordering.<BR/>In an interview with the Administrator on 08/22/2024 at 7:53 AM, the Administrator stated the medications should be re-ordered on time to prevent missed medications. The Administrator said it was not good for the residents if they missed their medications. The Administrator said she would coordinate with the DON about the issue to address it.<BR/>Record review of facility policy, Local Pharmacy Medication ordering - R/S, LTC [NAME] Policy ENTERPRISE Rehab/Skilled & Long-Term Care: Therapy & Rehab revised 08/29/2023 revealed Procedure . 2. If a new medication or STAT medication . use emergency kit . medications are out . communicate to the pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for eight (Residents #4, #7, #8, #21, #23, #31, #51, and #61) of eighteen residents reviewed for medication storage. 1. The facility failed to ensure that Resident #4's pain ointment was not inside the room on 09/17/2025. 2. The facility failed to ensure that Resident #7's TUMS, eye drops, and oral analgesia were not inside the room on 09/17/2025. 3. The facility failed to ensure that a wound cleanser was not left inside Resident #8's room on 09/17/2025. 4. The facility failed to ensure Resident #21's medication was not left inside the room on 09/17/2025 and 09/18/2025. 5. The facility failed to ensure that a tube of zinc oxide (medicated cream used to prevent skin irritation) was not left inside Resident #23's room on 09/17/2025. 6. The facility failed to ensure a bottle of hydrogen peroxide was not left inside Resident #31's room [ROOM NUMBER]/17/2025. 7. The facility failed to ensure a tube of zinc oxide was not left inside Resident #51's room on 09/17/2025. 8. The facility failed to ensure Resident #61's eye drop was inside the room on 09/17/2025. These failures could place residents at risk of misuse of medications that could lead to overdosing or underdosing. Findings include: 1. Record review of Resident #4's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with osteoarthritis. Record review of Resident #4's Comprehensive MDS Assessment, dated 07/21/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had osteoarthritis. Record review of Resident #4's Comprehensive Care Plan, dated 08/04/2025, reflected that the resident had chronic pain R/T arthritis to foot and one of the interventions was to monitor pain quality, severity, location, and aggravating factors. Record review of Resident #4's Physician's Order, dated 09/27/2023, reflected Voltaren Arthritis Pain External Gel 1 % Diclofenac Sodium (Topical)). Apply to . topically every 4 hours as needed for pain. During an observation and interview on 09/17/2025 at 9:08 AM revealed Resident #4 was in her bed, awake. A tube of diclofenac sodium topical gel was observed on top of the resident's overbed table. The resident said the ointment had been in her room and had always been on top of the overbed table or her side table where she easily accessed it. An observation on 09/18/2025 at 10:43 AM revealed the tube of diclofenac sodium topical gel was still on top of Resident 4's overbed table. During an observation and interview on 09/18/2025 at 11:28 AM, RN B stated the pain ointment should not be inside Resident #4's room. She said it should be inside the nurses' carts because the nurses were supposed to be the ones administering the pain ointment. She said she did not know who left the pain ointment with the resident and she did not notice there was a tube of pain ointment on the resident's overbed table. She said the resident might use it more than the recommended and could result in skin redness or dryness. RN B went inside the resident's room and took the tube of pain ointment. 2. Record review of Resident #7's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with gastro-esophageal reflux disease and dementia. Record review of Resident #7's Comprehensive MDS Assessment, dated 07/16/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident had gastro-esophageal reflux disease and dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #7's Comprehensive Care Plan, dated 07/23/2025, reflected that the resident had gastro-esophageal reflux disease and dementia. Record review of Resident #7's Physician's Order, dated 04/25/2025, reflected Aluminum-Magnesium-Simethicone Suspension 200-200-20 MG/5ML (Alum &Mag Hydroxide-Simeth) Give 30 ml by mouth every 4 hours as needed for indigestion. Record review of Resident #7's Physician Order, dated 10/20/2021, reflected Refresh Solution 1.4 - 0.6 % (Polyvinyl Alcohol Povidone PF) Instill 1 drop in both eyes two times a day for Dry eyes. Record review of Resident #7's Physician Order on 09/17/2025 reflected no order for TUMS. Record review of Resident #7's Physician Order on 09/17/2025 reflected no order for oral analgesia. During an observation and interview on 09/17/2025 at 9:46 AM revealed Resident #7 was sitting at the side of her bed. A bottle of TUMS, 2 eyedrops, and a tube of oral analgesic were noted on the resident's side table. She said those were her medications and she always put them on top of her side table. 3. Record review of Resident #8's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with a personal history of diseases of the skin and subcutaneous (under the skin) tissue. Record review of Resident #8's Comprehensive MDS Assessment, dated 09/08/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident had skin issues. Record review of Resident #8's Comprehensive Care Plan, dated 09/04/2025, reflected that the resident had a skin tear on the left elbow and right forearm and one of the interventions was to provide wound care as ordered. Record review of Resident #8's Physician Order, dated 08/29/2025, reflected wound care: cleanse wound (left elbow) with NS, pat dry, apply moisturizer and cover arm with tubi grip (elastic tubular bandage) one time a day. Record review of Resident #8's Physician Order, dated 08/29/2025, reflected Wound care: cleanse wound to right forearm with NS, pat dry, apply moisturizer and cover with tubi grip one time a day. During an observation and interview on 09/17/2025 at 9:40 AM revealed Resident #8 was in her wheelchair, awake. It was observed that there was a wound cleanser on the resident's sink. She said the staff used it when she had a skin tear to both arms. She said the skin tears were already healed. 4. Record review of Resident #31's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with repeated falls. Record review of Resident #31's Quarterly MDS Assessment, dated 08/30/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated that the resident was at risk of repeated falls. Record review of Resident #31's Comprehensive Care Plan, dated 07/25/2025, reflected the resident had an actual fall due to poor balance and one of the interventions was to monitor bruises. Record review of Resident #31's Physician Order on 09/17/2025 reflected that the resident did not have any wound care. During an observation and interview on 09/17/2025 at 9:38 AM revealed Resident #31 was in her wheelchair, awake. A bottle of hydrogen peroxide was observed on top of the resident's sink. The resident said the hydrogen peroxide was for her feet. 5. Record review of Resident #51's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with benign prostatic hyperplasia with lower urinary tract symptoms. Record review of Resident #51's Quarterly MDS Assessment, dated 09/07/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated that the resident was incontinent for bowel. Record review of Resident #51's Comprehensive Care Plan, dated 09/05/2025, reflected the resident had an ADL self-care performance and one of the interventions was to inspect the skin. Record review of Resident #51's Physician Order, dated 09/03/2025, reflected BARRIER CREAM/OINT AFTER EACH INCONTINENT EPISODE AND PRN AS INDICATED every shift. An observation on 09/17/2025 at 9:43 AM revealed Resident #51 was not inside the room. A tube of zinc oxide of hydrogen peroxide was observed on top of the resident's sink. During an observation and interview on 09/18/2025 at 7:13 AM, RN C stated all medications should be inside the nurses' carts or the medication aide' cart. She said the zinc oxide, hydrogen peroxide, and the wound cleanser should also be stored inside the carts. She said medications should not be stored inside the resident's rooms because the residents might consume the medications more than the recommended and could result to overdose. She said zinc oxide, hydrogen peroxide, and wound cleanser should not be inside the room as well because the residents might accidentally consume them, especially confused residents, and could result to adverse reactions like stomach upset. She went inside the residents' rooms and took the eyedrops, TUMS, oral analgesia, hydrogen peroxide, and wound cleanser. She said she would also check the rooms on her hall to see if there were medications or items used to facilitate healing. In an interview on 09/18/2025 at 1:08 PM, CNA F stated RN C told her about the zinc oxide and calmoseptine that were found inside the room. She said the zinc oxide should be in the cart and just ask for it when needed. She said the zinc oxide could be placed in a small cup so that the tube would stay in the cart. She said the facility also had them in sachet so just bring one or two, depending on the need. She said they should not be left inside the room where the resident or other residents could reach it and accidentally put it in their mouth. She said she was not sure what could happen but she was sure zinc oxide and calmoseptine were not for consumption. She said the resident could put it in their eyes that could cause reactions. 6. Record review of Resident #21's Face Sheet, dated 09/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with anemia and kidney disease. Record review of Resident #21's Quarterly MDS Assessment, dated 09/09/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated that the resident had anemia and kidney disease. Record review of Resident #21's Comprehensive Care Plan, dated 07/17/2025, reflected the resident had anemia and encourage intake of foods high in iron and vitamin C. Record review of Resident #21's Physician Order, dated 09/16/2025, reflected Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth two times a day for supplement for 15 Days. Record review of Resident #21's Physician Order, dated 05/18/2025, reflected Metformin HCl Oral Tablet 500 MG (Metformin HCl). Give 1 tablet by mouth two times a day for DM. During an observation and interview on 09/17/2025 at 9:56 AM revealed Resident #21 was in her bed, awake. It was observed that the resident was about to take three pills from a small cup that was on her tray. She said the cup was left by the staff and the staff told her to take the medications after she was done with breakfast. In an interview on 09/18/2025 at 6:51 AM, MA G stated medications should not be left with the residents because the residents might not take them or just throw the medications away. She said she left Resident #21's medications because there was a resident that was about to fall. She said she should have brought the medication with her before leaving the room, put it back in the cart, or called somebody else to help the resident that she said was about to fall. An observation on 09/18/2025 at 10:29 AM revealed CNA E provided incontinent care to Resident #21. He brought with him three sachets of calmoseptine. Before fastening the brief, he opened a calmoseptine ointment and spread it on the resident's bottom. He then fastened the brief and washed his hands. He still had two sachets of calmoseptine on hand and he left them on top of the resident's dresser beside the bed and left the room. 7. Record review of Resident #23's Face Sheet, dated 09/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with weakness. Record review of Resident #23's Quarterly MDS Assessment, dated 07/15/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated that the resident was at risk for pressure ulcers. Record review of Resident #23's Comprehensive Care Plan, dated 08/07/2025, reflected the resident had impairment to skin integrity and one of the interventions was to use lotion on dry skin. Record review of Resident #23's Physician Order, dated 02/14/2025, reflected Moisture barrier ointment as indicated to keep irritants or moisture from skin surface every shift. During an observation and interview on 09/17/2025 at 10:43 AM revealed Resident #23 was in her bed, awake. A tube of zinc oxide was observed on top of the resident's overbed table. The resident just shrugged her shoulders when asked who left the zinc oxide on top of the overbed table. During an observation and interview on 09/18/2025 at 10:40 AM, LVN D said it should not be left inside the room she went inside and took the sachets. She called CNA E and told him not to leave the sachets inside the rooms of the residents because the resident might use them inappropriately or confused residents might consume them. She said pills should not be left with a resident. She said if the staff needed to leave, put the medication back to the cart. She also said the zinc oxide should be inside the cart and the staff should just ask if needed. 8. Record review of Resident #61's Face Sheet, dated 09/18/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with need for assistance with personal care and delirium Record review of Resident #61s Comprehensive MDS Assessment, dated 08/28/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had delirium. Record review of Resident #61's Physician's Order on 09/17/2025 reflected no order for eye drops. Observation and interview on 09/17/2025 at 9:28 AM revealed Resident #61 was in her bed, awake. It was observed that an eye drop was on top of the resident's side table. The resident said she was using the eye drop every morning because her eyes were dry in the morning most of the time. She said she was not sure if the staff knew she was using an eye drop. In an interview on 09/19/2025 at 6:47 AM, LVN H stated she was not aware that Resident #61 had an eye drop inside her room. She said the eye drop should be inside the cart because the staff were supposed to administer them. She said there should be no medications inside the residents' room because the resident might overuse it. In an interview on 09/19/2025 at 7:01 AM, the DON stated medications should not be stored inside the resident's room. He said TUMS, eyedrops, zinc oxide, hydrogen peroxide, pain ointments, and wound cleanser should be inside the carts to secure them. He said the resident could overdose and some form of medications that were applied topically could be harmful when ingested. He said when using calmoseptine, the staff should only get what was supposed to be used from the supply room. He said he already initiated an in-service about medication storage. In an interview on 09/19/2025 at 7:33 AM, ADON A stated medications should not be inside the residents' rooms and should be in the carts. The pills, eye drops, pain ointments, zinc oxides, hydrogen peroxide, and wound cleanser should be secured so the residents, especially the confused resident, would not get a hold of them. She said the residents could overdose because nobody was monitoring how often the resident was taking the medication. She said residents with poor eyesight could mistakenly thought that zinc oxide and calmoseptine were sauce and put them on their food. She said the expectation was for the staff not to leave any medication inside the room. She said the zinc oxides, hydrogen peroxide, and wound cleanser were forms of medication because they were used for wound care. She said the DON already started an in-service about medication storage. In an interview on 09/19/2025 at 8:02 AM, the Administrator stated the expectation was for the staff to be mindful not to leave any medication inside the room and to scan the room to make sure there were no medications inside the resident's rooms. She said the residents might consume the medications inappropriately. She said the DON already started an in-service about medication storage. Record review of the facility's policy entitled, Medication Labeling and Storage reflected Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys . 9. Antiseptics, disinfectants, and germicides used in any aspect of resident care . shall be stored separately from regular medications.

Based on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. <BR/>The facility failed to ensure foods in the facility's dry storage area, refrigerator, and freezer were stored and dated according <BR/>to guidelines.<BR/>The facility failed to ensure that staff was wearing the proper head coverings when serving food.<BR/>The facility failed to ensure staff wore gloves when preparing food and remove, wash hands and doff new gloves during <BR/>kitchen task changes according to guideline.<BR/>These failures could place residents at risk for cross contamination.<BR/>Findings included:<BR/>In an observation of the kitchen on 07/18/23 at 9:00 AM the following were observed:<BR/>Two large box of yellow onions (approximately 20 or more) and purple onions approximately (18 or more )were unlabeled in <BR/>the refrigerator.<BR/>Seven boxes of brown boxes of food placed on the floor at the back of the freezer unlabeled. <BR/>All frozen foods in the facility freezer that were shelfed were unlabeled. Brisket, crab meat, other frozen meets, frozen green <BR/>beans and other vegetables <BR/>One large silver bowl with cooked potato cubes uncovered on the prep table in the kitchen.<BR/>One large silver bowl of chopped chicken uncovered on prep table in kitchen.<BR/>Observation and interview with DW A on 07/18/23 at 09:00 AM revealed DW A was observed entering and exiting the facility's only kitchen, DW A was observed not wearing a hairnet, and using a surgical mask to cover his facial hair. Which was exposed on jaw line. He stated that the DM approved for him to wear a surgical mask in the kitchen to cover his beard. He was then directed by the DM to discard the surgical mask and put on a beard covering. DW A followed the directions and returned wearing a beard mask. A revisit to the kitchen on 07/18/23 at 11:30 AM DW A was wearing beard covering. <BR/>Observation and interview with DA B on 07/18/23 at 09:03 AM DA B was wearing a blue ball cap with his hair exposed in the back and not covered with a beard restraint. She was observed on 07/17/23 at 11:30 AM prepping soup without gloves. She was pouring soup back in the electric heating device, then scooped back out in the soup bowls. She then gathered a paper town and wiped the spilled soup off the counter and bowls, and returned to task. She was not wearing gloves and was not observed handwashing before returning.to the task.<BR/>Observation of DA S on 07/18/23 at 11:50 AM in the facility's only kitchen revealed DA S in the kitchen preparing food for lunch and he changed kitchen task from the fryer, adjusted his gloves on the left hand with fingers from the right hand. Proceeding to a second task without removing gloves, hand washing , and doffing a new pair of gloves. The DM was notified immediately of the concern and the staff changed gloves and hand washed. No food was touched only utensils that were placed for washing. The gloves were loose fitting.<BR/>. <BR/>Interview with Dietary Manager on 07/20/23 at 09:00 AM revealed he had been the Dietary Manager for the Facility's only kitchen for 2 years. He was advised of the two (2) kitchen staff who were not in compliance with head and face covering and hand sanitation. He said the labels in the freezer and refrigerator were not labeled because the cold environment caused the labels to fall off. He does not like to label with black marker, so he was not labeling. He said boxes should not be stored on the floor per guidelines, however the truck just delivered the boxes and he was notified of the inspection by the administrator. He said the crab meat packages fell off the top shelf to the freezer floor. Dietary manager said it was important to wash hands and use gloves before and after handling food and changing kitchen task. He stated the risk of staff not wearing their head and face coverings appropriately could result in air borne illnesses. He advised that he would in-service his staff on Employee Hygiene and Dress Code. Dietary manager revealed all cooks and diet aides were responsible for labeling and dating inventory as they are delivered. He advised they must put a name on it and that day's date on it., which includes can goods. He stated first in first out. He was shown pictures of the concerns and He stated that all staff were required to monitor for any of these concerns and correcting it, but the dietary manager was overall responsible for ensuring that it is corrected. He stated whoever puts up the inventory must also check for expired foods and ensure all foods are sealed appropriately. She stated the risk of these issues not being resolved could result in spread of bacteria. The Dietary Manager displayed an In-service on proper head and face coverings with kitchen staff completed on 07/19/23. <BR/>Interview with RD on 07/20/23 at 9:30 AM revealed he and all cooks and diet aides are responsible for labeling and dating. He advised staff must label and put the date the shipment for kitchen. He was shown pictures of concerns referenced previously and he advised that everyone was responsible for ensuring these concerns do not happen and the Dietary Manager was overall responsible for monitoring and identifying any of the concerns mentioned including proper hair coverings. <BR/>In an interview with DA B on 07/20/23 at 9:45 AM revealed she always wore a ball cap for a hair covering and she forgot to put on her gloves for the policy was to wear gloves while handling food. She said failing to cover hair and practice hand sanitation while handling food could result in her hair falling into the food and causing food realted illneses. She attended the in-service on 07/19/23. <BR/>An interview was requested with DW A on 07/20/23 at 9:50 AM and the DM stated he was not working today. DW A signature was observed on the Inservice conducted on 7/19/23.<BR/>An interview was requested with DA S on 07/20/23 at 9:57AM and the DM stated that he was not working today. DA S signature was observed on the Inservice conducted on 7/1923.<BR/>Review of the facility's policy and procedures on Food Storage, dated 06/21/2022, revealed The product should not be consumed after the date on the package due to the product's perishable nature and the product should be disposed of. Foods that have been opened or prepared must be covered<BR/>Review of dietary policies and procedures Titled Personal Hygiene and Professional Appearances Dated 05/08/2019, stated that all culinary members who are responsible for food preparation and/or service shall wear hair restraints. Subsection titled <BR/>Hair Restraints:<BR/>During food preparation, team members wear hair restraints, such as hats, hair coverings or nets, beard restraints, and clothing that cover the body hair, which are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, lines, and single service items. All loose hair needs to be covered with hats or nets. Front of the house servers shall tie their hair back during service. All long and loose hair needs to be styled to be away from contact with exposed food, clean equipment, utensils, lines, and single service items. Standards Followed: We adhere to the current DFS Food Code guidelines.<BR/>Review of the facility's policy and procedures on Employee Hygiene and Dress Code - Food and Nutrition Services, dated 8/10/2022 revealed Hairnets or hair restraints and beard nets or beard restraints are used when cooking, preparing, and assembling food or ingredients.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Resident #7, Resident #29, Resident #39, and Resident #40) of fifteen residents observed for Infection Control. <BR/>1. <BR/>The facility failed to ensure that CNA C performed hand hygiene while providing incontinent care to Resident #7 and Resident #39.<BR/>2. <BR/>The facility failed to ensure that CNA B would not lower the catheter bag to the floor before transferring Resident #29.<BR/>3. <BR/>The facility failed to ensure that LPN D perform hand hygiene during Resident #40's wound care.<BR/>These failures could place the residents at risk of cross-contamination and development of infections.<BR/>Findings included:<BR/>1. <BR/>Review of Resident #7's Face Sheet, dated 08/21/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Resident #7 was diagnosed with spastic hemiplegia (muscles on one side of the body being in constant state of contraction) affecting left side.<BR/>Review of Resident #7's Comprehensive MDS Assessment reflected that the resident was not able to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated Resident #7 was frequently incontinent for bladder and bowel and dependent on staff for self-care needs.<BR/>Review of Resident #7's Comprehensive Care Plan, dated 07/02/2024, reflected that the resident had bowel and bladder incontinence and one of the interventions was to provide skin care after each incontinent care.<BR/>Observation on 08/21/24 at 10:52 AM revealed CNA C and CNA F washed their hands in resident's room prior to providing incontinence care. CNA C explained to Resident #7 what the staff was going to do. CNA F stood on the opposite side of the bed. CNA F assisted CNA C to pull Resident #7's pants down and unfasten tabs on the brief. CNA C cleaned one side of the labia, from the top down, repeated on the other side, and then the vaginal area from the top down. A clean wipe was used with each pass. CNA C removed the soiled gloves and put on clean gloves. CNA C did not sanitize her hands before putting on the new gloves. CNA F assisted CNA C to roll Resident #7 on her right side and CNA F held Resident #7 while CNA C cleaned Resident #7s bottom. CNA C cleaned each side of Resident #7's bottom, then the rectal area, wiping away from the vagina. A clean wipe was used with each pass. CNA C removed the soiled gloves and applied clean gloves. CNA C did not sanitize her hands before putting on the new gloves. CNA C placed a clean brief under Resident #7 and Resident #7 was turned to lie flat on the bed. CNA F and CNA C secured the tabs on the front of the brief and pulled up Resident #7's pants. CNA C and CNA F removed their gloves washed their hands in the sink before leaving Resident #7's room. <BR/>Review of Resident #39's Face Sheet, dated 08/21/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Resident #39 was diagnosed with need for assistance with personal care.<BR/>Review of Resident #39's Comprehensive MDS Assessment, dated 05/17/2024, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated Resident #39 was frequently incontinent for bladder and bowel.<BR/>Review of Resident #39's Comprehensive Care Plan, dated 05/17/2024, reflected that the resident had an ADL selfcare performance deficit and one of the interventions was to assist to bathroom every 2 hours while awake.<BR/>Observation on 08/21/2024 at 7:11 AM revealed CNA C was about to transfer Resident #39 to her wheelchair because the resident wanted to go to the bathroom. CNA C put on a pair of gloves. He did not do hand hygiene before putting on the gloves. CNA C then transferred Resident #39 from bed to wheelchair and ushered the resident to the bathroom. When inside the bathroom, CNA C transferred the resident from the wheelchair to the toilet. While the resident was sitting on the toilet, CNA C took off the resident's hospital gown and put a new blouse on. CNA C then took the waste can and pulled a plastic bag from beneath the waste can. He did not change his gloves nor did hand hygiene after touching the waste can. When the resident said she was done, CNA C ripped the soiled brief on both sides and threw it in the waste can. CNA C then requested the resident to stoop forward and cleaned the resident's bottom. After cleaning the resident's bottom, CNA C took the new brief from the sink and put it on the resident. After putting the new brief, CNA C put on the resident's pants. He did not change his gloves nor performed hand hygiene after cleaning the resident's bottom. CNA C then transferred the resident to her wheelchair. CNA C washed his hands after incontinent care.<BR/>An interview with CNA C on 08/21/2024 at 11:00 AM, CNA C stated hands should be washed or sanitized before and after doing incontinent care. He said the hands should also be sanitized before putting on clean gloves. CNA C said hand hygiene was important to prevent the spread of germs and that staff had an in-service on incontinence care about a month ago. He said he should have done hand hygiene and changed his gloves after touching the waste can, after touching the soiled brief, after cleaning the resident's bottom, and before touching the new brief.<BR/>In an interview with LPN A 08/22/2024 at 08:32 AM, LPN A stated hand sanitizer and handwashing was part of the staff's uniform, especially those that were providing direct care. She said staff should use sanitizer before going inside a room and when they come out of the room. She said, during incontinent care, the staff should do hand hygiene before and after. She continued that the gloves should be changed after touching anything that was dirty or soiled and before touching the clean items. She said hands should also be sanitized in between changing of gloves. She said sanitizers were available in the halls and sanitizers in a container were provided by the facility. LPN A said if hand hygiene and changing of gloves were not done, cross contamination and infection could happen. <BR/>An interview with the QAPI Nurse Manager on 08/22/24 at 08:57 AM revealed when she made her rounds and staff observation, she reminded them to sanitize before going inside the room of the residents and before touching the residents. She said staff should wash hands or sanitize before putting on new gloves. She said staff should wash their hands or use hand sanitizer before and after providing care. She said by doing so, cross contamination could be prevented.<BR/>2. Review of Resident #29's Face Sheet, dated 08/21/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Resident #29 was diagnosed with neuromuscular dysfunction of the bladder (the muscles and nerves that control the bladder do not work properly due to illness).<BR/>Review of Resident #29's Quarterly MDS Assessment, dated 07/14/2024, reflected Resident #29 had a moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated that the resident had an indwelling catheter.<BR/>Review of Resident #29's Comprehensive Care Plan, dated 08/13/2024, reflected Resident #29 had an indwelling catheter related to neurogenic bladder (the normal bladder function is disrupted due to nerve damage) and one of the interventions was catheter care every shift.<BR/>Review of Resident #29's Physician Order, dated 11/07/2023, reflected CATHETER: 16fr (French: unit used to indicate the size of the catheter) with 10 cc balloon to dependent drainage. Change catheter and drainage bag monthly on the 13th, and PRN if dislodged or plugged and unable to clear with irrigation. One time a day starting on the 13th and ending on the 13th every month related to NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED AND as needed for patency.<BR/>Observation on 08/20/2024 at 9:47 AM revealed CNA B was about to transfer Resident #29 from wheelchair to the recliner. It was observed that the resident had catheter bag hanging at the bottom of the wheelchair. The catheter bag was inside a privacy bag. Before transferring the resident to the recliner, CNA B took the catheter bag from the privacy bag and put it on the floor. CNA B proceeded with the transfer. When the resident was already in the recliner, CNA B took the catheter bag from the floor and hung it on the side of the recliner. CNA B put the catheter bag inside the privacy bag. The privacy bag was touching the floor.<BR/>In an interview with CNA B on 08/21/2024 at 2:07 PM, CNA B stated the catheter bag or the privacy bag should not be touching the floor because germs could get inside. She said she should have transferred the resident first and then hook the catheter bag at the side of the recliner or hook first the catheter bag on the recliner then transfer the resident. She said instead of transferring the catheter bag to the recliner, she should have just placed it at the side of the wheelchair to make sure the privacy bag was not touching the floor. <BR/>In an interview with LPN A on 08/22/2024 at 8:32 AM, LPN A stated the Foley bag should not touch the floor because it would pick up germs and could cause infection such as urinary tract infection. She said even though the catheter bag was inside privacy bag, the privacy bag should not touch the floor. She said she would check to ensure Resident's 29's bag was not touching the floor.<BR/>3. Review of Resident #40's Face Sheet, dated 08/21/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Resident #40 was diagnosed with venous thrombosis (blood clot forms in the veins) and venous embolism (clot travels through the vein).<BR/>Review of Resident #40's Comprehensive MDS Assessment, dated 05/21/2024, reflected that the resident had a severe impairment in cognition with a BIMS score of 01. The Comprehensive MDS Assessment indicated Resident #40 was at risk of developing pressure ulcer (injury to skin due to prolonged pressure).<BR/>Review of Resident #40's Comprehensive Care Plan, dated 06/30/2024, reflected that the resident had an actual impairment to skin integrity R/T immobility to right lateral ankle and one of the interventions was to monitor location, size, and treatment of skin injury.<BR/>Review of Resident #40's Physician Order, dated 08/09/2024, reflected Apply skin prep to peri (around) wound, apply Alginate Calcium cover with island dressing daily, x 30-day one time a day for right lateral ankle.<BR/>Observation and interview on 08/21/2024 at 9:57 AM revealed LPN D was about to do wound care. She sanitized her hands and put on a gown and a pair of gloves. LPN D prepared the things needed for wound care. She said the treatment for the resident's wound to the right ankle was cleaned with normal saline, apply calcium alginate, and then cover with a border dressing. Before doing the wound care, she took off her gloves, went to the other side of the bed, grabbed the waste basket with her bare hands, and placed it on her side. After touching the waste basket, LPN D proceeded to put on a pair of gloves. After placing the waste basket on her side, LPN D proceeded with wound care. She did not perform hand hygiene before putting on a new pair of gloves. She said she should have worn a pair of gloves before touching the waste basket because apparently the waste basket was dirty. She also said that she should have washed her hands after touching the waste basket. She said not changing the gloves and doing hand hygiene could cause infection.<BR/>In an interview with the ADON on 08/22/2024 at 7:15 AM, the ADON stated hand hygiene was included in all the procedures of any care. She said the staff should be mindful that they were to take care of the residents and not give them additional medical issues. She said the staff should do hand hygiene before and after any care. She said gloves should be changed when transitioning from dirty to clean. She said for these instances, after touching the waste can, after touching the soiled brief, and after cleaning the residents' bottom. She said the hands should be washed or sanitized before putting on a new pair of gloves. She also said that the catheter bag should always be off the floor, even though the catheter bag was inside a privacy bag. She said all the issues discussed were causes of cross contamination and probable development of infections. She said the expectation was for the staff to do hand hygiene before and after every care, after changing their gloves, when transitioning from a dirty area to a clean area, sanitizing their hands when changing their gloves, and not to put the catheter bag on the floor. The ADON said she would coordinate with the DON on how to go forward.<BR/>In an interview with the DON on 08/22/2024 at 7:35 AM, the DON stated all the staff should know that hand hygiene was the most effective way to prevent cross contamination and infection. He said, first, the gloves should be changed after touching any soiled items. He said for this case, the gloves should have been changed after removing the soiled brief, after cleaning the resident's bottom, and after touching the waste basket. He continued that secondly, every time staff change their gloves, they should do hand hygiene before putting on a new pair of gloves. He said there could be instances that while they were providing care, the staff did not notice the gloves were torn, and the germs could enter the gloves and soil the hands. He said that was why it was important to do hand hygiene when changing the gloves. He said this should have been done during incontinent care and wound care. He also said, the catheter bag should not be placed on the floor during transfer. He said the staff could have just left it on the side of the wheelchair to be sure it was off the floor. He said the expectation was for the staff to do hand hygiene before and after any care, to change their gloves from dirty to clean, to do hand hygiene when changing the gloves, and not to put the catheter bag on the floor. He said he would do an in-service about infection control immediately after the interview and he would monitor the staff.<BR/>In an interview with the Administrator on 08/22/2024 at 7:53 AM, the Administrator stated not doing hand hygiene before and after any care, not changing the gloves after touching soiled items, not sanitizing the hands in between changing of gloves, and placing the catheter bag on the floor could contribute to cross contamination and probable infection. She said the expectation was for the staff to follow the policy and procedures pertaining to infection control. She said he would collaborate with the DON to in-service the staff about infection control.<BR/>Review of facility policy, Hand Hygiene Policy Infection Prevention revised 03/29/2022 revealed Purpose . to establish hand hygiene as the single most important factor in preventing the spread of disease-causing organisms . Policy . All employee in patient care areas will adhere . hand hygiene . 1. Entering room . 2. Before clean task . 3. After bodily fluid/Glove removal . 4. Exiting room . When moving from contaminated body site to clean body site.<BR/>Review of facility policy, Catheter: Care, Insertion, & Removal, Drainage bags, Irrigation, Specimen - AL, R/S & LTC Policy Assisted Living: Rehab/Skilled & Long-term Care revised 07/30/2024 revealed Policy . Catheter tubing/drainage bags . should never be allowed to touch the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 6 (room [ROOM NUMBER], #1111, #1113, #1114, #1115, and #1116) of 12 resident rooms and the facility's high traffic areas reviewed for cleanliness and sanitization.<BR/>The facility failed to ensure that Resident Rooms #1109, #1111, #1113, #1114, #1115, and #1116 were thoroughly cleaned and sanitized.<BR/>This failure could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. <BR/>Findings included:<BR/>An observation on 08/20/24 at 10:44 AM of Resident room [ROOM NUMBER] reflected the corners of the floor in the resident bathroom had dirt particles and built-up dust. The widow blinds had a film of this dust on them. The trashcan in the bathroom had no trash bag in it, and it had two unused adult diapers in it. The backside of the entry door had black dirt stains near the door handle and the door frame.<BR/>An observation on 08/20/24 at 10:49 AM of Resident room [ROOM NUMBER] reflected the corners of the floor in the resident bathroom and behind the toilet, had dirt particles and built-up dust. The sink drain hole had rust on the metal ring circling the drain hole.<BR/>An observation on 08/20/24 at 10:53 AM of Resident room [ROOM NUMBER] reflected the corners of the floor in the resident bathroom and behind the toilet, had dirt particles and built-up dust. <BR/>An observation on 08/20/24 at 10:57 AM of Resident room [ROOM NUMBER] reflected the corners of the floor in the resident bathroom and behind the toilet, had dirt particles and built-up dust. The sink drain hole had rust on the metal ring circling the drain hole. The light greenish bedside table in the resident's room had dried up brownish stains and black dirt stains along the bottom of the table. <BR/>An observation on 08/20/24 at 11:18 AM of Resident room [ROOM NUMBER] reflected the corners of the floor in the resident bathroom and behind the toilet, had dirt particles and built-up dust. The trashcan in the resident room had reddish and brownish stains all over the outside of the trashcan.<BR/>An observation on 08/20/24 at 11:23 AM of Resident room [ROOM NUMBER] reflected the corners of the floor in the resident bathroom and behind the toilet, had dirt particles and built-up dust. There was a dead cricket near the trashcan in the bathroom. The floor in front of the toilet had yellowish stains.<BR/>In an interview on 08/22/24 at 10:13 AM, Housekeeper A stated she had been cleaning for 12 years. She stated she cleaned the 100 and 400 halls, but they sometime switched up. She stated they were supposed to clean everything in the room, such as the bathroom, floors, and wipe things down. She stated the residents liked her because she got things done. She was shown pictures of the concerns observed in resident room [ROOM NUMBER], #1111, #1113, #1114, #1115, and #1116, and she stated she was concerned that her peers were not consistent when cleaning rooms and she had received feedback from residents with the same concerns. She stated she worked to ensure the residents room were thoroughly cleaned but her peers skipped over areas and then the dirt would build up. She stated she had pointed this out to housekeeping supervisor, but she had not seen any changes in their behaviors.<BR/>In an interview on 08/22/24 at 10:26 AM, the Environmental services supervisor stated he had been at the facility for 37 years. He stated housekeeping were supposed to clean everything in the room, but sometimes they were unable to clean everything every day. He was shown pictures of the concerns observed in resident room [ROOM NUMBER], #1111, #1113, #1114, #1115, and #1116, and he stated he had inspected the rooms to ensure they were cleaned but needed to look a little closer. He stated deep cleaning was done as needed, but it was primarily done once a month. He stated the concerns observed were an infection control concern, and it could also impact their morale.<BR/>In an interview on 08/22/24 at 10:50 AM, the Administrator stated she had not been made fully aware of the concerns observed in the resident rooms. She was shown pictures of the concerns observed in resident rooms #1109, #1111, #1113, #1114, #1115, and #1116. She stated that she would follow-up with the Environmental services supervisor to ensure these concerns were addressed. She stated her expectation was for housekeeping to ensure they were thoroughly cleaning rooms. She stated the risk of not thoroughly cleaning resident rooms could result in infections and it was not good for their dignity. <BR/>Review of the facility's policy on Housekeeping (undated) reflected Rehabilitation/skilled care settings provide care and services to residents who are often vulnerable to infections and effects of infections due to weakened immune systems. As such, thorough, routine, and high-quality cleaning procedures are necessary to minimize the prevalence of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Residents #37) of 6 residents reviewed for (ADLs) care provided to dependent residents.<BR/>1.The facility failed to ensure Resident #37 received scheduled showers for his days scheduled, nor had had the resident received any unscheduled showers reviewed since the resident was admitted to the facility on [DATE]. <BR/>2. The facility failed to ensure Resident #37's toes were trimmed since admitting to the facility on [DATE]. <BR/>These failures placed the resident at risk of not receiving necessary services to maintain good personal hygiene and decreased self- esteem.<BR/>Findings included:<BR/>Record review of Resident #37's Face Sheet, dated 08/21/2024, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included Kidney Failure and required ADL assistance. <BR/>Record review of Resident #37's Quarterly MDS dated [DATE] revealed, he had a BIMS score of 12 (cognitively intact) and for ADL care it stated, for transfers, toileting, and bathing, the resident required total assistance.<BR/>In an observation and interview on 08/20/24 at 11:05 AM, Resident #37 was observed sitting in his wheelchair in his room. His clothing appeared dingy and stained. His feet were observed, and his toenails were at least a &frac12; long. He was asked if he was receiving his showers and he shook his head no. He was asked if he wanted a shower, and he shook his head yes. He was asked if he wanted his toenails trimmed and he shook his head yes. <BR/>Record review of the facility's shower sheet for Resident #37 from 07/21/24 to 08/21/24 reflected refused showers for the resident on 07/24/24, 08/01/24, 08/23/24, 08/08/24, 08/13//24, and 08/15/24.<BR/>In an interview on 08/22/24 at 08:55 AM, CNA A stated she had been at the facility for nearly 6 years. She stated that Resident #37 normally showered in the evenings. She stated they completed shower sheets, and she was scheduled to provide the resident a shower today. She stated if a resident refused a shower, the CNA attempted to convince the resident to take a shower and if the resident refused, they had to get a nurse to go in the room with them to hear them attempt to provide the resident a shower and if the resident refused, they would chart it as a refusal. She stated that they were supposed to document the refusal in the progress notes and then the nurses and DON would receive an alert. She stated she had observed the resident's toe nails today and they were horrible. She stated she had not told a nurse because today was her first day working with the resident in quite a while. She stated she normally tells a nurse when she observed toenails that needed to be trimmed and they would say that they were scheduling a podiatrist to come to the facility to trim resident toes nails. She stated that if the resident was not receiving his scheduled showers, he could have an infection and his toes could get cuts. She stated the resident was a sweet guy and she had not known him for refusing showers, maybe from certain CNAs he might not like, but she had not had any problems. She stated he was scheduled to receive his showers on Tuesday, Thursday, and Saturday. <BR/>In an interview on 08/22/24 at 09:13 AM, RN D stated she had been at the facility for 6 years and she was the 06:00 AM - 02:00 PM nurse for the 100 hall. She was advised that Resident #37 shower information was reviewed from 07/21/24 to 08/21/24 and it indicated that he had refused all of his showers. She stated that if a resident refused a shower, the CNA must alert the nurse and if the resident still refused, they must alert the DON. She stated the DON would attempt to encourage him into taking a shower. She stated she was not sure if the resident refused showers, because he was scheduled to receive his showers in the evenings. She stated if the resident continued to refuse a shower, they must also document it in the progress notes. She stated she had noticed the length of the resident's toenails and stated that he was on the podiatrist list, and they came every three months. She stated that the resident arrived at the facility with the long toenails, but no action was taken. She stated the resident was not a diabetic, so she was able to trim the resident's toenails. She stated the resident could get an infection or the resident could have skin problems if he did not receive showers or have his feet manicured.<BR/>In an interview on 08/22/24 at 09:50 AM, the DON stated he was made aware of the concerns for Resident #37 by RN D, and he stated he was unaware that the resident was refusing showers. He stated that if a resident refused a shower, it must be documented, and the nurse must inform him. He stated that he was unaware of the resident ever refusing showers and he had never observed the resident's feet. He stated that the nurses were able to trim resident toenails, but a lot of them were uncomfortable trimming toenails. He confirmed that the resident was not a diabetic, so the nurses were able to trim his toes. He stated that he was told by his staff that the resident had arrived at the facility on 06/25/24 with his toenails in bad condition but no one had made him aware of the need for his feet to be addressed at that time. He stated that if the resident refused showers, it should have been care planned. He stated the risk of the residents, feet not being addressed could result in him getting an infection, and the resident not getting showers could result in skin problems. <BR/>Record review of facility policy on Bathing, dated 08/29/2023, <BR/>Purpose:<BR/>Promote cleanliness and general hygiene.<BR/>To stimulate circulation of the skin<BR/>To promote comfort, relaxation, and wellbeing.<BR/>To observe resident's condition.<BR/>To assist resident with personal care.<BR/>To promote safety for the resident in the bath.

Based on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. <BR/>The facility failed to ensure foods in the facility's dry storage area, refrigerator, and freezer were stored and dated according <BR/>to guidelines.<BR/>The facility failed to ensure that staff was wearing the proper head coverings when serving food.<BR/>The facility failed to ensure staff wore gloves when preparing food and remove, wash hands and doff new gloves during <BR/>kitchen task changes according to guideline.<BR/>These failures could place residents at risk for cross contamination.<BR/>Findings included:<BR/>In an observation of the kitchen on 07/18/23 at 9:00 AM the following were observed:<BR/>Two large box of yellow onions (approximately 20 or more) and purple onions approximately (18 or more )were unlabeled in <BR/>the refrigerator.<BR/>Seven boxes of brown boxes of food placed on the floor at the back of the freezer unlabeled. <BR/>All frozen foods in the facility freezer that were shelfed were unlabeled. Brisket, crab meat, other frozen meets, frozen green <BR/>beans and other vegetables <BR/>One large silver bowl with cooked potato cubes uncovered on the prep table in the kitchen.<BR/>One large silver bowl of chopped chicken uncovered on prep table in kitchen.<BR/>Observation and interview with DW A on 07/18/23 at 09:00 AM revealed DW A was observed entering and exiting the facility's only kitchen, DW A was observed not wearing a hairnet, and using a surgical mask to cover his facial hair. Which was exposed on jaw line. He stated that the DM approved for him to wear a surgical mask in the kitchen to cover his beard. He was then directed by the DM to discard the surgical mask and put on a beard covering. DW A followed the directions and returned wearing a beard mask. A revisit to the kitchen on 07/18/23 at 11:30 AM DW A was wearing beard covering. <BR/>Observation and interview with DA B on 07/18/23 at 09:03 AM DA B was wearing a blue ball cap with his hair exposed in the back and not covered with a beard restraint. She was observed on 07/17/23 at 11:30 AM prepping soup without gloves. She was pouring soup back in the electric heating device, then scooped back out in the soup bowls. She then gathered a paper town and wiped the spilled soup off the counter and bowls, and returned to task. She was not wearing gloves and was not observed handwashing before returning.to the task.<BR/>Observation of DA S on 07/18/23 at 11:50 AM in the facility's only kitchen revealed DA S in the kitchen preparing food for lunch and he changed kitchen task from the fryer, adjusted his gloves on the left hand with fingers from the right hand. Proceeding to a second task without removing gloves, hand washing , and doffing a new pair of gloves. The DM was notified immediately of the concern and the staff changed gloves and hand washed. No food was touched only utensils that were placed for washing. The gloves were loose fitting.<BR/>. <BR/>Interview with Dietary Manager on 07/20/23 at 09:00 AM revealed he had been the Dietary Manager for the Facility's only kitchen for 2 years. He was advised of the two (2) kitchen staff who were not in compliance with head and face covering and hand sanitation. He said the labels in the freezer and refrigerator were not labeled because the cold environment caused the labels to fall off. He does not like to label with black marker, so he was not labeling. He said boxes should not be stored on the floor per guidelines, however the truck just delivered the boxes and he was notified of the inspection by the administrator. He said the crab meat packages fell off the top shelf to the freezer floor. Dietary manager said it was important to wash hands and use gloves before and after handling food and changing kitchen task. He stated the risk of staff not wearing their head and face coverings appropriately could result in air borne illnesses. He advised that he would in-service his staff on Employee Hygiene and Dress Code. Dietary manager revealed all cooks and diet aides were responsible for labeling and dating inventory as they are delivered. He advised they must put a name on it and that day's date on it., which includes can goods. He stated first in first out. He was shown pictures of the concerns and He stated that all staff were required to monitor for any of these concerns and correcting it, but the dietary manager was overall responsible for ensuring that it is corrected. He stated whoever puts up the inventory must also check for expired foods and ensure all foods are sealed appropriately. She stated the risk of these issues not being resolved could result in spread of bacteria. The Dietary Manager displayed an In-service on proper head and face coverings with kitchen staff completed on 07/19/23. <BR/>Interview with RD on 07/20/23 at 9:30 AM revealed he and all cooks and diet aides are responsible for labeling and dating. He advised staff must label and put the date the shipment for kitchen. He was shown pictures of concerns referenced previously and he advised that everyone was responsible for ensuring these concerns do not happen and the Dietary Manager was overall responsible for monitoring and identifying any of the concerns mentioned including proper hair coverings. <BR/>In an interview with DA B on 07/20/23 at 9:45 AM revealed she always wore a ball cap for a hair covering and she forgot to put on her gloves for the policy was to wear gloves while handling food. She said failing to cover hair and practice hand sanitation while handling food could result in her hair falling into the food and causing food realted illneses. She attended the in-service on 07/19/23. <BR/>An interview was requested with DW A on 07/20/23 at 9:50 AM and the DM stated he was not working today. DW A signature was observed on the Inservice conducted on 7/19/23.<BR/>An interview was requested with DA S on 07/20/23 at 9:57AM and the DM stated that he was not working today. DA S signature was observed on the Inservice conducted on 7/1923.<BR/>Review of the facility's policy and procedures on Food Storage, dated 06/21/2022, revealed The product should not be consumed after the date on the package due to the product's perishable nature and the product should be disposed of. Foods that have been opened or prepared must be covered<BR/>Review of dietary policies and procedures Titled Personal Hygiene and Professional Appearances Dated 05/08/2019, stated that all culinary members who are responsible for food preparation and/or service shall wear hair restraints. Subsection titled <BR/>Hair Restraints:<BR/>During food preparation, team members wear hair restraints, such as hats, hair coverings or nets, beard restraints, and clothing that cover the body hair, which are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, lines, and single service items. All loose hair needs to be covered with hats or nets. Front of the house servers shall tie their hair back during service. All long and loose hair needs to be styled to be away from contact with exposed food, clean equipment, utensils, lines, and single service items. Standards Followed: We adhere to the current DFS Food Code guidelines.<BR/>Review of the facility's policy and procedures on Employee Hygiene and Dress Code - Food and Nutrition Services, dated 8/10/2022 revealed Hairnets or hair restraints and beard nets or beard restraints are used when cooking, preparing, and assembling food or ingredients.

**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 care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #19) of thirteen residents reviewed for dignity.<BR/>The facility failed to treat Resident #19 with dignity and promote enhancement of her quality of life when the resident was not provided a privacy bag for her catheter bag.<BR/>This failure placed residents at risk of not having their right to a dignified existence maintained.<BR/>Findings included: <BR/>Review of Resident #19's Face Sheet, dated 08/21/2024, reflected that the resident was an [AGE] year-old female admitted on [DATE]. Resident #19 was diagnosed with neuromuscular dysfunction of bladder (the muscles and nerves that control the bladder do not work properly due to illness).<BR/>Review of Resident #19's Quarterly MDS Assessment, dated 07/13/2024, reflected Resident #19 was cognitively intact with a BIMS score of 13. The Quarterly MDS Assessment indicated that the resident had an indwelling catheter.<BR/>Review of Resident #19's Comprehensive Care Plan, dated 06/28/2024, reflected Resident #19 had an indwelling catheter related to neurogenic bladder (the normal bladder function is disrupted due to nerve damage) and one of the interventions was catheter care every shift.<BR/>Review of Resident #19's Physician Order, dated 11/07/2023, reflected CATHETER: Foley 18fr (French: unit used to indicate the size of the catheter) with 10 cc balloon to dependent drainage. Change catheter and drainage bag monthly on the 3rd, and prn one time a day every 1 month(s) starting on the 3rd for 1 day(s) related to NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED <BR/>AND as needed for patency.<BR/>Observation and interview with Resident #19 on 08/21/2024 at 6:30 AM revealed Resident #19 was in her bed, awake. Resident #19 had a catheter bag hanging at the railings below her bed. The urine inside catheter bag was observed visible from the hallway and upon entrance to the room. The catheter bag did not have a privacy bag. Resident #19 stated she had the catheter for the longest time because there was something wrong with her bladder. Resident #19 said she was not aware her catheter bag was exposed. Resident #19 said she did not know how long it had been exposed.<BR/>Observation on 08/21/2024 at 7:13 AM revealed Resident #19's catheter bag was still hanging on the railings below her bed. It still did not have a privacy bag. The content of the catheter bag was still visible from the hallway and upon entrance to the room.<BR/>In an interview with CNA C on 08/21/2024 at 7:15 AM, CNA C confirmed that Resident #19's catheter bag did not have a privacy bag. CNA C stated he saw it when he made his rounds, and he should have gotten a privacy bag as soon as he saw it. CNA C said the privacy bag was used so that the content of catheter bag wiould not be seen by other people. CNA C added that the privacy bag was used to prevent embarrassment. CNA C said he would get a privacy bag and put it on the railing below the bed. CNA C said the resident had a privacy bag on the wheelchair but then said there should also be a privacy bag when the resident was inside the room.<BR/>In an interview with LPN A on 08/22/2024 at 8:32 AM, LPN A stated the staff needed to make sure Foley bags were inside a privacy bag. LPN A said there should be a privacy bag for the catheter bag so that it will not be visible to other residents or visitors. She said without the privacy bag, the resident might be embarrassed, humiliated, or uncomfortable going out of the room. She said she did not notice the urine drainage bag was exposed the day before. She said she would make a round and check if the residents with catheter had their privacy bags. She said she was responsible in making sure the catheter bag had a privacy bag.<BR/>In an interview with the ADON on 08/22/2024 at 7:15 AM, the ADON stated all the residents should be treated with dignity. She said dignity could be in the form of pulling the privacy curtain while providing care or making sure nothing was exposed when transporting the residents. She said, for a resident with catheter, there should be privacy bag to maintain dignity. She said the expectation was for the staff to be mindful of the feelings of the residents with catheter. She said they would do an in-service pertaining to maintaining the residents' dignity.<BR/>In an interview with the DON on 08/22/2024 at 7:35 AM, the DON stated the catheter bag should have been placed inside a privacy bag to avoid embarrassment and humiliation. The DON said all the residents had the right for a dignified existence and not having a privacy bag was not one of them. She said all the staff, including her, were responsible in providing dignity to the residents with catheter. The DON said the expectation was for the staff to make sure the catheter bag had a privacy bag when the resident was inside or outside the room. She concluded that she would continually remind the staff the importance of dignity and privacy for residents with catheter through an in-service.<BR/>In an interview with the Administrator on 08/22/2024 at 7:53 AM, the Administrator stated her expectation was for all the staff to provide dignity to all the residents. She said a catheter bag without a privacy bag was a dignity issue because if the urine bag was visible from the hallway, it could cause embarrassment. She said he would coordinate with the DON concerning the privacy bag.<BR/>Review of facility policy, Resident Dignity - Rehab/Skilled Rehab/Skilled & Long Term Care: Therapy & Rehab revised 11/16/2023 revealed Purpose: To maintain dignity . Policy: The location will promote care . enhances each resident's dignity and respect in full recognition of his or her individuality . Procedure . l. Refraining from practices demeaning to residents such as keeping urinary catheter bags uncovered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #4 and Resident #23) of thirteen residents reviewed for reasonable accommodation of needs. <BR/>The facility failed to ensure the call light system in Resident #4 and Resident #23's rooms were in a position that was accessible to the residents.<BR/>This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.<BR/>Findings included: <BR/>Resident #4 <BR/>Review of Resident #4's Face Sheet, dated 08/20/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Resident #4 was diagnosed with generalized muscle weakness and chronic pain.<BR/>Review of Resident #4's Quarterly MDS Assessment, dated 08/15/2024, reflected that Resident #4 had a moderate impairment in cognition with a BIMS score of 12. Resident #4 required limited assistance for transfer and toileting. <BR/>Review of Resident #4's Comprehensive Care Plan, dated 05/16/2024, reflected that Resident #4 was at risk for falls and one of the interventions was to call for assistance.<BR/>Observation on 08/20/2024 at 9:32 AM revealed Resident #4 was in her wheelchair, awake. It was observed that the resident's call light was on the floor between the bed and the wall. <BR/>Observation and interview with Resident #4 on 08/20/2024 at 10:38 AM revealed Resident #4 was in her wheelchair, awake. Resident #4's call light was still on the floor between the bed and the wall of the room. Resident #4 stated she would use her call light if she needed assistance from the staff. She said she wanted her call light near her especially at night in case she could not stand up or move around. Resident #4 checked the side of her bed and said she could not find her call light. Resident #4 saw the cord of the call light behind her bed and said she could not reach it. She said she needed her call light to call the staff.<BR/>Resident #23 <BR/>Review of Resident #23's Face Sheet, dated 08/20/2024, reflected the resident was an [AGE] year-old female admitted on [DATE]. Resident #23 had history of falling.<BR/>Review of Resident #23's Quarterly MDS Assessment, dated 07/14/2024, reflected Resident #23 had a severe cognitive impairment with a BIMS score of 00. Resident #23 needed moderate assistance for transfers. <BR/>Review of Resident #23's Comprehensive Care Plan, dated 07/29/2024, reflected Resident #23 was at risk for falls related to gait balance problems and one of the interventions was to ensure/provide a safe environment.<BR/>Observation on 08/20/2024 at 9:43 AM revealed Resident #23 was on her wheelchair inside the room. It was observed that the resident's call light was on the floor at the end of the bed. The resident was asked about the call light, the resident only smiled back.<BR/>In an interview and observation with LPN A on 08/20/2024 at 10:42 AM, LPN A stated the call lights should be with the residents all the time because they used the call lights to call for assistance if needed. She said the residents used the call lights to communicate to the staff that they needed something. She added that if the call lights were not with the residents, the residents might fall. Some of the residents would be mad and frustrated because they could not call the staff. She said all the staff were responsible in making sure the call lights were within reach of the residents. LPN A went inside Resident #4's room and confirmed the call light was on the floor in between the bed and wall. LPN A pulled the call light and put it on top of the bed where Resident #4 could reach it. Then LPN A went to Resident #23's room and also confirmed that the call light was on the floor. LPN A picked up the call light and put it on top of the bed where Resident #23 could access it.<BR/>In an interview with the ADON on 08/22/2024 at 7:15 AM, the ADON stated the call lights should not be on the floor or in a place not accessible to the residents. The ADON said the call light must be within reach of the residents at all times because they use the call light to call the staff if they needed refill of their pitcher or if they needed to be changed. The ADON said if the call lights were far from the residents, the residents would not be able to call the staff and their needs would not be met. The ADON said the resident might even have a fall if they try to do things by themselves because they could not call the staff. The ADON said the expectation was for all the staff to make sure the call lights were within the reach of all the residents. The ADON said they would do an in-service about call lights being accessible to the residents. <BR/>In an interview with the DON on 08/22/2024 at 7:35 AM, the DON stated call lights were very essential for the residents and they should be placed where the residents could easily reach it. The DON said, for some residents, the call lights were the only way of communication between the residents and the staff. The DON said the call lights were used by the resident if they needed something, like pain medication, refill of water, or to turn the lights off. The DON said without the call lights, the needs of the residents would not be known and would not be met. The DON said the expectation was for the staff would be mindful that every time they leave the resident's room, the call lights were with the residents. The DON said he would conduct an in-service about the call lights. He said the in-service would be for the nurses, CNAs, housekeeping, therapists, and management. He said he would personally monitor that all the residents' call lights were within reach.<BR/>In an interview with the Administrator on 08/22/2024 at 7:53 AM, the Administrator stated the call lights should not be far from the residents because they were used by the residents to call the staff. The Administrator said the residents might be having an emergency and staff would not know. The Administrator said the staff should be sensible about call light placement. The Administrator said she would coordinate with the DON regarding call lights and would constantly remind them that before leaving the room, make sure the call lights were with the resident.<BR/>Record review of facility's policy Call Light - R/S, LTC, Therapy & Rehab /Skilled & Long Term Care: Therapy & Rehab revised 07/29/2024 revealed Purpose: To ensure resident always had a method of calling for assistance . Procedure . 4. When leaving the room, place call light within easy reach of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure assessments accurately reflected the resident's status for one (Resident #27) of six residents reviewed for Accuracy of Assessments.<BR/>The facility failed to ensure Resident #27's Quarterly MDS Assessment accurately reflected that Resident #27 was on oxygen therapy.<BR/>This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.<BR/>Findings included:<BR/>Review of Resident #27's Face Sheet, dated 08/21/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Resident #27 was diagnosed with chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and pleural effusion (collection of fluid around the lungs).<BR/>Review of Resident #27's Quarterly MDS Assessment, dated 04/13/2024, reflected Resident #27 was cognitively intact with a BIMS score of 15. Resident #27's Quarterly MDS Assessment did not indicate that the resident was on oxygen therapy.<BR/>Review of Resident #27's Comprehensive Care Plan, dated 08/02/2024, reflected Resident #27 had oxygen therapy related to COPD and one of the interventions was oxygen therapy continuous. <BR/>Review of Resident #27's Physician Order, dated 07/27/2022, reflected O2 via nasal cannula 1-3L every shift.<BR/>Observation and interview with Resident #27 on 08/21/2024 at 9:37 AM revealed the resident was on her wheelchair, awake. She was on oxygen administration via nasal cannula at 2 to 3 liters per minute. According to Resident #27, she was on oxygen for years because sometimes she had a hard time breathing. <BR/>In an interview with the ADON on 08/22/2024 at 7:15 AM, the ADON stated if a resident was using oxygen, it should be reflected on the system to make sure all the needed respiratory care was given to the resident. She added there should be an accurate assessment to know how to care for the residents. The ADON said if there was no accurate assessment, there could be a misunderstanding about the care needed by the resident and the resident might not be able to get the treatment needed. She said she would coordinate with the DON and the MDS Nurse to address the issues.<BR/>In an interview with the DON on 08/22/2024 at 7:35 AM, the DON stated an accurate assessment was important so that the staff would know how to take care of the residents. He said the care plan of the residents would be based on the assessment. He said if a resident was using oxygen, it should be reflected on the medical diagnosis, physician orders, the MDS, and the care plan. He said if the residents were not properly assessed, the proper care and needs would not be met. The DON said the expectation was that the residents were properly assessed not only during admission but every day to see if there were changes in condition, any refusal of care, or a resident acting different than usual. He said he would collaborate with the MDS Nurse and the ADON to audit the MDS Assessments and make proper changes.<BR/>In an interview with the Administrator on 08/22/2024 at 7:53 AM, the Administrator stated the MDS should reflect the current condition of the resident. She said, by doing so, the needs of the residents would be addressed. She said she would coordinate with the DON to evaluate the situation, discuss it during quality assurance, and conduct in-services.<BR/>Observation and interview with MDS Nurse on 08/22/2024 at 8:16 AM, the MDS Nurse stated she was responsible in doing the MDS Assessment and the care plan. She said once the staff put in the initial order, it would take seven days before the MDS was triggered. She said the medical diagnosis, physician order, the MDS, and the care plan should be all in-line and should match to provide a clear overview of the resident's current condition. She turned on the computer and went to Resident #27's profile. The MDS nurse reviewed the date of the resident's order for oxygen. The resident's Physician order reflected that the order for oxygen was placed on the system last 07/27/2022. She then checked the resident's MDS and confirmed that the resident was not triggered for oxygen use. The MDS nurse said the MDS was used to make the care plan. She said if the MDS was not triggered, the care might be missed. She said she would make an audit to make sure the MDS would reflect the current condition of the residents.<BR/>Record review of facility policy, Resident Assessment (Comprehensive Assessment), LTC Rehab/Skilled & Long-Term Care: Therapy & Rehab revised 07/20/2023 revealed Purpose: To identify the resident's care needs . Procedure . during examination . any shortness of breath.

**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 for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for three (Resident #9, Resident #15, and Resident #106) of eight residents reviewed for Care Plans. <BR/>1. <BR/>The facility failed to ensure Resident #9 was care planned for indwelling Foley catheter.<BR/>2. <BR/>The facility failed to ensure Resident #15 were care planned for oxygen administration.<BR/>3. <BR/>The facility failed to ensure Resident #106 were care planned for oxygen administration.<BR/>These failures could place the residents at risk of not receiving the necessary care and services.<BR/>Findings included:<BR/>1. <BR/>Review of Resident #9's Face Sheet, dated 08/21/2024, revealed Resident #9 was a [AGE] year-old male who was admitted to the facility 07/22/2024. Relevant diagnoses included benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged and not cancerous) with lower urinary tract symptoms and chronic kidney disease. <BR/>Review of Resident #9 Quarterly MDS Assessment, dated 07/28/24, revealed Resident #9 was cognitively intact with a BIMS score of 15, an indwelling foley catheter, and was dependent on staff for toileting hygiene.<BR/>Review of Resident #9's Physician Order, dated 07/22/2024, revealed Catheter: 18 f (French: unit used to indicate the size of the catheter) with cc balloon to dependent drainage.<BR/>Review of Resident #9's Comprehensive Care Plan on 08/21/2024 reflected no care plan for indwelling catheter.<BR/>Observation on 08/21/2024 at 12:46 PM revealed Resident #9 had a foley catheter hanging on his wheelchair. It was in a privacy bag and not touching the floor. <BR/>2. <BR/>Review of Resident #15's Face Sheet, dated 08/20/2024, reflected that the resident was an [AGE] year-old male admitted on [DATE]. Resident #15 was diagnosed with chronic respiratory failure (condition where there is not enough oxygen in the body or too much carbon dioxide in the body) with hypoxia (insufficient amount of oxygen in the body).<BR/>Review of Resident #15's Quarterly MDS Assessment, dated 07/23/2024, reflected that Resident #15 was cognitively intact with a BIMS score of 15. Resident #15's Quarterly MDS Assessment indicated that the resident had oxygen therapy while a resident of the facility.<BR/>Review of Resident #15's Physician Order, dated 07/27/2022, reflected Oxygen via nasal cannula 1-4 liters per minute continuously and as needed for dyspnea (difficulty in breathing), hypoxia (low level of oxygen in the blood) or acute angina (chest pain). As needed for dyspnea, hypoxia, acute angina, AND every shift.<BR/>Review of Resident #15's Comprehensive Care Plan on 08/20/2024 reflected no care plan for oxygen therapy.<BR/>Observation on 08/20/2024 at 9:09 AM revealed Resident #15 was on his bed, asleep. It was observed that Resident #15 had oxygen administration via nasal cannula at 3 liters per minute. The nasal cannula was connected to an oxygen concentrator.<BR/>In an interview with Resident #15 on 08/20/2024 at 11:27 AM, Resident #15 stated he had been using oxygen for almost two years. He said he used the oxygen day and night.<BR/>3. <BR/>Review of Resident #106's Face Sheet, dated 08/21/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Resident #106 was diagnosed with pneumonia (inflammation and fluid in the lungs caused by a bacterial, viral, or fungal infection) and anxiety disorder.<BR/>Review of Resident #106's Quarterly MDS Assessment, dated 04/30/2024, reflected Resident #106 was cognitively intact with a BIMS score of 15. Resident #106's Quarterly MDS Assessment did not indicate that the resident was on oxygen therapy.<BR/>Review of Resident #106's Physician Order, dated 08/16/2024, reflected Oxygen at 2 LPM (per nasal cannula, face mask, facial tent) via O2 concentrator and/or tank at bedtime every night shift for SOB.<BR/>Review of Resident #106's Comprehensive Care Plan on 08/21/2024 reflected no care plan for oxygen therapy.<BR/>Observation and interview with Resident #106 on 08/20/2024 at 9:09 AM revealed that Resident #106 was on her bed, awake. It was observed that she had a nasal cannula connected to an oxygen concentrator. According to Resident #106, she would use the oxygen at night.<BR/>In an interview with the ADON on 08/22/2024 at 7:15 AM, the ADON stated it was important that residents had a care plan to fully provide the care and services the residents needed. The ADON said that for this case, there should be a care plan for the indwelling catheter and oxygen administration. She said without the care plan, there could be confusion on the care of the residents and their needs would not be addressed. She said she was responsible in making the care plan. She said the expectation was all the issue of the residents were care planned.<BR/>In an interview with the DON on 08/22/2024 at 7:35 AM, the DON stated every resident needed a comprehensive care plan to make sure the residents received the applicable and appropriate care needed. The DON said the care plan should be in place so that the staff providing care would be on the same page. The DON stated the care plan was important because it reflected the resident's needs. He said the care plan should be resident-centered and should show what specific care the resident needed. He said the expectation was for all residents to have a complete and detailed care plan. He said he would coordinate with the ADON and the MDS Nurse to audit the care plans of the resident. <BR/>In an interview with the Administrator on 08/22/2024 at 7:53 AM, the Administrator stated all the residents should have a care plan appropriate to their needs. She said without the care plan, the staff would not know the goals and the interventions needed by the residents. The Administrator concluded that the expectation was for the staff to ensure that the residents were care planned accordingly. She said she would coordinate with the DON and the MDS Nurse to make sure all the residents were care planned.<BR/>Observation and interview with MDS Nurse on 08/22/2024 at 8:16 AM, the MDS Nurse confirmed that Resident #9 did not have a care plan for the indwelling catheter. She also confirmed that Resident #15 and Resident #106 did not have a care plan for oxygen therapy. She stated she missed it and would add the care plan for the indwelling catheter and oxygen therapy. The MDS Nurse stated care plans were important to ensure the residents were getting the care needed. She said care plans served as guides on how the staff would take care of the residents. The MDS Nurse added that without the care plans, the staff could miss significant interventions needed by the residents. <BR/>Record review of facility's policy, Comprehension Care Plan and Care Conferences - Rehab/Skilled Rehab/Skilled & Long-Term Care: Therapy & Rehab revised 12/04/2023 revealed Purpose: to develop a person-centered care plan for each resident . Procedure . 5. Formulating the care Plan . a. The care plan is driven by identified resident issues/conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Residents #27 and Resident #106 ) of eight residents reviewed for Respiratory Care.<BR/>1. <BR/>The facility failed to ensure Resident #27's breathing mask used for nebulization was properly stored.<BR/>2. <BR/>The facility failed to ensure Resident #106's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored.<BR/>These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.<BR/>Findings included: <BR/>1. <BR/>Review of Resident #27's Face Sheet, dated 08/21/2024, reflected that the resident was an [AGE] year-old female admitted on [DATE]. Resident #27 was diagnosed with chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and pleural effusion (collection of fluid around the lungs).<BR/>Review of Resident #27's Quarterly MDS Assessment, dated 04/13/2024, reflected Resident #27 was cognitively intact with a BIMS score of 15. Resident #27's Quarterly MDS Assessment indicated that the resident had COPD.<BR/>Review of Resident #27's Comprehensive Care Plan, dated 08/02/2024, reflected Resident #27 had oxygen therapy related to COPD and one of the interventions was oxygen therapy continuous. <BR/>Review of Resident #27's Physician Order, dated 03/01/2024, reflected Arformoterol Tartrate Inhalation Nebulization Solution (Arformoterol Tartrate) 2 ml inhale orally via nebulizer two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE.<BR/>Observation and interview with Resident #27 on 08/21/2024 at 9:37 AM revealed the resident was on her wheelchair, awake. It was noted that Resident #27's nebulizer machine was observed sitting on top of the resident's side table. A breathing mask was connected to the nebulizer machine. The breathing mask was observed on the table. The breathing mask was not bagged. The part of the nebulizer mask that touched the face when in use was in contact with the table. Resident #27 said she had a breathing treatment twice a day because of her breathing problem. Resident #27 said the nurse would put a solution on the container connected to the mask, would turn it on, and would put the mask on her face. Resident #27 said she was not sure if the nurse was putting it in a bag, but she never saw a bag for her nebulizer mask.<BR/>Observation and interview with LPN D on 08/20/2024 at 11:57 AM, LPN D stated the breathing mask should not be exposed nor touching anything because it could cause cross contamination and infection. LPN D said the breathing mask should be bagged when not in use. LPN D went inside Resident #27's room and confirmed the breathing mask was on top of the table. LPN D said she did administer the resident's breathing treatment but was not able to put the mask in the plastic bag when the treatment was done. LPN D disconnected the breathing mask and said she would obtain a new one and would put it in a plastic bag. LPN D went to her cart, opened the last drawer, took a new breathing mask and a plastic bag out. LPN D went back to Resident #27's room, connected the new breathing mask and then placed it inside a plastic bag.<BR/>2. <BR/>Review of Resident #106's Face Sheet, dated 08/21/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Resident #106 was diagnosed with pneumonia (inflammation and fluid in the lungs caused by a bacterial, viral, or fungal infection) and anxiety disorder.<BR/>Review of Resident #106's Quarterly MDS Assessment, dated 04/30/2024, reflected Resident #106 was cognitively intact with a BIMS score of 15. Resident #106's Quarterly MDS Assessment did not indicate that the resident was on oxygen therapy.<BR/>Review of Resident #106's Comprehensive Care Plan on 08/21/2024 reflected no care plan for oxygen therapy.<BR/>Review of Resident #106's Physician Order, dated 08/16/2024, reflected Oxygen at 2 LPM) (per nasal cannula, face mask, facial tent) via O2 concentrator and/or tank at bedtime every night shift for SOB.<BR/>Observation and interview with Resident #106 on 08/20/2024 at 9:09 AM revealed that Resident #106 was on her bed, awake. It was observed that she had a nasal cannula that was coiled on the railings of the resident's bed. The nasal cannula was not bagged. She said she would use the nasal cannula once in a while. She said sometimes the nurse would put it on and off. She said she never saw a plastic bag for her nasal cannula. <BR/>Interview with RN E on 08/21/2024 at 10:41 AM, RN E stated the nasal cannula should not be coiled in the railing of bed because the railing of the bed was not clean. She said this could cause cross contamination and probable infection. She said coiling the tubing of the nasal cannula could also compromise the passage of oxygen on the tubing. She said she did not notice that the nasal cannula was not bagged. She said she would check on Resident 106's nasal cannula. She said she would also change it and put it in a bag.<BR/>In an interview with the ADON on 08/22/2024 at 7:15 AM, the ADON stated the breathing mask, and the nasal cannula should be bagged when the resident was not using it to prevent cross contamination and infection. She said the staff who took off the mask and the nasal cannula should put it in a bag. She said if the resident was the one taking it off, there should be a bag ready for them to put the mask in. She also said that the resident should be educated why the mask should be bagged. She said the expectation was for the staff to bag the breathing mask and the nasal cannula when not in use. She said she would coordinate with the DON to conduct an in-service pertaining to bagging the nasal cannula and the breathing mask when the residents were not using them. She said she would also make a round to check if the breathing masks and nasal cannula not in used were bagged.<BR/>In an interview with the DON on 08/22/2024 at 7:35 AM, the DON stated the breathing mask, and the nasal cannula should be bagged when not in use to keep it clean. The DON said the proper way of storing the breathing mask and the nasal cannula was to place them inside the plastic bag when the resident was done with the breathing treatment or when the resident was not using the nasal cannula. He said if those breathing apparatus were not bagged, were exposed, or touching surfaces that were not clean, then oxygen administration could be compromised. The DON said the staff, including him, were responsible in monitoring that the breathing mask and the nasal cannula were bagged when not in use. He said the expectation was the breathing mask and the nasal cannula would be stored properly. The DON said she would continually remind the staff to be diligent in making sure the procedures for respiratory care were followed. He said he would re-educate the staff providing respiratory care.<BR/>In an interview with the Administrator on 08/22/2024 at 7:53 AM, the Administrator stated everything used by the residents should be kept clean. She said the nasal cannula and the breathing mask should be stored properly to prevent respiratory infections. The Administrator said the expectation was for the staff to do their due diligence in order to provide the highest level of respiratory care. The Administrator said he would coordinate with the DON to address the issue.<BR/>Review of facility policy Oxygen Administration, Safety, Mask Types - R/S, LTC, Therapy & Rehab Rehab/Skilled & Long -Term Care: Therapy & Rehab revised 07/08/2024 revealed Purpose: To keep oxygen equipment clean and maintained in good condition . Procedure . Oxygen cylinder . 14. When oxygen is not in use, store cannula, face mask . plastic bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that two (Resident #19 and Resident #48) of five residents were provided medications and/or biologicals and pharmaceutical services to meet their needs.<BR/>The facility failed to ensure MA re-ordered medications in a timely manner for Resident #19 (Torsemide 20 mg) and Resident #48 (Solifenacin 5 mg). <BR/>This failure could place the residents at risk of not receiving medications as ordered by the physician.<BR/>Findings included: <BR/>Resident # 19<BR/>Review of Resident #19's Face Sheet, dated 08/21/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included cystitis (inflammation of the bladder) and acute kidney failure.<BR/>Review of Resident #19's Quarterly MDS Assessment, dated 06/13/2024, reflected resident was cognitively intact with a BIMS score of 13. The Quarterly MDS Assessment also indicated Resident #19 had an acute kidney failure.<BR/>Review of Resident #19's Comprehensive Care Plan, dated 06/28/2024, reflected resident was on diuretic therapy the intervention was monitor resident's condition related to use of torsemide.<BR/>Review of Resident #19's Physician Order for torsemide, dated 07/27/2023, reflected Torsemide Oral Tablet 20 MG (Torsemide) Give 0.5 tablet by mouth one time a day for edema.<BR/>Resident #48 <BR/>Review of Resident #48's Face Sheet, dated 08/21/2024, reflected that resident was a [AGE] year-old male admitted on [DATE]. Resident #48 was diagnosed with chronic kidney disease.<BR/>Review of Resident #48's Quarterly MDS Assessment, dated 07/26/2024, reflected resident had a severe impairment in cognition with a BIMS score of 06. The Quarterly MDS Assessment indicated Resident #48 was diagnosed with renal (pertaining to the kidney) failure.<BR/>Review of Resident #48's Care Plan on 08/21/2024 revealed no care plan for renal failure.<BR/>Review of Resident #48's Physician's Order for Solifenacin 5 mg reflected Solifenacin Succinate Oral Tablet 5 MG (Solifenacin Succinate). Give 5 mg by mouth one time a day for antispasmodic.<BR/>In an observation and interview with MA on 08/21/2024 at 6:30 AM revealed MA was preparing Resident #19's medication. MA said Resident #19 did not have a blister pack for torsemide. She said she would ask the nurse to get it from the e-kit. MA looked for the nurse and told her that she needed torsemide for Resident #19. MA continued to prepare Resident #19's medication and then gave it to Resident #19. MA then prepared Resident #48's medication. MA placed the last pill of Resident #48's Solifenacin. MA finished preparing the medications and gave it to Resident #48. She said she did not have another blister pack for Resident #48's Solifenacin. She said she would check her cart because it might be with the other resident's medication. While still looking for the medication, the nurse came and gave her Resident #19's torsemide that was placed in a small plastic cup. MA checked the name and milligrams of the medication, opened it, placed it in a small cup, and gave it to Resident #19. MA said the medication should be re-ordered as soon as the medications reach the last line. MA explained they could re-order medications through the system, through faxing, or by calling the pharmacy. MA said she would go ahead and re-order the medications. MA said she was responsible for re-ordering medication that were running low. MA stated she did notice that the medications were running low but was not able to re-order them. MA said if medications were not re-ordered on a timely manner, the residents might run out of medications and their present medical situations might worsen. MA stated she would check her medication carts and re-order the medications that were running low.<BR/>In an interview with LPN A on 08/21/2024 at 1:50 PM, LPN A confirmed that MA asked her to get Resident #19's torsemide from the e-kit. She said the e-kit would be for emergencies and new admissions and not for the medications that were not re-ordered in a timely manner. She said the medications should have been re-ordered when there were only four or five medications left in the blister card. She said things could happen and the pharmacy would not be able to deliver or refill the e-kit. She continued that if that happened, the residents would not have medications to take. She said adverse outcome could happen. She stated sometimes the computer would let you know that it was time to re-order certain medications so there would be no reason for not re-ordering on a timely manner.<BR/>In an interview with the ADON on 08/22/2024 at 7:15 AM, the ADON stated the staff should re-order the medications once the medications hit the last dark line of the blister pack. The ADON said the nurses and the MA were responsible in re-ordering medications once they were running low. The ADON said if the MA was busy, the nurses could re-order the medications. The ADON said if the medications were not re-ordered on a timely manner, there could be a possibility the residents would not have their medications. The ADON added without the medications the medical issues of the residents could worsen. The ADON said the expectation was for the staff to be diligent in re-ordering the medications to prevent missed medications. The ADON said the facility had an e-kit but said the e-kit should not be used because the medications were not re-ordered in a timely manner. The ADON said she would do an in-service for ordering and re-ordering the medications. <BR/>In an interview with the DON on 08/22/2024 at 7:35 AM, the DON stated medications should be re-ordered in a timely manner. The DON said anything could happen that could affect the delivery of the medications from the pharmacy. The DON said the staff must make sure they re-order the medications in a timely manner so the residents would have their needed medications all the time. The DON said the staff should not wait for the last minute to re-order the medications. The DON said if the residents did not get their medications, their medical issues may worsen. The DON said they would in-service the staff about re-ordering medications. The DON said whichever staff observed the medication was running low should have re-ordered it. The DON continued the staff only needed to click the re-supply button on the residents' profile, fax it to the pharmacy, or call the pharmacy. The DON concluded the expectation was for the staff to be diligent in re-ordering medications and said they would audit all the carts, MA's and nurses', to check which medications needed re-ordering.<BR/>In an interview with the Administrator on 08/22/2024 at 7:53 AM, the Administrator stated the medications should be re-ordered on time to prevent missed medications. The Administrator said it was not good for the residents if they missed their medications. The Administrator said she would coordinate with the DON about the issue to address it.<BR/>Record review of facility policy, Local Pharmacy Medication ordering - R/S, LTC [NAME] Policy ENTERPRISE Rehab/Skilled & Long-Term Care: Therapy & Rehab revised 08/29/2023 revealed Procedure . 2. If a new medication or STAT medication . use emergency kit . medications are out . communicate to the pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Resident #7, Resident #29, Resident #39, and Resident #40) of fifteen residents observed for Infection Control. <BR/>1. <BR/>The facility failed to ensure that CNA C performed hand hygiene while providing incontinent care to Resident #7 and Resident #39.<BR/>2. <BR/>The facility failed to ensure that CNA B would not lower the catheter bag to the floor before transferring Resident #29.<BR/>3. <BR/>The facility failed to ensure that LPN D perform hand hygiene during Resident #40's wound care.<BR/>These failures could place the residents at risk of cross-contamination and development of infections.<BR/>Findings included:<BR/>1. <BR/>Review of Resident #7's Face Sheet, dated 08/21/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Resident #7 was diagnosed with spastic hemiplegia (muscles on one side of the body being in constant state of contraction) affecting left side.<BR/>Review of Resident #7's Comprehensive MDS Assessment reflected that the resident was not able to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated Resident #7 was frequently incontinent for bladder and bowel and dependent on staff for self-care needs.<BR/>Review of Resident #7's Comprehensive Care Plan, dated 07/02/2024, reflected that the resident had bowel and bladder incontinence and one of the interventions was to provide skin care after each incontinent care.<BR/>Observation on 08/21/24 at 10:52 AM revealed CNA C and CNA F washed their hands in resident's room prior to providing incontinence care. CNA C explained to Resident #7 what the staff was going to do. CNA F stood on the opposite side of the bed. CNA F assisted CNA C to pull Resident #7's pants down and unfasten tabs on the brief. CNA C cleaned one side of the labia, from the top down, repeated on the other side, and then the vaginal area from the top down. A clean wipe was used with each pass. CNA C removed the soiled gloves and put on clean gloves. CNA C did not sanitize her hands before putting on the new gloves. CNA F assisted CNA C to roll Resident #7 on her right side and CNA F held Resident #7 while CNA C cleaned Resident #7s bottom. CNA C cleaned each side of Resident #7's bottom, then the rectal area, wiping away from the vagina. A clean wipe was used with each pass. CNA C removed the soiled gloves and applied clean gloves. CNA C did not sanitize her hands before putting on the new gloves. CNA C placed a clean brief under Resident #7 and Resident #7 was turned to lie flat on the bed. CNA F and CNA C secured the tabs on the front of the brief and pulled up Resident #7's pants. CNA C and CNA F removed their gloves washed their hands in the sink before leaving Resident #7's room. <BR/>Review of Resident #39's Face Sheet, dated 08/21/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Resident #39 was diagnosed with need for assistance with personal care.<BR/>Review of Resident #39's Comprehensive MDS Assessment, dated 05/17/2024, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated Resident #39 was frequently incontinent for bladder and bowel.<BR/>Review of Resident #39's Comprehensive Care Plan, dated 05/17/2024, reflected that the resident had an ADL selfcare performance deficit and one of the interventions was to assist to bathroom every 2 hours while awake.<BR/>Observation on 08/21/2024 at 7:11 AM revealed CNA C was about to transfer Resident #39 to her wheelchair because the resident wanted to go to the bathroom. CNA C put on a pair of gloves. He did not do hand hygiene before putting on the gloves. CNA C then transferred Resident #39 from bed to wheelchair and ushered the resident to the bathroom. When inside the bathroom, CNA C transferred the resident from the wheelchair to the toilet. While the resident was sitting on the toilet, CNA C took off the resident's hospital gown and put a new blouse on. CNA C then took the waste can and pulled a plastic bag from beneath the waste can. He did not change his gloves nor did hand hygiene after touching the waste can. When the resident said she was done, CNA C ripped the soiled brief on both sides and threw it in the waste can. CNA C then requested the resident to stoop forward and cleaned the resident's bottom. After cleaning the resident's bottom, CNA C took the new brief from the sink and put it on the resident. After putting the new brief, CNA C put on the resident's pants. He did not change his gloves nor performed hand hygiene after cleaning the resident's bottom. CNA C then transferred the resident to her wheelchair. CNA C washed his hands after incontinent care.<BR/>An interview with CNA C on 08/21/2024 at 11:00 AM, CNA C stated hands should be washed or sanitized before and after doing incontinent care. He said the hands should also be sanitized before putting on clean gloves. CNA C said hand hygiene was important to prevent the spread of germs and that staff had an in-service on incontinence care about a month ago. He said he should have done hand hygiene and changed his gloves after touching the waste can, after touching the soiled brief, after cleaning the resident's bottom, and before touching the new brief.<BR/>In an interview with LPN A 08/22/2024 at 08:32 AM, LPN A stated hand sanitizer and handwashing was part of the staff's uniform, especially those that were providing direct care. She said staff should use sanitizer before going inside a room and when they come out of the room. She said, during incontinent care, the staff should do hand hygiene before and after. She continued that the gloves should be changed after touching anything that was dirty or soiled and before touching the clean items. She said hands should also be sanitized in between changing of gloves. She said sanitizers were available in the halls and sanitizers in a container were provided by the facility. LPN A said if hand hygiene and changing of gloves were not done, cross contamination and infection could happen. <BR/>An interview with the QAPI Nurse Manager on 08/22/24 at 08:57 AM revealed when she made her rounds and staff observation, she reminded them to sanitize before going inside the room of the residents and before touching the residents. She said staff should wash hands or sanitize before putting on new gloves. She said staff should wash their hands or use hand sanitizer before and after providing care. She said by doing so, cross contamination could be prevented.<BR/>2. Review of Resident #29's Face Sheet, dated 08/21/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Resident #29 was diagnosed with neuromuscular dysfunction of the bladder (the muscles and nerves that control the bladder do not work properly due to illness).<BR/>Review of Resident #29's Quarterly MDS Assessment, dated 07/14/2024, reflected Resident #29 had a moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated that the resident had an indwelling catheter.<BR/>Review of Resident #29's Comprehensive Care Plan, dated 08/13/2024, reflected Resident #29 had an indwelling catheter related to neurogenic bladder (the normal bladder function is disrupted due to nerve damage) and one of the interventions was catheter care every shift.<BR/>Review of Resident #29's Physician Order, dated 11/07/2023, reflected CATHETER: 16fr (French: unit used to indicate the size of the catheter) with 10 cc balloon to dependent drainage. Change catheter and drainage bag monthly on the 13th, and PRN if dislodged or plugged and unable to clear with irrigation. One time a day starting on the 13th and ending on the 13th every month related to NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED AND as needed for patency.<BR/>Observation on 08/20/2024 at 9:47 AM revealed CNA B was about to transfer Resident #29 from wheelchair to the recliner. It was observed that the resident had catheter bag hanging at the bottom of the wheelchair. The catheter bag was inside a privacy bag. Before transferring the resident to the recliner, CNA B took the catheter bag from the privacy bag and put it on the floor. CNA B proceeded with the transfer. When the resident was already in the recliner, CNA B took the catheter bag from the floor and hung it on the side of the recliner. CNA B put the catheter bag inside the privacy bag. The privacy bag was touching the floor.<BR/>In an interview with CNA B on 08/21/2024 at 2:07 PM, CNA B stated the catheter bag or the privacy bag should not be touching the floor because germs could get inside. She said she should have transferred the resident first and then hook the catheter bag at the side of the recliner or hook first the catheter bag on the recliner then transfer the resident. She said instead of transferring the catheter bag to the recliner, she should have just placed it at the side of the wheelchair to make sure the privacy bag was not touching the floor. <BR/>In an interview with LPN A on 08/22/2024 at 8:32 AM, LPN A stated the Foley bag should not touch the floor because it would pick up germs and could cause infection such as urinary tract infection. She said even though the catheter bag was inside privacy bag, the privacy bag should not touch the floor. She said she would check to ensure Resident's 29's bag was not touching the floor.<BR/>3. Review of Resident #40's Face Sheet, dated 08/21/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Resident #40 was diagnosed with venous thrombosis (blood clot forms in the veins) and venous embolism (clot travels through the vein).<BR/>Review of Resident #40's Comprehensive MDS Assessment, dated 05/21/2024, reflected that the resident had a severe impairment in cognition with a BIMS score of 01. The Comprehensive MDS Assessment indicated Resident #40 was at risk of developing pressure ulcer (injury to skin due to prolonged pressure).<BR/>Review of Resident #40's Comprehensive Care Plan, dated 06/30/2024, reflected that the resident had an actual impairment to skin integrity R/T immobility to right lateral ankle and one of the interventions was to monitor location, size, and treatment of skin injury.<BR/>Review of Resident #40's Physician Order, dated 08/09/2024, reflected Apply skin prep to peri (around) wound, apply Alginate Calcium cover with island dressing daily, x 30-day one time a day for right lateral ankle.<BR/>Observation and interview on 08/21/2024 at 9:57 AM revealed LPN D was about to do wound care. She sanitized her hands and put on a gown and a pair of gloves. LPN D prepared the things needed for wound care. She said the treatment for the resident's wound to the right ankle was cleaned with normal saline, apply calcium alginate, and then cover with a border dressing. Before doing the wound care, she took off her gloves, went to the other side of the bed, grabbed the waste basket with her bare hands, and placed it on her side. After touching the waste basket, LPN D proceeded to put on a pair of gloves. After placing the waste basket on her side, LPN D proceeded with wound care. She did not perform hand hygiene before putting on a new pair of gloves. She said she should have worn a pair of gloves before touching the waste basket because apparently the waste basket was dirty. She also said that she should have washed her hands after touching the waste basket. She said not changing the gloves and doing hand hygiene could cause infection.<BR/>In an interview with the ADON on 08/22/2024 at 7:15 AM, the ADON stated hand hygiene was included in all the procedures of any care. She said the staff should be mindful that they were to take care of the residents and not give them additional medical issues. She said the staff should do hand hygiene before and after any care. She said gloves should be changed when transitioning from dirty to clean. She said for these instances, after touching the waste can, after touching the soiled brief, and after cleaning the residents' bottom. She said the hands should be washed or sanitized before putting on a new pair of gloves. She also said that the catheter bag should always be off the floor, even though the catheter bag was inside a privacy bag. She said all the issues discussed were causes of cross contamination and probable development of infections. She said the expectation was for the staff to do hand hygiene before and after every care, after changing their gloves, when transitioning from a dirty area to a clean area, sanitizing their hands when changing their gloves, and not to put the catheter bag on the floor. The ADON said she would coordinate with the DON on how to go forward.<BR/>In an interview with the DON on 08/22/2024 at 7:35 AM, the DON stated all the staff should know that hand hygiene was the most effective way to prevent cross contamination and infection. He said, first, the gloves should be changed after touching any soiled items. He said for this case, the gloves should have been changed after removing the soiled brief, after cleaning the resident's bottom, and after touching the waste basket. He continued that secondly, every time staff change their gloves, they should do hand hygiene before putting on a new pair of gloves. He said there could be instances that while they were providing care, the staff did not notice the gloves were torn, and the germs could enter the gloves and soil the hands. He said that was why it was important to do hand hygiene when changing the gloves. He said this should have been done during incontinent care and wound care. He also said, the catheter bag should not be placed on the floor during transfer. He said the staff could have just left it on the side of the wheelchair to be sure it was off the floor. He said the expectation was for the staff to do hand hygiene before and after any care, to change their gloves from dirty to clean, to do hand hygiene when changing the gloves, and not to put the catheter bag on the floor. He said he would do an in-service about infection control immediately after the interview and he would monitor the staff.<BR/>In an interview with the Administrator on 08/22/2024 at 7:53 AM, the Administrator stated not doing hand hygiene before and after any care, not changing the gloves after touching soiled items, not sanitizing the hands in between changing of gloves, and placing the catheter bag on the floor could contribute to cross contamination and probable infection. She said the expectation was for the staff to follow the policy and procedures pertaining to infection control. She said he would collaborate with the DON to in-service the staff about infection control.<BR/>Review of facility policy, Hand Hygiene Policy Infection Prevention revised 03/29/2022 revealed Purpose . to establish hand hygiene as the single most important factor in preventing the spread of disease-causing organisms . Policy . All employee in patient care areas will adhere . hand hygiene . 1. Entering room . 2. Before clean task . 3. After bodily fluid/Glove removal . 4. Exiting room . When moving from contaminated body site to clean body site.<BR/>Review of facility policy, Catheter: Care, Insertion, & Removal, Drainage bags, Irrigation, Specimen - AL, R/S & LTC Policy Assisted Living: Rehab/Skilled & Long-term Care revised 07/30/2024 revealed Policy . Catheter tubing/drainage bags . should never be allowed to touch the floor.

Based on observation, interview and record review, the facility failed to ensure the residents' rights to privacy for 15 (#4, #44, #8, #11, #49, #10, #157, #16, #43, #13, #15, #40, #21, #22, #27) of 15 residents reviewed for personal privacy. <BR/>The facility failed to ensure LPN D locked the computer screen, displaying the names of 15 residents, while LPN D was in a resident's room administering a treatment. <BR/>This failure could allow residents' protected HIPAA information to be shared with individuals who did not have a need or right to know.<BR/>The findings included:<BR/>An observation 08/21/24 at 09:58 AM revealed an open laptop on the nurse's cart on hall 300. The screen displayed the full name and room number of 15 residents on hall 300. The nurse was in a resident's room providing a treatment at the time. The cart was outside the door of the room the nurse was in. No visitors or other residents were near the laptop when the observation was made. <BR/>During an interview 08/22/24 at 07:13 AM, LPN D stated she was supposed to lock the screen when away from the computer. She stated it was a HIPAA violation to leave the screen open, unattended, with resident information displayed. <BR/>During an interview with the DON 08/22/24 at 08:18 AM, he stated LPN D should close the computer when not using it, because resident information could be seen. He stated this was a privacy issue. <BR/>During an interview with the QAPI Nurse Manager 08/22/24 at 08:57 AM, she stated when a staff member was not using a computer, they should lock the screen or close the computer. She stated anyone who walked by the open screen could look at residents' information and information should be kept private. <BR/>Review of the facility policy, revised 11/16/23 and titled Resident Dignity, stated maintaining an environment . able to be seen by visitors and/or other residents that includes confidential clinical or personal information.

Based on observation, interview and record review, the facility failed to ensure the residents' rights to privacy for 15 (#4, #44, #8, #11, #49, #10, #157, #16, #43, #13, #15, #40, #21, #22, #27) of 15 residents reviewed for personal privacy. <BR/>The facility failed to ensure LPN D locked the computer screen, displaying the names of 15 residents, while LPN D was in a resident's room administering a treatment. <BR/>This failure could allow residents' protected HIPAA information to be shared with individuals who did not have a need or right to know.<BR/>The findings included:<BR/>An observation 08/21/24 at 09:58 AM revealed an open laptop on the nurse's cart on hall 300. The screen displayed the full name and room number of 15 residents on hall 300. The nurse was in a resident's room providing a treatment at the time. The cart was outside the door of the room the nurse was in. No visitors or other residents were near the laptop when the observation was made. <BR/>During an interview 08/22/24 at 07:13 AM, LPN D stated she was supposed to lock the screen when away from the computer. She stated it was a HIPAA violation to leave the screen open, unattended, with resident information displayed. <BR/>During an interview with the DON 08/22/24 at 08:18 AM, he stated LPN D should close the computer when not using it, because resident information could be seen. He stated this was a privacy issue. <BR/>During an interview with the QAPI Nurse Manager 08/22/24 at 08:57 AM, she stated when a staff member was not using a computer, they should lock the screen or close the computer. She stated anyone who walked by the open screen could look at residents' information and information should be kept private. <BR/>Review of the facility policy, revised 11/16/23 and titled Resident Dignity, stated maintaining an environment . able to be seen by visitors and/or other residents that includes confidential clinical or personal information.

Based on observation, interview, and record review the facility failed to maintain essential kitchen equipment in safe operating condition for the facility's only kitchen reviewed for essential equipment. <BR/>1.The facility failed to report a damaged baffle (rubber guard in disposal) to Maintenance director per guidelines of the facility. <BR/>These failures could place residents who had their meals prepared in the facility kitchen at risk of having delayed services, staff injuries, and kitchen equipment malfunction, and serve resident meals in safe operating condition.<BR/>Findings included:<BR/>Observation on 07/18/23 at 9:00 a.m. during the initial kitchen tour in the facility only kitchen, revealed the food disposal to have a damaged worn discolored baffle (rubber object with fin shape to keep food from down) disposal cover (black and brown) and key functions of the baffle were designed to protect back flow of food and objects from the food placed in the disposal. The fins of baffle were so worn that they were stiff, and open. <BR/>In an interview on 07/20/23 at 9:00 AM with the dietary manager revealed he did not notify maintenance of the worn sink baffle as they were very busy. He said that he had not submitted a work order. He said it was all staff working int eh kitchen to report concerns of kitchen equipment that need to be reviewed or repaired. He said staff report to him and he submit work order for the maintenance to assess and order new parts. He said failing to submit an order to maintenance could lead to unsafe operations conditions in the kitchen and delay in resident meals. <BR/>A request for maintenance orders and maintenance orders for worn equipment were requested on 07/18/23 at 2:00 PM from administrator and dietary manager. Did not receive the requested items prior to exiting. <BR/>A second request for maintenance work orders for 6 months were requested on 7/20/23 at 9:00 am.<BR/>In an interview on 7/20/23 at 11:55 AM p.m. with the Administrator revealed she was not aware that there the disposal baffle was worn and soiled. She expects the Dietary Manager to submit work request to the maintenance director for equipment maintenance, replacement, and repairs immediately for the baffle replacement parts once the staff notified DM or being observed. She said the failure of not reporting could lead to unsafe operation conditions in the kitchen. She said the part has been ordered and provided the work order receipt.<BR/>The facility maintenance director did not provide the work orders requested. The administrator provided documentation of the new baffle part being ordered on July 19/23. <BR/>Record review for guidance from FDA Food 2017 on July 20, 2023 revealed Reference guidance from FDA Food 2017, 4-5 MAINTENANCE AND OPERATION Subparts 4-501 Equipment: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.

Based on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. <BR/>The facility failed to ensure foods in the facility's dry storage area, refrigerator, and freezer were stored and dated according <BR/>to guidelines.<BR/>The facility failed to ensure that staff was wearing the proper head coverings when serving food.<BR/>The facility failed to ensure staff wore gloves when preparing food and remove, wash hands and doff new gloves during <BR/>kitchen task changes according to guideline.<BR/>These failures could place residents at risk for cross contamination.<BR/>Findings included:<BR/>In an observation of the kitchen on 07/18/23 at 9:00 AM the following were observed:<BR/>Two large box of yellow onions (approximately 20 or more) and purple onions approximately (18 or more )were unlabeled in <BR/>the refrigerator.<BR/>Seven boxes of brown boxes of food placed on the floor at the back of the freezer unlabeled. <BR/>All frozen foods in the facility freezer that were shelfed were unlabeled. Brisket, crab meat, other frozen meets, frozen green <BR/>beans and other vegetables <BR/>One large silver bowl with cooked potato cubes uncovered on the prep table in the kitchen.<BR/>One large silver bowl of chopped chicken uncovered on prep table in kitchen.<BR/>Observation and interview with DW A on 07/18/23 at 09:00 AM revealed DW A was observed entering and exiting the facility's only kitchen, DW A was observed not wearing a hairnet, and using a surgical mask to cover his facial hair. Which was exposed on jaw line. He stated that the DM approved for him to wear a surgical mask in the kitchen to cover his beard. He was then directed by the DM to discard the surgical mask and put on a beard covering. DW A followed the directions and returned wearing a beard mask. A revisit to the kitchen on 07/18/23 at 11:30 AM DW A was wearing beard covering. <BR/>Observation and interview with DA B on 07/18/23 at 09:03 AM DA B was wearing a blue ball cap with his hair exposed in the back and not covered with a beard restraint. She was observed on 07/17/23 at 11:30 AM prepping soup without gloves. She was pouring soup back in the electric heating device, then scooped back out in the soup bowls. She then gathered a paper town and wiped the spilled soup off the counter and bowls, and returned to task. She was not wearing gloves and was not observed handwashing before returning.to the task.<BR/>Observation of DA S on 07/18/23 at 11:50 AM in the facility's only kitchen revealed DA S in the kitchen preparing food for lunch and he changed kitchen task from the fryer, adjusted his gloves on the left hand with fingers from the right hand. Proceeding to a second task without removing gloves, hand washing , and doffing a new pair of gloves. The DM was notified immediately of the concern and the staff changed gloves and hand washed. No food was touched only utensils that were placed for washing. The gloves were loose fitting.<BR/>. <BR/>Interview with Dietary Manager on 07/20/23 at 09:00 AM revealed he had been the Dietary Manager for the Facility's only kitchen for 2 years. He was advised of the two (2) kitchen staff who were not in compliance with head and face covering and hand sanitation. He said the labels in the freezer and refrigerator were not labeled because the cold environment caused the labels to fall off. He does not like to label with black marker, so he was not labeling. He said boxes should not be stored on the floor per guidelines, however the truck just delivered the boxes and he was notified of the inspection by the administrator. He said the crab meat packages fell off the top shelf to the freezer floor. Dietary manager said it was important to wash hands and use gloves before and after handling food and changing kitchen task. He stated the risk of staff not wearing their head and face coverings appropriately could result in air borne illnesses. He advised that he would in-service his staff on Employee Hygiene and Dress Code. Dietary manager revealed all cooks and diet aides were responsible for labeling and dating inventory as they are delivered. He advised they must put a name on it and that day's date on it., which includes can goods. He stated first in first out. He was shown pictures of the concerns and He stated that all staff were required to monitor for any of these concerns and correcting it, but the dietary manager was overall responsible for ensuring that it is corrected. He stated whoever puts up the inventory must also check for expired foods and ensure all foods are sealed appropriately. She stated the risk of these issues not being resolved could result in spread of bacteria. The Dietary Manager displayed an In-service on proper head and face coverings with kitchen staff completed on 07/19/23. <BR/>Interview with RD on 07/20/23 at 9:30 AM revealed he and all cooks and diet aides are responsible for labeling and dating. He advised staff must label and put the date the shipment for kitchen. He was shown pictures of concerns referenced previously and he advised that everyone was responsible for ensuring these concerns do not happen and the Dietary Manager was overall responsible for monitoring and identifying any of the concerns mentioned including proper hair coverings. <BR/>In an interview with DA B on 07/20/23 at 9:45 AM revealed she always wore a ball cap for a hair covering and she forgot to put on her gloves for the policy was to wear gloves while handling food. She said failing to cover hair and practice hand sanitation while handling food could result in her hair falling into the food and causing food realted illneses. She attended the in-service on 07/19/23. <BR/>An interview was requested with DW A on 07/20/23 at 9:50 AM and the DM stated he was not working today. DW A signature was observed on the Inservice conducted on 7/19/23.<BR/>An interview was requested with DA S on 07/20/23 at 9:57AM and the DM stated that he was not working today. DA S signature was observed on the Inservice conducted on 7/1923.<BR/>Review of the facility's policy and procedures on Food Storage, dated 06/21/2022, revealed The product should not be consumed after the date on the package due to the product's perishable nature and the product should be disposed of. Foods that have been opened or prepared must be covered<BR/>Review of dietary policies and procedures Titled Personal Hygiene and Professional Appearances Dated 05/08/2019, stated that all culinary members who are responsible for food preparation and/or service shall wear hair restraints. Subsection titled <BR/>Hair Restraints:<BR/>During food preparation, team members wear hair restraints, such as hats, hair coverings or nets, beard restraints, and clothing that cover the body hair, which are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, lines, and single service items. All loose hair needs to be covered with hats or nets. Front of the house servers shall tie their hair back during service. All long and loose hair needs to be styled to be away from contact with exposed food, clean equipment, utensils, lines, and single service items. Standards Followed: We adhere to the current DFS Food Code guidelines.<BR/>Review of the facility's policy and procedures on Employee Hygiene and Dress Code - Food and Nutrition Services, dated 8/10/2022 revealed Hairnets or hair restraints and beard nets or beard restraints are used when cooking, preparing, and assembling food or ingredients.