MESQUITE TREE NURSING CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #1, and Resident #2) of 11 residents reviewed for ADLs. The facility failed to ensure:- Resident #1 had his fingernails cleaned and trimmed.- Resident #2 had his fingernails trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. 1- Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected Resident #1 was a [AGE] year-old male admitted to the facility on 02 /14/25, and readmission on [DATE] with diagnoses of Cerebrovascular Accident (Occurs when blood flow to the brain is interrupted, leading to brain cell death and potential neurological damage), Seizure Disorder or Epilepsy (a neurological condition characterized by recurrent seizer), Asthma (a chronic lung condition that causes inflammation and narrowing of the airways, leading to recurrent episodes of wheezing, shortness of breath, chest tightness, and coughing), Chronic Obstructive Pulmonary Disease (a type of progressive lung disease characterized by long term respiratory symptom and airflow limitation), Respiratory Failure, muscle wasting and atrophy (the decrease in size or wasting away of a body part, such as muscle or tissue, due to cell shrinkage or cell death). Resident#1 had a BIMS score of 06 which indicated severe cognitive impairment. Review of the functional ability section reflected that Resident #1 required substantial assistance with showering and personal hygiene. Record review of Resident #1's Comprehensive Care Plan revised on 07/29/25 reflected, Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Personal Hygiene: Limited x[BR1] 1. Bathing: Dependent x1 Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. In an observation and interview on 09/16/25 at 10:37 AM with Resident #1, revealed his fingernails on both hands were dirty with black discoloration underneath the nails and the nails were jagged. The fingernails were 0.5-0.7 centimeter in length extending from the tips of his fingers. Resident #1 stated he would like his nails to be cleaned and trimmed. 2- Record review of Resident #2's Quarterly MDS assessment dated [DATE], reflected Resident #2 was a [AGE] year-old male admitted to the facility with initial admission date of 05 /09/25, with diagnoses of Hypertension (Elevated blood pressure), Asthma, Chronic Obstructive Pulmonary Disease, muscle weakness, and cognitive communication deficit. Resident#2 had a BIMS score of 13 which indicated intact cognition. Review of functional ability section reflected that Resident #2 required substantial/maximal assistance with showering and setup or clean-up assistance for personal hygiene. Record review of Resident #2's Comprehensive Care Plan revised on 07/21/25 reflected, Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Personal Hygiene: Limited x1. Bathing: Dependent x1 Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. In an observation and interview on 09/16/25 at 10:50 AM with Resident #2, revealed his fingernails on both hands were dirty with black discoloration underneath the nails, and the fingernails were 0.4-0.6 centimeter in length extending from the tips of his fingers. Resident #2 stated he would like his nails to be cleaned and trimmed. In an interview/observation on 09/16/25 at 11:00 AM CNA A checked both residents' fingernails and stated they needed to be cleaned and trimmed. CNA A stated CNAs and nurses were responsible for nail care. She stated that nurses were responsible for nail care for diabetic residents. She stated nail care for residents was done on shower days and as needed. She added the risk to the resident for not trimming or cleaning their nails was decreased skin integrity and risk of infections. In an interview on 09/16/2 11:14 AM with LVN B revealed, CNAs were responsible for resident nail care, unless the resident had diagnoses of diabetes, then nurses were responsible for trimming the resident's nails. She stated dirty, long fingernails could expose the residents to the risk of developing infections or skin tears. LVN B further stated that although CNAs were responsible for nail care, it was ultimately the responsibility of the charge nurse to ensure residents' fingernails were always cleaned and trimmed. Interview on 09/16/25 at 2:24 PM the DON stated all the staff were responsible for the residents fingernail care. She stated CNAs should make sure residents' fingernails were cleaned and trimmed all the time, and if the resident had diabetes mellitus it was strictly the responsibility of the nurses to trim their fingernails. She stated the risk to residents, they could be harboring germs underneath the fingernails, they could develop infection and they could injure themselves or others. Record review of the facility policy titled, Activities of Daily Living Guidelines dated 2/11/2021 reflected, Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care ,including tracheostomy care and tracheal suctioning, were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #1) residents reviewed for respiratory care. The facility failed to ensure physician's orders were written for oxygen use via nasal canula for Resident #1 on readmission [DATE] to 09/16/2025. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records. Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected Resident #1 was a [AGE] year-old male admitted to the facility on 02 /14/25, and readmission on [DATE] with diagnoses of Cerebrovascular Accident (Occurs when blood flow to the brain is interrupted, leading to brain cell death and potential neurological damage), Seizure Disorder or Epilepsy (a neurological condition characterized by recurrent seizer), Asthma (a chronic lung condition that causes inflammation and narrowing of the airways, leading to recurrent episodes of wheezing, shortness of breath, chest tightness, and coughing), Chronic Obstructive Pulmonary Disease (a type of progressive lung disease characterized by long term respiratory symptom and airflow limitation), Respiratory Failure, muscle wasting and atrophy (the decrease in size or wasting away of a body part, such as muscle or tissue, due to cell shrinkage or cell death). Resident #1 had a BIMS score of 06 which indicated severe cognitive impairment. Review of section J. J1100. Shortness of Breath (dyspnea) revealed: C. Shortness of breath or trouble breathing when lying flat. Review of respiratory treatment C1 oxygen therapy was not market for oxygen use. Record review of Resident #1's Comprehensive Care Plan revised on 07/29/25 reflected no indication of oxygen use. Record review of Resident #1's electronic medical record on 09/16/25 revealed: 1- No physician's order for oxygen use for readmission on [DATE] to 09/16/2025 2- The MAR did not reflect oxygen use or setting. In an observation and interview on 09/16/25 at 10:37 AM revealed Resident#1 was lying in bed, on oxygen via nasal canula and his oxygen concentrator was beeping with the yellow alarm light flushing. Resident #1 stated he did not feel good. Resident #1's oxygen concentrator float/flow indicator device was not visible inside the flowmeter tube. Observation on 09/16/25 at 11:14 AM revealed LVN B responding to the Resident #1's call light. LVN B checked the oxygen concentrator and turned the knob until the float was visible in the flowmeter. LVN B adjusted the oxygen flow to 2 L/ minutes. Observation revealed LVN B asking Resident #1 how he was feeling, and he replied he was feeling better. Interview with LVN B revealed Resident #1 was on oxygen as needed, and some time Resident #1 liked to adjust the flow rate. LVN B stated, she reeducated Resident #1 not to adjust the oxygen rate for his safety. LVN B stated adjusting the oxygen flow too high or too low could affect the amount of oxygen the resident was receiving and his breathing quality. In interview on 09/16/25 at 2:29 PM the DON stated Resident #1's oxygen was as needed, and sometimes he played with the concentrator flowmeter. The DON stated her expectation was every resident with oxygen must have order, because oxygen was a medication that could be given by the physician order only. The DON stated the risk to Resident #1 for not having a physician's order for oxygen use was respiratory issue. Interview with the Administrator on 09/16/25 at 3:20 PM, she stated orders drive care and she expected nursing staff to obtain orders for care. The Administrator stated she expected Resident #1 to have orders for his oxygen use. Record review of policy titled, Consulting Physician/Practitioner Orders dated 09/28/2021, reflected Policy: The policy provide guidance on receiving and following physician orders. c. Carry out and implement physician orders d. Document resident response to physician order in the medical record as indicated . Record review of policy titled, Oxygen Administration date 01/05/2020, reflected Policy: To describe methods of delivering oxygen to improve tissue oxygenation.during a respirator emergency it is appropriate for nursing to administer oxygen immediately and then notify physician for orders and further clinical guidance. 1.Verify physician order 2. Orders should have when to call the physician parameters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to be adequately equipped to allow residents to call for assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 11 residents (Resident #1) reviewed for reasonable accommodations. The facility failed to ensure the call light in the resident room, used by Resident #1, was always within reach. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected Resident #1 was a [AGE] year-old male admitted to the facility on 02 /14/25, and readmission on [DATE] with diagnoses of Cerebrovascular Accident (Occurs when blood flow to the brain is interrupted, leading to brain cell death and potential neurological damage), Seizure Disorder or Epilepsy (a neurological condition characterized by recurrent seizer), Asthma (a chronic lung condition that causes inflammation and narrowing of the airways, leading to recurrent episodes of wheezing, shortness of breath, chest tightness, and coughing), Chronic Obstructive Pulmonary Disease (a type of progressive lung disease characterized by long term respiratory symptom and airflow limitation), Respiratory Failure, muscle wasting and atrophy (the decrease in size or wasting away of a body part, such as muscle or tissue, due to cell shrinkage or cell death). Resident#1 had a BIMS score of 06 which indicated severe cognitive impairment. Review of functional ability self-care was coded as (2) meaning Resident #1 Needed Some Help - Resident needed partial assistance from another person to complete any activities. Record review of Resident #1's Comprehensive Care Plan revised on [DATE] reflected, Focus: Resident has the potential for falls. Resident with poor safety awareness and impulsive. Goal: Resident will not sustain a fall related injury by utilizing fall precautions through next review date. Interventions: Reeducate the resident to use the call light when wanting to transfer. Place the resident's call light is within reach and encourage the resident to use it for assistance as needed. In an observation and interview on [DATE] at 10:37 AM revealed Resident#1 was lying in bed, on oxygen via nasal canula and his oxygen concentrator was beeping. Resident#1 stated, he did not feel good. Resident#1 was unable to call for help, because his call light was in the closed nightstand drawer. CNA A walked into the Resident #1's room and got the call light button from the nightstand drawer and clipped it to Resident #1's pillowcase. Interview on [DATE] at 11:00 AM CNA A stated, she put the call light button in the nightstand drawer this morning when she changed Resident #1's bed linen, and she forgot to put it within Resident #1's reach before leaving the room. CNA A stated she did not know the call light was not within the reach of the resident. CNA A stated the call light device was used by the residents to alert the staff about the resident's needs, and the call light was expected to be working and within the reach of the resident all the time. In an interview on [DATE] at 2:29 PM with the DON revealed all residents were expected to always have their call light within reach and it was the responsibility of all the employees to ensure the call light was within reach of each resident. The DON stated not having a call light within reach could put a resident at risk for going without incontinent care after a bowel movement, going without care at the time of a health crisis. Interview with the Administrator on [DATE] at 3:20 PM she stated it was her expectation for all the employees to make sure the resident's call light was always within reach and not having the call light within reach could lead to the risk of not getting assistance in a timely manner, it could lead to not receiving incontinent care, skin break. Record review of the facility's Call light response policy dated [DATE] reflected The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. The policy reflected the process as follows . All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light . With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed . Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 8 residents (Resident #60) reviewed for reasonable accommodations. <BR/>The facility failed to ensure the call light in resident room [ROOM NUMBER] A used by Resident #60 was always within reach. <BR/>This failure could place resident at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.<BR/>Findings included:<BR/>Review of Resident #60's face sheet dated [DATE] reflected she was an [AGE] year-old female with an admission date of [DATE]. admission diagnoses reflected Resident #60 had a diagnosis of type 2 diabetes, fracture of shaft of left ULNA (fracture of left forearm), cognitive communication deficit (a condition makes it difficult to communicate). <BR/>Review of the current diagnosis dated [DATE] reflected resident #60 was diagnosed with Enterocolitis due to clostridium difficile (an inflammation of intestines caused by bacteria).<BR/>Review of Resident #60's MDS assessment dated [DATE] revealed Resident #60 had a BIMS score of 12 which indicates moderate cognitive impairment, required substantial/maximal assistance with toileting hygiene, moderate assistance with transfers, and always incontinent of bowel and urine. <BR/>Review of Resident #60's care plan dated [DATE] reflected Resident #60 was at risk for unstable blood sugar levels and abnormal lab results, had an ADL selfcare performance deficit and was at risk for not having needs met in a timely manner, resident was incontinent of bowel/bladder.<BR/>Interview and observation of Resident #60 on [DATE] at 11:39 AM in her room revealed the resident was on isolation for contact and droplet precautions due to Enterocolitis due to clostridium difficile. The resident was lying on her bed, the call light was found on the floor, away from resident's reach. Resident #60 stated she wanted to call the nurse for assistance at that time but noticed the call light was not attached to her pillow/bedsheet, nobody could hear her verbally calling the nurse since the door was closed as she was on isolation. The surveyor observed the call light was lying on the floor, away from the resident's reach. Resident stated she could not remember since how long the call light was not within her reach. <BR/>Interview with LVN C on [DATE] at 11:44 AM in Resident #60's room revealed he was the charge nurse for Resident #60. Resident #60 was on isolation precaution for enterocolitis due to clostridium difficile. LVN C observed Resident #60's call light was not within reach and was lying on the floor. LVN C stated he did not know the call light was not within the reach of the resident, the call light device was used by the residents to alert the staff about resident's needs and the call light was expected to be working and within the reach of the resident all the time. LVN C stated the absence of a call light device within reach could create several problems for the residents such as not getting changed or cleaned on time, not getting drinks or snacks as needed, not getting help during a health crisis. LVN C stated he had received in-services on call lights on a regular basis, the last time he received an in-service was 2 weeks ago. LVN C sated all the staff working with the resident were responsible to ensure the call light device was working and within reach of the resident.<BR/>Interview with CNA G on [DATE] at 01:47 PM. She stated it was the responsibility of all the employees to ensure the call light was always within the reach of the residents, not having a call light within reach could lead to fall, injury, dehydration, missing nursing care, incontinent care. CNA G stated she had received in service on call lights within the past few weeks.<BR/>Interview with ADON D on [DATE] at 10:35 AM revealed all residents were expected to always have their call light within reach and it was the responsibility of all the employees to ensure the call light was within reach of each resident. ADON D stated not having a call light within reach could put a resident at risk for going without incontinent care after a bowel movement, going without care at the time of a health crisis. <BR/>Interview with the Administrator on [DATE] at 11:27 AM revealed she was not aware the Resident #60's call light was not within reach, she stated it was her expectation for all the employees to make sure the resident call light was always within reach and not having the call light within reach could lead to the risk of not getting assistance in a timely manner, it could lead to not receiving incontinent care, skin break. The Administrator stated all the employees received in service regarding call lights every month and after each incident. <BR/>Record review of the facility's call light response policy dated [DATE] reflected The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. The policy stated the process as follows . All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light . With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed . Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet residents' mental and psychosocial needs, for 1 (Resident #55) of 6 residents reviewed for comprehensive care plans.<BR/>The facility failed to ensure Resident #55 had a person-centered care plan to include significant advance directive code status change from full code to DNR code, when they received Resident#55 consent on [DATE]. <BR/>This failure could place resident at risk of been resuscitated and not honoring her DNR wishes.<BR/>Findings included:<BR/>Review of Resident #55's face sheet dated [DATE] revealed the resident was a [AGE] year-old female admitted on [DATE] with diagnoses including hypertension (High blood pressure), Non-Alzheimer's Dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Cerebrovascular accident. <BR/>Review of Resident#55's quarterly MDS assessment dated [DATE] revealed Resident #55 had a BIMS score of 00/15 indicating severe cognitive impairment. <BR/>Review of Resident#55 electronic medical record on [DATE] at 08:11 AM revealed a consent for DNR dated [DATE].<BR/>Review of Resident #55's Physician's Order Sheet dated [DATE] revealed Code status: DNR.<BR/>Review of Resident #55's Comprehensive care plan last reviewed [DATE] revealed Focus. Full Code: Resident has physician's orders that include a status of full code. Goal: Staff will administer CPR if resident has an arrest. Interventions: Ensure Full Code order on chart. Ensure staff is aware of code status through designated systems. Monitor for changes in resident's code status and update as needed. Review at least quarterly. Begin CPR after absence of vital signs, call 911, notify physician, and notify family/responsible party.<BR/>Attempted interview and observation on [DATE] at 10:08 AM with Resident#55, revealed she was lying in bed unable to participate in interview.<BR/>Interview on [DATE] at 08:09 AM with the MDS coordinator, she stated the code status order for the Resident#55 was DNR. She stated according to her the care plan was updated on [DATE] when she got the order, and it stated the resident code status had been changed to DNR. She stated the SW was responsible for the care plan part for the code status of the residents. The MDS coordinator stated the importance of care plan was for the staff to know what kind of care to render to the residents.<BR/>Interview on [DATE] at 08:31 AM with ADON D, she stated the SW was responsible for that changing, meaning the status code for the residents in the care plan. The ADON stated if the care plan was not updated it can affect the resident's care, and in this case Resident#55 may got resuscitated against her wishes. <BR/>Interview on [DATE] at 12:33 PM with the Administrator, she stated they thought they had to wait for the order to correct the care plan, and it was supposed to be done whenever they received the resident's consent. The Administrator stated the SW was responsible for the code status part of the care plan update. She stated the risk to the resident it would not following with her wishes by doing t CPR on the Resident#55, who wanted to be a DNR.<BR/>Interview on [DATE] at 05:31 PM with the SW revealed she was responsible for the care plan code status update for the residents. She stated she did not update Resident#55's care plan after she received the consent, because she was waiting for the nurse to transcribe the order in the Resident#55 e-record. She stated the risk to Resident#55 if the care plan was not updated; Resident#55 could be resuscitated will she was a DNR.<BR/>Review of facility Document titled Care Plan Guidance's, revised [DATE], revealed, .Care Plan Updates. The IDT will review the care plans Annually, Quarterly, and as needed to ensure all the goals and approaches are appropriate .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #1, and Resident #2) of 11 residents reviewed for ADLs. The facility failed to ensure:- Resident #1 had his fingernails cleaned and trimmed.- Resident #2 had his fingernails trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. 1- Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected Resident #1 was a [AGE] year-old male admitted to the facility on 02 /14/25, and readmission on [DATE] with diagnoses of Cerebrovascular Accident (Occurs when blood flow to the brain is interrupted, leading to brain cell death and potential neurological damage), Seizure Disorder or Epilepsy (a neurological condition characterized by recurrent seizer), Asthma (a chronic lung condition that causes inflammation and narrowing of the airways, leading to recurrent episodes of wheezing, shortness of breath, chest tightness, and coughing), Chronic Obstructive Pulmonary Disease (a type of progressive lung disease characterized by long term respiratory symptom and airflow limitation), Respiratory Failure, muscle wasting and atrophy (the decrease in size or wasting away of a body part, such as muscle or tissue, due to cell shrinkage or cell death). Resident#1 had a BIMS score of 06 which indicated severe cognitive impairment. Review of the functional ability section reflected that Resident #1 required substantial assistance with showering and personal hygiene. Record review of Resident #1's Comprehensive Care Plan revised on 07/29/25 reflected, Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Personal Hygiene: Limited x[BR1] 1. Bathing: Dependent x1 Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. In an observation and interview on 09/16/25 at 10:37 AM with Resident #1, revealed his fingernails on both hands were dirty with black discoloration underneath the nails and the nails were jagged. The fingernails were 0.5-0.7 centimeter in length extending from the tips of his fingers. Resident #1 stated he would like his nails to be cleaned and trimmed. 2- Record review of Resident #2's Quarterly MDS assessment dated [DATE], reflected Resident #2 was a [AGE] year-old male admitted to the facility with initial admission date of 05 /09/25, with diagnoses of Hypertension (Elevated blood pressure), Asthma, Chronic Obstructive Pulmonary Disease, muscle weakness, and cognitive communication deficit. Resident#2 had a BIMS score of 13 which indicated intact cognition. Review of functional ability section reflected that Resident #2 required substantial/maximal assistance with showering and setup or clean-up assistance for personal hygiene. Record review of Resident #2's Comprehensive Care Plan revised on 07/21/25 reflected, Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Personal Hygiene: Limited x1. Bathing: Dependent x1 Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. In an observation and interview on 09/16/25 at 10:50 AM with Resident #2, revealed his fingernails on both hands were dirty with black discoloration underneath the nails, and the fingernails were 0.4-0.6 centimeter in length extending from the tips of his fingers. Resident #2 stated he would like his nails to be cleaned and trimmed. In an interview/observation on 09/16/25 at 11:00 AM CNA A checked both residents' fingernails and stated they needed to be cleaned and trimmed. CNA A stated CNAs and nurses were responsible for nail care. She stated that nurses were responsible for nail care for diabetic residents. She stated nail care for residents was done on shower days and as needed. She added the risk to the resident for not trimming or cleaning their nails was decreased skin integrity and risk of infections. In an interview on 09/16/2 11:14 AM with LVN B revealed, CNAs were responsible for resident nail care, unless the resident had diagnoses of diabetes, then nurses were responsible for trimming the resident's nails. She stated dirty, long fingernails could expose the residents to the risk of developing infections or skin tears. LVN B further stated that although CNAs were responsible for nail care, it was ultimately the responsibility of the charge nurse to ensure residents' fingernails were always cleaned and trimmed. Interview on 09/16/25 at 2:24 PM the DON stated all the staff were responsible for the residents fingernail care. She stated CNAs should make sure residents' fingernails were cleaned and trimmed all the time, and if the resident had diabetes mellitus it was strictly the responsibility of the nurses to trim their fingernails. She stated the risk to residents, they could be harboring germs underneath the fingernails, they could develop infection and they could injure themselves or others. Record review of the facility policy titled, Activities of Daily Living Guidelines dated 2/11/2021 reflected, Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. <BR/>1. The facility failed to ensure dish machine reached minimum of 120 degrees F for wash and rinse on 10/24/23.<BR/>2. The facility failed to ensure food in the kitchen's refrigerator and freezer were stored in sealed containers, labeled, and dated. The facility failed to ensure food item in refrigerator was not spoiled.<BR/>3. The facility failed to maintain cleanliness of the inside of the ice machine. <BR/>These failures could place residents at risk for food contamination and food-borne illness.<BR/>Findings included:<BR/>1. Observations on 10/24/23 at 10:07 AM revealed the Dietary Manager ran the dish machine with first two wash/rinse low temperature dish machine reading 100 temp F for wash and rinse. The third time dish machine ran cycle the temperature only reached 110 temp F for wash and rinse. Dietary Manager ran the dish machine two more times with 115 temperature F and 118 temperature. <BR/>Interview on 10/24/23 at 10:15 AM with the Dietary Manager stated it was a low temp dish machine which should reach at least 120 degrees F for wash and rinse. He looked at the temperature log on the wall and stated they had not checked the dish machine temperature yet this morning. The Dietary Manager stated there had been a couple of loads already ran through prior to checking the dish machine. He stated they will temporarily not use the dish machine until were are able to have it working properly. He stated it was important for the dish machine to reach at least minimum temperature to clean the dishes. <BR/>Interview on 10/26/23 at 8:48 AM with the Maintenance Director revealed dish machine representative came out on 10/24/23 to look at dish machine on 10/24/23 verifying the dish machine water temperature was not reaching minimum water temperature as required. He stated he had to replace the kitchen's water heater circulator pumps before able to get hot water at minimum temperatures. He stated he was not aware of any issues with the kitchen dish machine water temperatures until 10/24/23 when they contacted dish machine representative. Surveyor requested service order for dish machine. <BR/>2. Observation on 10/24/23 at 10:20 AM revealed 1 of 2 freezers had frozen meat not dated or labeled. <BR/>Observation on 10/24/23 at 10:21 AM revealed 1 of 2 refrigerator contained a sealed plastic food item with shredded purple and yellowish shredded produce labeled green cabbage not labeled or dated. No expiration date was on the item or date on the item.<BR/>Interview on 10/24/23 at 10:22 AM the Dietary Manager revealed the frozen meat was chicken which should have been labeled and dated when opened. The Dietary Manager stated he thought the item in the refrigerator was coleslaw and looked like it had turned bad. He stated he will throw it away. It should be labeled and dated so they know when item was open and received. He stated if food items were not dated when opened then they will not be able to know how long it will last. <BR/>3. Observation on 10/24/23 at 10:26 AM revealed ice machine in the kitchen had dark blackish stains and particles covering about four inch area on the left inner part above the ice. <BR/>Interview on 10/24/23 at 10:27 AM and 10:34 AM with the Dietary Manager revealed he had not noticed the blackish particles inside the ice machine. He stated it could drip down and contaminate the ice. He stated Maintenance had cleaned it last month when it was not working. He stated Maintenance usually cleaned it monthly at least. <BR/>Review of facility's policy Frozen and Refrigerated Foods Storage revised 12/5/17 reflected Items stored in the refrigerator must be dated upon receipt, unless they contain a manufacturer use by, sell by, best by date, or a date delivered .11. All refrigerated and frozen items in storage will contain a minimum label of common name of product and dated as noted above .<BR/>The facility did not provide a specific policy on the ice machine or the dish machineat the date and time of exit from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Resident #53, Resident #7, Resident # 26, and Resident # 220) of five residents observed for infection control in that: <BR/>CNA B failed to perform hand hygiene during incontinent care and failed to bag soiled wipes and briefs prior to placing them on the end of the bed for Residents # 53, #220, #26 and # 7.<BR/>Theses failure could place residents at risk for infection and cross contamination. <BR/>Findings included:<BR/>1. Review of Resident #53's face sheet dated 08/24/22 reflected a [AGE] year-old male, admitted to the facility on [DATE], and a readmission date of 08/01/22. His primary diagnosis included sepsis due to methicillin susceptible staphylococcus aureus (bacteria resistant to several widely used antibiotics), abscess of right hand and Huntington's disease (inherited condition in which nerve cells in the brain break down).<BR/>Observation on 08/24/22 at 09:25 AM revealed CNA B entered Resident #53's room to assist LVN C with wound care. CNA B washed her hands and donned gloves. CNA B held Resident #53's right arm and hand up while LVN C cut away the old dressing. CNA B grabbed the old dressing as it fell away and held it until LVN C could retrieve it and dispose of it in a biohazard bag. CNA B continued to hold the resident arm and hand while LVN C completed the wound care. CNA B, while wearing the same soiled gloves used to assist with the wound care, went to the resident's closet and retrieved a clean brief and laid it on the head of the bed, picked up the bed remote and lowered the resident's bed and then removed her soiled gloves and performed hand hygiene. CNA B re-gloved, raised the resident bed up and unfastened the resident's brief to reveal he had been incontinent of urine. CNA B then pushed the soiled brief down between the resident's legs toward his buttocks and took a wet wipe and wiped down each groin and then wiped up and down the shaft of the resident's penis trying to remove a white sticky substance. CNA B used the same wipe without changing the surface of the wipe with each swipe. CNA B then rolled the resident onto his side and picked up the clean brief with her soiled gloves and placed it under the dirty brief. CNA B proceeded to wipe the resident's buttocks from front to back, removed the soiled brief and placed it and the used wipes on the end the bed. While wearing the same soiled gloves, CNA B reached into the resident chest of drawers and retrieved a package of barrier wipe and applied the barrier cream to the resident's buttocks. CNA B then rolled the resident back onto his back, fastened the brief and pulled up the residents' pants. CNA B then picked up the soiled brief and wipes and placed them in the trash can, removed her gloves and performed hand hygiene. <BR/>2. Review of Resident #220's face sheet dated 08/24/22 reflected an [AGE] year-old male, admitted to the facility on [DATE]. His primary diagnosis included Chronic Obstructive Pulmonary disease, diabetes and history or COVID-19. <BR/>Observation on 08/24/22 at 09:50 AM revealed CNA B entered Resident #220's room to answer his call light. Resident #220 stated he needed to be changed. CNA B washed her hands and donned gloves and gathered wipes and a brief. Resident #220 stood up out of his wheelchair and started to lay down on the bed. CNA B told him to stand and turn around and she pulled down his pants and unfastened the resident's brief to reveal he had been incontinent of urine. CNA B then wiped the resident's anal area, revealing he was having a bowel movement. CNA B asked the resident if he thought he needed to go to the toilet to finish and he stated yes. Resident #220 ambulated to the bathroom. CNA B removed her gloves, washed her hands, and told the resident she would be back. CNA B returned to the room with a gait belt, washed her hands and put on clean gloves. CNA B had the resident stand up and proceeded to wipe the resident's buttocks from front to back and then took another wipe and wiped the residents front and placed a clean brief on the resident and pulled up his pants without changing gloves or performing hand hygiene. CNA B then placed a gait belt around the resident and had him stand at the sink to wash his hands. Resident #220 ambulated back to his wheelchair with CNA B holding onto the gait belt. CNA B then picked up the resident's O2 tubing and handed it to him. Resident #220 stated he was thirsty and needed a drink. CNA B then removed the gait belt from the resident and placed it in her pocket and reached for the resident's water pitcher, knocking the lid off. CNA B replaced the lid, still wearing the same gloves she had worn to provide incontinent care and handed the pitcher to the resident. CNA B then gathered the trash, removed her gloves, and washed her hands with soap and water. <BR/>3. Review of Resident #26's face sheet dated 08/24/22 reflected a [AGE] year-old female, admitted to the facility on [DATE]. Her primary diagnosis included dementia, epilepsy, and extended spectrum beta lactamase resistance (enzyme produced by some bacteria which causes some antibiotics not to work for treating bacterial infections)<BR/>Observation on 08/24/22 at 10:10 AM revealed CNA B entered Resident #26's room to provide incontinence care. CNA B washed her hands and donned gloves, gathered a brief and wipes and placed them on the bed side table. CNA B unfastened the resident's brief to reveal she had been incontinent of urine and had a large bowel movement. CNA B then pushed the soiled brief down between the resident's legs toward her buttocks and took a wet wipe and wiped down each groin and once down the middle. CNA B used the same wipe without changing the surface of the wipe with each swipe. CNA B then rolled the resident onto her side and picked up the clean brief with her soiled gloves and placed it under the dirty brief. CNA B proceeded to wipe the resident's buttocks from front to back, removed the soiled brief and placed it and the used wipes on the end the bed. While wearing the same soiled gloves, CNA B placed the soiled brief into the trash can by the door and reached into the resident chest of drawers and retrieved a tube of barrier wipe and applied the barrier cream to the resident's buttocks. CNA B then rolled the resident back onto her back and took another wipe and wiped again down the resident's groin, removing more bowel movement. CNA B then fastened the brief and covered the resident with sheet and blanket, put the tube of barrier cream back in the residents' chest of drawers, repositioned her bedside table and then removed her gloves and placed in the trash and washed her hands. CNA B then proceeded to provide incontinence care to the roommate, Resident #7. <BR/>4. Review of Resident #7's face sheet dated 08/24/22 reflected an [AGE] year-old female, admitted to the facility on [DATE]. Her primary diagnosis included Parkinson's disease, dementia, and left side hemiplegia (paralysis)<BR/>Observation on 08/24/22 at 10:15 AM revealed CNA B washed her hands and donned gloves, gathered a brief and wipes and placed them on Resident #7 bed side table. CNA B unfastened the resident's brief to reveal she had been incontinent of urine. CNA B then pushed the soiled brief down between the resident's legs toward her buttocks and took a wet wipe and wiped down each groin and once down the middle. CNA B used the same wipe without changing the surface of the wipe with each swipe. CNA B then rolled the resident onto her side and picked up the clean brief with her soiled gloves and placed it under the dirty brief. CNA B proceeded to wipe the resident's buttocks from front to back, removed the soiled brief and placed it and the used wipes on the end the bed, had the resident roll back on her back and fastened the clean brief. While wearing the same soiled gloves, CNA B placed the soiled brief into the trash can by the door, returned to the resident to adjust her clothing and took a clean wipe an washed the bottom of the residents' feet that were covered in with a black substance. CNA B then covered the resident with her bed covers, removed her gloves, and tied up the trash and washed her hands. <BR/>In an interview with CNA B on 08/24/22 at 10:05 AM revealed she had worked at the facility approximately 6 months. When asked when she was supposed to perform glove changes and hand hygiene during incontinence care she stated before you start and after you had completed care. She stated she was not aware she had to change her gloves during incontinence care. She stated she was taught the end of the bed was considered dirty, which was why she placed the soiled brief and wipes at the end of the bed until she had completed care. She stated she knew you were supposed to wipe from front to back and change the surface to the wipes each time, and stated she thought she had done that. She stated she had recently been in serviced on hand hygiene and knew the importance of hand hygiene to prevent infections. <BR/>Review of the facilities in-services on infection control, which covered the facilities hand hygiene policy, dated 08/04/22 revealed neither CNA B had attended. <BR/>In an interview with the DON on 08/24/22 at 1:00 PM revealed staff were to perform hand hygiene before incontinence care and during care they were to remove their gloves and perform hand hygiene when they went from dirty to clean and once, they completed care, they were to perform hand hygiene again. She stated they were always supposed to place dirty wipes and briefs and linens in a plastic bag. She stated failing to follow these procedures placed residents at risk of cross contamination and increased risk of urinary tract infections. She stated all staff were skills checked upon hire and again if training issues were identified. <BR/>In an interview with ADON A on 08/24/22 at 01:15 PM she stated staff were to perform hand hygiene when they entered a resident's room, after contact with any bodily fluid, and they were to change their gloves and perform hand hygiene during incontinent care when they went from dirty to clean. She stated they were never to place dirty linen on the floor or chairs in the room, stating it was to be always supposed to be bagged. She stated she observed CNA B during her skills checks off upon hire and she had performed the procedure correctly at that time. She stated by not following standard precautions with hand hygiene it placed residents at risk of infections and cross contamination. <BR/>Review of the facility's policy titled, Incontinence Care, dated February 2022, reflected, .Have all needed equipment at bedside on the over bed table wipes (at least 7), gloves (at least 3 pair), barrier cream, plastic bag or trash can .Wash hands and put on gloves Remove soiled clothing and brief and place the brief in the trash bag .Take off the gloves, put them in the trash bag. Wash your hands and put on new gloves Cleanse the peri area with wipes going front to back/clean to dirty. Separate the labia. Use a new wipe with ach stroke: Wipe one side, wipe the other side, wipe down the center and then once from hip bone to hip bone .Repeat cleansing until the resident is clean .take off the gloves, put them into the trash bag with the soiled brief and wipes .Wash your hands, put on gloves and apply protective ointment if needed and a clean brief .Remove gloves and wash your hands .Reposition the resident, offer fluids .Remove trash from room .Wash your hands .If performing incontinent care for a male resident .Take the wipe in one hand and gently grasp the penis shift .wipe the head of the penis beginning at the urethra opening working outward or away from the penis head, Cleanse in a circular motion away from the urethra. Use new wipe each time .Cleanse the penis shaft with wipe from the top of the shaft towards the rectum, including the scrotum .Using a new wipe with each stroke clean from the upper part of the leg to the hip <BR/>Review of the facility's policy titled, Infection Control Guidelines, dated February 2021, reflected, .Hand Hygiene Protocol .Staff shall use hand hygiene when coming on duty, between patient contacts, after handling contaminated objects, after PPE removal, and before going off duty .Staff shall wash their hands with an antiseptic preparation before performing patient care procedures and when providing .For routine care, staff shall wash their hands with soap and water or a waterless alcohol agent before and after patient contact .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one (Resident #2) of four residents reviewed for abuse. <BR/>The facility failed to protect Resident #2 from physical abuse by HA B. On 2/16/24 at 9:45 PM , HA B physically grabbed snacks from Resident #2, then proceeded to grab his arm and became involved in a physical interaction of tugging items back and forth with Resident #2 until Resident #2 fell on the ground without any physical injuries or harm.<BR/>The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 02/16/24 at 9:45 PM and ended on 02/23/24. The facility had corrected the noncompliance before the Incident investigation began on 10/22/24.<BR/>The facility terminated HA B on 02/16/24, with no other incidents that involved Resident #2, and staff were reeducated regarding Abuse and Neglect on 02/16/24 through 02/20/24.<BR/>This failure could place residents at risk of serious injury and harm. <BR/>Findings included: <BR/>Record review of the facility policy titled, Policy and Procedures: Abuse, Neglect and Exploitation revised 9/6/2024, reflected, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.<BR/>Record review of Resident #2's face sheet, dated 12/23/24, revealed Resident #2 was a [AGE] year-old male, with original admission date of 10/05/2017 with diagnoses that included: Paranoid Schizophrenia, hypertension, Cognitive Communication Deficit, Major depressive disorder, and Unsteadiness on feet.<BR/>Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed that he was unable to complete the BIMS with score of 0. Resident #2 was independent for ADL for toileting and personal hygiene. Quarterly MDS also revealed, Resident #2 did not exhibit any behaviors. <BR/>Record review of Resident #2's Care Plan dated revised on 08/17/2021 reflected, that Resident #2 had been Care planned for Focus: Cognitive Impairment: [Resident #2] has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to: Psych Diagnosis, Paranoid Schizophrenia, Auditory Hallucinations, Delusional Disorder and Other Amnesia. Goal: Resident will have needs met in a timely manner, dignity will be maintained, and current level of functioning will be maintained through the next 90 days. Intervention . COMMUNICATION: Identify yourself at each interaction. Face resident when speaking and make eye contact. Stop and return if the resident becomes agitated.<BR/>Record review of Provider Investigation Report (PIR) (Form 3613-A of Texas Health and Human Services) dated 02/23/24 reflected that, Incident date and time as 2/16/2024 on 9:45 PM. Incident report within the PIR completed by LVN E reflected, LVN E was called to dining room, received report that altercation between Resident #2 and staff [HA B], the Resident #2 was sitting on the floor. Upon visual assessment, [Resident #2] noted to be in no distress and [Resident #2] refused for 911 to be called, stating [Resident #2] was alright. [Resident #2] denied hitting his head on the floor or any pain. [LVN E] stayed with the resident in the dining room for safety. [Resident #2] reported that the staff [HA B] push him down while they were going back and forth of altercation. No Injuries observed at time of incident. Incident report within the PIR completed by LVN E also revealed predisposing physiological factors: Gait Imbalance. Incident report within the PIR completed by LVN E reflected, [Resident #2] allowed the [LVN E] to assess his upper body, he refused to allow [LVN E] to assess beyond that point. No Injuries observed at time of incident. The resident was alert and ambulated without assistance. The resident was oriented to time, place, person, and situation.<BR/>In an observation and attempt to interview on 10/22/24 at 10:09 AM, Resident #2 was standing in the hallway by himself. Resident #2 appeared to be sensitive to noises as evidenced by covered his ears while the housekeeping Staff was vacuuming the floors on the hallway. The writer attempted to speak with Resident #2, resident crossed his arms in X form and walked away. Observed resident had a very slow gait.<BR/>In an interview on 10/22/24 at 10:23 AM, with CNA M, stated she had worked at the facility for about 5 months. She stated she was familiar with Resident'#2's care and stated he kept to himself, frequently refused ADL care from staff members. She stated Resident #2 was sensitive to voices, usually would walk around the facility, especially the dining room. She stated Resident #2 had an unsteady gait.<BR/>In another observation and attempt to interview on 10/22/24 at 1:36 PM, Resident #2 was in his room that had 2 beds in the room with door closed. Resident was by himself in the room and sitting on the unoccupied bed with curtains drawn. Resident #2 refused to speak with the writer.<BR/>In an attempted phone interview on 10/22/24 at 1:53 PM with HA B, left voice message for the staff to call back the writer.<BR/>In an interview on 10/22/24 at 2:45 PM, RN D revealed that she usually worked the 2 -10 PM shift in the facility. She stated that on her 2-10 PM shift on 02/16/24 around 09:45 PM, she heard loud noises from the dining room. She stated that when she entered the dining room, she saw HA B was speaking loudly with Resident #2. She stated from what she could see was Resident #2's back, before RN D could reach him, Resident #2 staggered backwards and lost his balance and fell to the floor. She then stated that HA B continued to loom over Resident #2 and engaged in loud verbal disagreement with him. RN D and CNA C ensured that HA B and Resident #2 were separated immediately. She stated that at this time, she called Resident #2's assigned nurse [LVN E] to the dining room and it was determined that Resident #2 was fine, and no injuries were sustained. RN D then left the dining hall to care for her residents.<BR/>In an interview on 10/22/24 at 3:00 PM, LVN E revealed that she was the assigned nurse for Resident #2 on 2/16/24 2-10 PM shift. She stated that she did not witness the incident. She was called to the dining room by a staff member and received report that altercation between Resident #2 and HA B. When she came to the dining room, Resident #2 was sitting on the floor. She stated that upon visual assessment, Resident #2 noted to be in no distress, and he refused to go to the hospital and denied hitting his head on the floor. Resident #2 refused head to toe assessment initially but then allowed LVN E to complete assessment until his back only, after the DON spoke with him. She stated that police came to the facility, but she was not sure if they were able to speak with Resident #2. She stated Resident #2 was alert and oriented, ambulated without assistance. LVN E added she had care for Resident #2 multiple times and was familiar with his care. Resident #2 had a history of unsteady gait and often refused ADL care. She also stated Resident #2 usually kept to himself and did not like anyone invading his personal space.<BR/>In a phone interview on 10/22/24 at 3:27 PM, HA B started working in the facility on 02/07/24 as a Hospitality Aide. She stated she was on on-the-job training on 02/16/24 on the 2 - 10 PM shift and Resident #2 was one of the residents on her assigned hall. She stated that she no longer worked in the facility. She stated around 9:30 - 9:45 PM on 2/16/24, Resident #2 had taken night-time snacks that belonged to other residents. She asked Resident #2 to give back the snack packets that were in his possession. She stated Resident #2 refused to comply, so she reached for the snacks in his jacket. She stated that when she reached for the snacks, Resident #2 tried to swing at her and stated his rights. She stated that there was verbal argument with Resident #2, and he made threats to her. She stated she tried to remove his possessions and held Resident #2's arm. She added there was a physical tussle between her, and Resident #2 and he then threw hot liquid from his cup on her face. She stated that she called for help from other staff and tried to push him back to maintain distance to protect her safety. Resident #2 started losing his balance and she eased him to the ground. As he was getting to the floor, she saw two other employees reaching the dining room. She stated that called the police to report the incident since she was pregnant. She stated she does not remember if she received training on abuse and neglect when she started her employment with the facility.<BR/>In an interview on 10/22/24 at 3:39 PM with CNA C who also worked the PM -10 PM shift on 2/16/24 in the facility stated that she was taking the leftover trays to the dining room. She saw Resident #2 standing in the dining room. She stated HA B was a new employee and asked CNA C if she had seen Resident #2. She stated that Resident #2 was in the dining hall and left to take care for her assigned residents. She stated that around 9:45 PM on 2/16/24, she heard someone screaming help, help from the dining room. RN D and herself ran to the dining hall, where HA B was screaming that Resident #2 poured hot water on HA B. She stated that she did not witness this incident. She stated that HA B was talking very loudly to Resident #2 and continued to engage verbally with the resident. CNA C asked HA B to leave the Resident #2 alone, and she was acting like she was trying to push at Resident #2, but he staggered and fell. CNA C stated that LVN E came to dining room and she left the dining room to attend to her residents.<BR/>In a final attempt to interview on 10/23/24 at 9:52 AM, with Resident #2, he quoted he is not taking any visitors today and to respect his space.<BR/>In an observation on 10/23/24 at 10:26 AM, the facility camera along with the Administrator, timestamped 2/16/24 21:42:05 (9:42 PM) to 2/16/24 21:45:04 (9:45 PM) revealed during the incident, the camera in the dining room showed Resident #2 standing in the dining room eating snacks. HA B talked with another resident in the dining room and came near to Resident #2. HA B and Resident #2 have some conversation [which could not be heard since the camera only had video footage and no audio] and HA B tried to stick her hand in the pocket of Resident #2's jacket he was wearing. Resident #2 knocked HA B's hand away. The camera further revealed that the two talked again for few seconds and HA B tried to reach for Resident #2's jacket one more time. Resident #2 again tried to knock her hand away and then HA B grabbed the coffee cup that he was drinking out of. Further, camera footage revealed that HA B may have picked multiple of his items, and they tugged back and forth. HA B went ahead to set the cup on the table while continuing to hold one of Resident #2's arm. She took the items from him and had walked away, when Resident #2 picked up his coffee cup and threw the liquid on HA B. At this point, HA B walked back towards Resident #2, grabbed his things, and tussled with him. This went for a brief time, until HA B grabbed Resident#2's arm that made the Resident #2 propel backwards, HA B continued to argue with Resident #2 until he became unsteady on his feet and fell to the floor. The video revealed CNA C and RN D arrived at the incident location while the resident was falling on the ground and had to separate HA B from Resident #2 as she continued to engage verbally with the resident. <BR/> In an interview on 10/23/24 at 10:30 AM, the Administrator revealed that HA B was a new employee. When she heard about the incident from the facility staff, she immediately reached the facility. She stated she was the designated abuse coordinator for the facility and investigated and reported the incident. She stated that HA B was reaching for Resident #2 jacket for snacks. She stated that HA B made a choice to get the snacks out from Resident #2 by reaching for it physically and was pointing fingers, being verbally aggressive with the resident. She added that further investigation revealed as Resident #2 was about to go to the floor, RN D and CNA C entered the dining room. RN D and CNA C had to separate HA B from Resident #2, while HA B continued to be argumentative. She stated that, later when she had a statement from HA B, who verbalized she was upset and angry with Resident #2 and made a choice to grab his arm after he threw the hot liquid on her. Resident #2 refused to have head to toe assessment initially, then allowed to look at his back only. She stated Resident #2 did not sustain any injuries during or after the incident. She stated that police were called regarding the incident. The Administrator stated, as a result of the investigation, she confirmed the allegation of resident abuse by HA B as evidenced by HA B's physical aggressiveness and abuse towards Resident #2. The administrator verbalized that HA B was first suspended and then terminated on 02/16/24. She stated that her expectation was for all staff to always follow abuse and neglect protocols and policies and maintain resident safety. She stated an in-service for abuse and neglect was conducted for all staff members following the incident. <BR/> In an interview on 10/23/24 at 11:23 AM, the DON revealed she had been the DON in the facility since December 2023. She stated that it was her expectation that all staff to always follow abuse and neglect protocols and policies as well as report any abuse or neglect to the abuse coordinator immediately. She stated that abuse and neglect in-services / training are done upon hire for all employees. She stated that the Administrator, ADONs and DON were responsible for providing abuse and neglect in-services. She stated she did not remember the incident between Resident #2 and HA B very well, however stated that Resident #2 sometimes displayed behaviors of eating from other residents' tray and getting snacks. She stated that staff were aware of Resident #2's behaviors. She further added that Resident #2 had limited food intake in the past, so the facility let him have snacks as needed. She stated HA B should have let him have the snacks and should not had intruded his personal space by reaching for items in his jacket. She stated HA B made the choice of grabbing items/snacks from Resident #2 physically and continuing to engage with him in a physical tussle. The DON added Resident #2 did not suffer any physical injuries during or after the incident. <BR/> Record review of detailed police report for Incident 24014324 was requested but not obtained until the exit.<BR/>Record review of the HA B personnel file revealed HA B was hired on 2/7/24 and terminated from Employment on 2/16/24. The facility had conducted Texas Department of Public Safety Criminal History verification and Employee Misconduct Registry Employability status check without any concerns. Record review of HA B personnel file also revealed resident had completed abuse, and neglect training on 2/7/24. <BR/>Interviews on 10/22/24 and 10/23/24 across multiple shifts with various staff members (CNA C, RN D, LVN E, LVN F, LVN G, CNA H, MA I, CNA J, CNA K, CNA L, CNA M) over various shifts revealed facility had conducted abuse and neglect in-services on a routine basis and as needed. The above-mentioned staff members were able to verbalize abuse and different forms of abuse and neglect. They also stated that any incidence of alleged abuse and neglect or any abuse and neglect witnessed will be reported to the facility abuse coordinator immediately. They also verbalized that they had the abuse coordinators name and contact number handy to report abuse. <BR/>Record Review of abuse and neglect in-services conducted by the facility from 2/16/24 to 2/20/24 revealed that the facility staff was trained on abuse and neglect, types of abuse, who is the abuse coordinator and when should abuse be reported. <BR/>The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 02/16/24 9:45 PM and ended on 02/23/24. The facility had corrected the noncompliance before the Incident investigation began. HA B was terminated from employment and Resident #2 had no other incidents. The facility staff were reeducated regarding Abuse and Neglect on 02/16/24 through 02/20/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #1, and Resident #2) of 11 residents reviewed for ADLs. The facility failed to ensure:- Resident #1 had his fingernails cleaned and trimmed.- Resident #2 had his fingernails trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. 1- Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected Resident #1 was a [AGE] year-old male admitted to the facility on 02 /14/25, and readmission on [DATE] with diagnoses of Cerebrovascular Accident (Occurs when blood flow to the brain is interrupted, leading to brain cell death and potential neurological damage), Seizure Disorder or Epilepsy (a neurological condition characterized by recurrent seizer), Asthma (a chronic lung condition that causes inflammation and narrowing of the airways, leading to recurrent episodes of wheezing, shortness of breath, chest tightness, and coughing), Chronic Obstructive Pulmonary Disease (a type of progressive lung disease characterized by long term respiratory symptom and airflow limitation), Respiratory Failure, muscle wasting and atrophy (the decrease in size or wasting away of a body part, such as muscle or tissue, due to cell shrinkage or cell death). Resident#1 had a BIMS score of 06 which indicated severe cognitive impairment. Review of the functional ability section reflected that Resident #1 required substantial assistance with showering and personal hygiene. Record review of Resident #1's Comprehensive Care Plan revised on 07/29/25 reflected, Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Personal Hygiene: Limited x[BR1] 1. Bathing: Dependent x1 Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. In an observation and interview on 09/16/25 at 10:37 AM with Resident #1, revealed his fingernails on both hands were dirty with black discoloration underneath the nails and the nails were jagged. The fingernails were 0.5-0.7 centimeter in length extending from the tips of his fingers. Resident #1 stated he would like his nails to be cleaned and trimmed. 2- Record review of Resident #2's Quarterly MDS assessment dated [DATE], reflected Resident #2 was a [AGE] year-old male admitted to the facility with initial admission date of 05 /09/25, with diagnoses of Hypertension (Elevated blood pressure), Asthma, Chronic Obstructive Pulmonary Disease, muscle weakness, and cognitive communication deficit. Resident#2 had a BIMS score of 13 which indicated intact cognition. Review of functional ability section reflected that Resident #2 required substantial/maximal assistance with showering and setup or clean-up assistance for personal hygiene. Record review of Resident #2's Comprehensive Care Plan revised on 07/21/25 reflected, Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Personal Hygiene: Limited x1. Bathing: Dependent x1 Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. In an observation and interview on 09/16/25 at 10:50 AM with Resident #2, revealed his fingernails on both hands were dirty with black discoloration underneath the nails, and the fingernails were 0.4-0.6 centimeter in length extending from the tips of his fingers. Resident #2 stated he would like his nails to be cleaned and trimmed. In an interview/observation on 09/16/25 at 11:00 AM CNA A checked both residents' fingernails and stated they needed to be cleaned and trimmed. CNA A stated CNAs and nurses were responsible for nail care. She stated that nurses were responsible for nail care for diabetic residents. She stated nail care for residents was done on shower days and as needed. She added the risk to the resident for not trimming or cleaning their nails was decreased skin integrity and risk of infections. In an interview on 09/16/2 11:14 AM with LVN B revealed, CNAs were responsible for resident nail care, unless the resident had diagnoses of diabetes, then nurses were responsible for trimming the resident's nails. She stated dirty, long fingernails could expose the residents to the risk of developing infections or skin tears. LVN B further stated that although CNAs were responsible for nail care, it was ultimately the responsibility of the charge nurse to ensure residents' fingernails were always cleaned and trimmed. Interview on 09/16/25 at 2:24 PM the DON stated all the staff were responsible for the residents fingernail care. She stated CNAs should make sure residents' fingernails were cleaned and trimmed all the time, and if the resident had diabetes mellitus it was strictly the responsibility of the nurses to trim their fingernails. She stated the risk to residents, they could be harboring germs underneath the fingernails, they could develop infection and they could injure themselves or others. Record review of the facility policy titled, Activities of Daily Living Guidelines dated 2/11/2021 reflected, Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Resident #53, Resident #7, Resident # 26, and Resident # 220) of five residents observed for infection control in that: <BR/>CNA B failed to perform hand hygiene during incontinent care and failed to bag soiled wipes and briefs prior to placing them on the end of the bed for Residents # 53, #220, #26 and # 7.<BR/>Theses failure could place residents at risk for infection and cross contamination. <BR/>Findings included:<BR/>1. Review of Resident #53's face sheet dated 08/24/22 reflected a [AGE] year-old male, admitted to the facility on [DATE], and a readmission date of 08/01/22. His primary diagnosis included sepsis due to methicillin susceptible staphylococcus aureus (bacteria resistant to several widely used antibiotics), abscess of right hand and Huntington's disease (inherited condition in which nerve cells in the brain break down).<BR/>Observation on 08/24/22 at 09:25 AM revealed CNA B entered Resident #53's room to assist LVN C with wound care. CNA B washed her hands and donned gloves. CNA B held Resident #53's right arm and hand up while LVN C cut away the old dressing. CNA B grabbed the old dressing as it fell away and held it until LVN C could retrieve it and dispose of it in a biohazard bag. CNA B continued to hold the resident arm and hand while LVN C completed the wound care. CNA B, while wearing the same soiled gloves used to assist with the wound care, went to the resident's closet and retrieved a clean brief and laid it on the head of the bed, picked up the bed remote and lowered the resident's bed and then removed her soiled gloves and performed hand hygiene. CNA B re-gloved, raised the resident bed up and unfastened the resident's brief to reveal he had been incontinent of urine. CNA B then pushed the soiled brief down between the resident's legs toward his buttocks and took a wet wipe and wiped down each groin and then wiped up and down the shaft of the resident's penis trying to remove a white sticky substance. CNA B used the same wipe without changing the surface of the wipe with each swipe. CNA B then rolled the resident onto his side and picked up the clean brief with her soiled gloves and placed it under the dirty brief. CNA B proceeded to wipe the resident's buttocks from front to back, removed the soiled brief and placed it and the used wipes on the end the bed. While wearing the same soiled gloves, CNA B reached into the resident chest of drawers and retrieved a package of barrier wipe and applied the barrier cream to the resident's buttocks. CNA B then rolled the resident back onto his back, fastened the brief and pulled up the residents' pants. CNA B then picked up the soiled brief and wipes and placed them in the trash can, removed her gloves and performed hand hygiene. <BR/>2. Review of Resident #220's face sheet dated 08/24/22 reflected an [AGE] year-old male, admitted to the facility on [DATE]. His primary diagnosis included Chronic Obstructive Pulmonary disease, diabetes and history or COVID-19. <BR/>Observation on 08/24/22 at 09:50 AM revealed CNA B entered Resident #220's room to answer his call light. Resident #220 stated he needed to be changed. CNA B washed her hands and donned gloves and gathered wipes and a brief. Resident #220 stood up out of his wheelchair and started to lay down on the bed. CNA B told him to stand and turn around and she pulled down his pants and unfastened the resident's brief to reveal he had been incontinent of urine. CNA B then wiped the resident's anal area, revealing he was having a bowel movement. CNA B asked the resident if he thought he needed to go to the toilet to finish and he stated yes. Resident #220 ambulated to the bathroom. CNA B removed her gloves, washed her hands, and told the resident she would be back. CNA B returned to the room with a gait belt, washed her hands and put on clean gloves. CNA B had the resident stand up and proceeded to wipe the resident's buttocks from front to back and then took another wipe and wiped the residents front and placed a clean brief on the resident and pulled up his pants without changing gloves or performing hand hygiene. CNA B then placed a gait belt around the resident and had him stand at the sink to wash his hands. Resident #220 ambulated back to his wheelchair with CNA B holding onto the gait belt. CNA B then picked up the resident's O2 tubing and handed it to him. Resident #220 stated he was thirsty and needed a drink. CNA B then removed the gait belt from the resident and placed it in her pocket and reached for the resident's water pitcher, knocking the lid off. CNA B replaced the lid, still wearing the same gloves she had worn to provide incontinent care and handed the pitcher to the resident. CNA B then gathered the trash, removed her gloves, and washed her hands with soap and water. <BR/>3. Review of Resident #26's face sheet dated 08/24/22 reflected a [AGE] year-old female, admitted to the facility on [DATE]. Her primary diagnosis included dementia, epilepsy, and extended spectrum beta lactamase resistance (enzyme produced by some bacteria which causes some antibiotics not to work for treating bacterial infections)<BR/>Observation on 08/24/22 at 10:10 AM revealed CNA B entered Resident #26's room to provide incontinence care. CNA B washed her hands and donned gloves, gathered a brief and wipes and placed them on the bed side table. CNA B unfastened the resident's brief to reveal she had been incontinent of urine and had a large bowel movement. CNA B then pushed the soiled brief down between the resident's legs toward her buttocks and took a wet wipe and wiped down each groin and once down the middle. CNA B used the same wipe without changing the surface of the wipe with each swipe. CNA B then rolled the resident onto her side and picked up the clean brief with her soiled gloves and placed it under the dirty brief. CNA B proceeded to wipe the resident's buttocks from front to back, removed the soiled brief and placed it and the used wipes on the end the bed. While wearing the same soiled gloves, CNA B placed the soiled brief into the trash can by the door and reached into the resident chest of drawers and retrieved a tube of barrier wipe and applied the barrier cream to the resident's buttocks. CNA B then rolled the resident back onto her back and took another wipe and wiped again down the resident's groin, removing more bowel movement. CNA B then fastened the brief and covered the resident with sheet and blanket, put the tube of barrier cream back in the residents' chest of drawers, repositioned her bedside table and then removed her gloves and placed in the trash and washed her hands. CNA B then proceeded to provide incontinence care to the roommate, Resident #7. <BR/>4. Review of Resident #7's face sheet dated 08/24/22 reflected an [AGE] year-old female, admitted to the facility on [DATE]. Her primary diagnosis included Parkinson's disease, dementia, and left side hemiplegia (paralysis)<BR/>Observation on 08/24/22 at 10:15 AM revealed CNA B washed her hands and donned gloves, gathered a brief and wipes and placed them on Resident #7 bed side table. CNA B unfastened the resident's brief to reveal she had been incontinent of urine. CNA B then pushed the soiled brief down between the resident's legs toward her buttocks and took a wet wipe and wiped down each groin and once down the middle. CNA B used the same wipe without changing the surface of the wipe with each swipe. CNA B then rolled the resident onto her side and picked up the clean brief with her soiled gloves and placed it under the dirty brief. CNA B proceeded to wipe the resident's buttocks from front to back, removed the soiled brief and placed it and the used wipes on the end the bed, had the resident roll back on her back and fastened the clean brief. While wearing the same soiled gloves, CNA B placed the soiled brief into the trash can by the door, returned to the resident to adjust her clothing and took a clean wipe an washed the bottom of the residents' feet that were covered in with a black substance. CNA B then covered the resident with her bed covers, removed her gloves, and tied up the trash and washed her hands. <BR/>In an interview with CNA B on 08/24/22 at 10:05 AM revealed she had worked at the facility approximately 6 months. When asked when she was supposed to perform glove changes and hand hygiene during incontinence care she stated before you start and after you had completed care. She stated she was not aware she had to change her gloves during incontinence care. She stated she was taught the end of the bed was considered dirty, which was why she placed the soiled brief and wipes at the end of the bed until she had completed care. She stated she knew you were supposed to wipe from front to back and change the surface to the wipes each time, and stated she thought she had done that. She stated she had recently been in serviced on hand hygiene and knew the importance of hand hygiene to prevent infections. <BR/>Review of the facilities in-services on infection control, which covered the facilities hand hygiene policy, dated 08/04/22 revealed neither CNA B had attended. <BR/>In an interview with the DON on 08/24/22 at 1:00 PM revealed staff were to perform hand hygiene before incontinence care and during care they were to remove their gloves and perform hand hygiene when they went from dirty to clean and once, they completed care, they were to perform hand hygiene again. She stated they were always supposed to place dirty wipes and briefs and linens in a plastic bag. She stated failing to follow these procedures placed residents at risk of cross contamination and increased risk of urinary tract infections. She stated all staff were skills checked upon hire and again if training issues were identified. <BR/>In an interview with ADON A on 08/24/22 at 01:15 PM she stated staff were to perform hand hygiene when they entered a resident's room, after contact with any bodily fluid, and they were to change their gloves and perform hand hygiene during incontinent care when they went from dirty to clean. She stated they were never to place dirty linen on the floor or chairs in the room, stating it was to be always supposed to be bagged. She stated she observed CNA B during her skills checks off upon hire and she had performed the procedure correctly at that time. She stated by not following standard precautions with hand hygiene it placed residents at risk of infections and cross contamination. <BR/>Review of the facility's policy titled, Incontinence Care, dated February 2022, reflected, .Have all needed equipment at bedside on the over bed table wipes (at least 7), gloves (at least 3 pair), barrier cream, plastic bag or trash can .Wash hands and put on gloves Remove soiled clothing and brief and place the brief in the trash bag .Take off the gloves, put them in the trash bag. Wash your hands and put on new gloves Cleanse the peri area with wipes going front to back/clean to dirty. Separate the labia. Use a new wipe with ach stroke: Wipe one side, wipe the other side, wipe down the center and then once from hip bone to hip bone .Repeat cleansing until the resident is clean .take off the gloves, put them into the trash bag with the soiled brief and wipes .Wash your hands, put on gloves and apply protective ointment if needed and a clean brief .Remove gloves and wash your hands .Reposition the resident, offer fluids .Remove trash from room .Wash your hands .If performing incontinent care for a male resident .Take the wipe in one hand and gently grasp the penis shift .wipe the head of the penis beginning at the urethra opening working outward or away from the penis head, Cleanse in a circular motion away from the urethra. Use new wipe each time .Cleanse the penis shaft with wipe from the top of the shaft towards the rectum, including the scrotum .Using a new wipe with each stroke clean from the upper part of the leg to the hip <BR/>Review of the facility's policy titled, Infection Control Guidelines, dated February 2021, reflected, .Hand Hygiene Protocol .Staff shall use hand hygiene when coming on duty, between patient contacts, after handling contaminated objects, after PPE removal, and before going off duty .Staff shall wash their hands with an antiseptic preparation before performing patient care procedures and when providing .For routine care, staff shall wash their hands with soap and water or a waterless alcohol agent before and after patient contact .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #1, and Resident #2) of 11 residents reviewed for ADLs. The facility failed to ensure:- Resident #1 had his fingernails cleaned and trimmed.- Resident #2 had his fingernails trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. 1- Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected Resident #1 was a [AGE] year-old male admitted to the facility on 02 /14/25, and readmission on [DATE] with diagnoses of Cerebrovascular Accident (Occurs when blood flow to the brain is interrupted, leading to brain cell death and potential neurological damage), Seizure Disorder or Epilepsy (a neurological condition characterized by recurrent seizer), Asthma (a chronic lung condition that causes inflammation and narrowing of the airways, leading to recurrent episodes of wheezing, shortness of breath, chest tightness, and coughing), Chronic Obstructive Pulmonary Disease (a type of progressive lung disease characterized by long term respiratory symptom and airflow limitation), Respiratory Failure, muscle wasting and atrophy (the decrease in size or wasting away of a body part, such as muscle or tissue, due to cell shrinkage or cell death). Resident#1 had a BIMS score of 06 which indicated severe cognitive impairment. Review of the functional ability section reflected that Resident #1 required substantial assistance with showering and personal hygiene. Record review of Resident #1's Comprehensive Care Plan revised on 07/29/25 reflected, Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Personal Hygiene: Limited x[BR1] 1. Bathing: Dependent x1 Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. In an observation and interview on 09/16/25 at 10:37 AM with Resident #1, revealed his fingernails on both hands were dirty with black discoloration underneath the nails and the nails were jagged. The fingernails were 0.5-0.7 centimeter in length extending from the tips of his fingers. Resident #1 stated he would like his nails to be cleaned and trimmed. 2- Record review of Resident #2's Quarterly MDS assessment dated [DATE], reflected Resident #2 was a [AGE] year-old male admitted to the facility with initial admission date of 05 /09/25, with diagnoses of Hypertension (Elevated blood pressure), Asthma, Chronic Obstructive Pulmonary Disease, muscle weakness, and cognitive communication deficit. Resident#2 had a BIMS score of 13 which indicated intact cognition. Review of functional ability section reflected that Resident #2 required substantial/maximal assistance with showering and setup or clean-up assistance for personal hygiene. Record review of Resident #2's Comprehensive Care Plan revised on 07/21/25 reflected, Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Personal Hygiene: Limited x1. Bathing: Dependent x1 Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. In an observation and interview on 09/16/25 at 10:50 AM with Resident #2, revealed his fingernails on both hands were dirty with black discoloration underneath the nails, and the fingernails were 0.4-0.6 centimeter in length extending from the tips of his fingers. Resident #2 stated he would like his nails to be cleaned and trimmed. In an interview/observation on 09/16/25 at 11:00 AM CNA A checked both residents' fingernails and stated they needed to be cleaned and trimmed. CNA A stated CNAs and nurses were responsible for nail care. She stated that nurses were responsible for nail care for diabetic residents. She stated nail care for residents was done on shower days and as needed. She added the risk to the resident for not trimming or cleaning their nails was decreased skin integrity and risk of infections. In an interview on 09/16/2 11:14 AM with LVN B revealed, CNAs were responsible for resident nail care, unless the resident had diagnoses of diabetes, then nurses were responsible for trimming the resident's nails. She stated dirty, long fingernails could expose the residents to the risk of developing infections or skin tears. LVN B further stated that although CNAs were responsible for nail care, it was ultimately the responsibility of the charge nurse to ensure residents' fingernails were always cleaned and trimmed. Interview on 09/16/25 at 2:24 PM the DON stated all the staff were responsible for the residents fingernail care. She stated CNAs should make sure residents' fingernails were cleaned and trimmed all the time, and if the resident had diabetes mellitus it was strictly the responsibility of the nurses to trim their fingernails. She stated the risk to residents, they could be harboring germs underneath the fingernails, they could develop infection and they could injure themselves or others. Record review of the facility policy titled, Activities of Daily Living Guidelines dated 2/11/2021 reflected, Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to, in accordance with State and Federal laws, ensure all drugs were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to these drugs, to meet the needs of each resident, for 1 (Resident #1) of four residents reviewed for medication storage.<BR/>The facility failed to ensure Resident #1 did not have wound treatment medications and unsecured medications in his room on 01/04/23.<BR/>This deficient practice could place residents at risk of, not being monitored for their medications, adverse reactions, and drug diversion. <BR/>Findings included:<BR/>Review of Resident #1's face sheet dated 01/04/23 reflected Resident #1 was a [AGE] year-old male admitted on [DATE] to the facility with diagnoses that included obesity, chronic hepatitis C, hyperlipidemia, hypokalemia, depression and peripheral vascular disease.<BR/>Review of Resident #1's quarterly MDS assessment dated [DATE] reflected he had a BIMS of 13 indicating he was cognitively intact.<BR/>Review of Resident #1's care plan reflected on 10/18/22 with target date of 04/06/23 that Resident #1 had potential for the development of a pressure ulcer. The comprehensive care plan did not reflect Resident #1 could self-administer his medications and keep medications in his room. <BR/>Review of Resident #1's January 2023 electronic physician order indicated Triamcinolone Acetonide Ointment (used help to relieve redness, itching, swelling, or other discomfort caused by skin condition) 0.1% apply to both legs topically every day shift wound. Silvadene Cream (used to prevent and treat wound infections) 1% apply to leg wound topically one time daily. Lidocaine Ointment (used to cause numbness or loss of feeling) 5% apply to wounds topically every 4 hours as needed for wounds.<BR/>Review of Resident #1's MAR/TAR for January 2023 reflected the resident was given Triamcinolone Acetonide Ointment 0.1% and Silvadene Cream 1% on the following dates: 01/01-01/03/23. <BR/>Observation and interview on 01/04/23 at 11:30 AM revealed Resident # 1 had 2 tubes of Lidocaine Ointment, 1 tubes of Triamcinolone Acetonide Ointment, and 2 tubes of Silvadene Cream in his unlocked bedside table drawer. Each had Resident #1's name written on it. There were no facility staff in resident's room. Resident #1 stated LVN A gave them to him, and Resident #1 said he uses each of the medications two times a day but that he only used a small amount of each medication cream. <BR/>An interview on 01/04/23 at 9:24 AM with LVN A revealed he did give Resident #1 medications and supplies to keep in his room to self-treat his wounds on the weekends. LVN A stated that the resident prefers to do his own treatments on the weekends. So on Fridays LVN A made sure he had the supplies he needed. LVN A stated he did not know if the resident was able to self-treat or not. LVN A stated the risk of having medications in a resident's room could result in drug being mishandled. <BR/>An interview on 01/04/23 at 10:34 AM with the ADON revealed Resident #1 should not have medications in his room and did not self-administer his medications. The ADON stated the nurses should not leave a resident's room without taking medications with them. The ADON stated that the risk of leaving medications in a resident room could result in another resident having access to unprescribed medication. <BR/>An interview on 01/04/23 at 12:30 PM with the DON revealed she observed the following medications: 2 tubes of Lidocaine Ointment, 1 tubes of Triamcinolone Acetonide Ointment and 2 tubes of Silvadene Cream in Resident #1's room. The DON stated she would address leaving the medications in Resident #1's room with LVN A. The DON stated that her expectation was for no medications to be left in a Resident's room. The DON stated the risk of having medications in a resident's room could result unauthorized access to a medication.<BR/>An interview on 01/04/23 at 2:16 PM with the ADM revealed LVN A should not have left medications in Resident #1's room. She stated Resident #1 should not have medications left in his room and she would take care of it. <BR/>Review of the facility's policy Medication Storage dated 01/20/21 reflected 1. General guidelines: a. All drugs and biologicals are stored in locked compartments (for example medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature. B. Only authorized personnel will have access to the keys to locked compartment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to provide a safe, clean, and homelike environment for 2 (Residents #188 and #84) of 24 residents reviewed for environment. <BR/>The facility failed to provide Residents #188 and #84 a handwashing sink that was not loose and a paper towel dispenser that worked properly without cover coming off in resident bathroom.<BR/>This failure could place residents at risk for living in an unsanitary and uncomfortable environment. <BR/>Findings included:<BR/>Review of Resident #188's face sheet dated 10/26/23 reflected Resident #188 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of displace avulsion fracture of right talus (broken bone in ankle), hypertension, diabetes, post-traumatic stress disorder, neuropathy, and heart disease. <BR/>Review of Resident #188's other MDS assessment dated [DATE] reflected Resident #188 had a BIMS score of 15 indicating he was cognitively intact. <BR/>Observation and Interview on 10/24/23 at 10:55 AM with Resident #188 revealed since he had been admitted to the facility, he had noticed the handwashing sink was loose and the paper towel dispenser cover in his bathroom would come off when pulling paper towel out of it. <BR/>Observations on 10/25/23 at 1:58 PM and 10/26/23 at 8:46 AM revealed Resident # 188 and Resident #84's bathroom had a loose sink and the paper towel dispenser cover was loose would come off when touched. <BR/>Interview on 10/26/23 at 8:48 AM with the Maintenance Director stated he was not aware of issues with Residents #188 and #84's bathroom sink and paper towel dispenser. He stated housekeeper should have reported the bathroom sink and paper towel dispenser to him. He stated the bathroom sink being loose needed to be fixed with 2 screws to secure it. He stated housekeeping had the paper towel dispenser replacement and would have to give it to him so he could replace it. He stated he can get the bathroom sink fixed and paper towel dispenser replaced. He stated the nurse, CNA and/or housekeeper should report any maintenance issues in the system and then he was notified of maintenance repairs. He stated he was not able to do rounds on all resident rooms and bathrooms and depended on facility staff to report to him any repairs. <BR/>Interview on 10/26/23 at 11:35 AM with CNA H revealed she was not aware of issues with Residents #188 and #84's bathroom sink or paper towel dispenser.<BR/>Interview on 10/26/23 at 11:38 AM with CNA D revealed she was not aware of issues with Residents #188 and #84's bathroom sink or paper towel dispenser. She stated Resident #188 used the bathroom and did not voice to her about any concerns with bathroom. <BR/>Interview on 10/26/23 at 12:52 PM with Housekeeper I revealed about three weeks ago she had noticed Resident #188 and #84's handwashing bathroom sink was loose and paper towel dispenser cover would come off. She stated she told Housekeeper Supervisor about it who filled out a work order.<BR/>Interview on 10/26/23 at 12:56 PM with Housekeeping Supervisor revealed she had put in a work order when Housekeeper made her aware of Resident #188 and #84's bathroom sink and paper towel dispenser and gave it to Receptionist. She stated receptionist told her she threw them away after they were put in electronic system.<BR/>Interview on 10/26/23 at 2:18 PM with Receptionist revealed she put in maintenance work orders into system but was not sure what Maintenance did with them afterwards. She did not have a copy of work order for resident bathroom room [ROOM NUMBER].<BR/>Interview on 10/26/23 at 2:33 PM with the DON revealed the maintenance work order for room [ROOM NUMBER] (Residents #188 and #84 bathroom) was put in this morning and facility could not locate a maintenance work order prior to today. <BR/>Review of facility's policy Preventative Maintenance undated reflected 1. The Facility will provide a written or computerized preventative program ensuring inspections are performed on schedule and continuously reviewing the program to make certain that the results are meeting the goals of the program. The preventative maintenance program .will ensure a safe, well-maintained environment for the Residents, Visitors and Staff. 2. The facility will provide a written quality control program that ensures a clean, safe, pleasant and functional environment for the Residents, Staff and Visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care ,including tracheostomy care and tracheal suctioning, were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #1) residents reviewed for respiratory care. The facility failed to ensure physician's orders were written for oxygen use via nasal canula for Resident #1 on readmission [DATE] to 09/16/2025. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records. Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected Resident #1 was a [AGE] year-old male admitted to the facility on 02 /14/25, and readmission on [DATE] with diagnoses of Cerebrovascular Accident (Occurs when blood flow to the brain is interrupted, leading to brain cell death and potential neurological damage), Seizure Disorder or Epilepsy (a neurological condition characterized by recurrent seizer), Asthma (a chronic lung condition that causes inflammation and narrowing of the airways, leading to recurrent episodes of wheezing, shortness of breath, chest tightness, and coughing), Chronic Obstructive Pulmonary Disease (a type of progressive lung disease characterized by long term respiratory symptom and airflow limitation), Respiratory Failure, muscle wasting and atrophy (the decrease in size or wasting away of a body part, such as muscle or tissue, due to cell shrinkage or cell death). Resident #1 had a BIMS score of 06 which indicated severe cognitive impairment. Review of section J. J1100. Shortness of Breath (dyspnea) revealed: C. Shortness of breath or trouble breathing when lying flat. Review of respiratory treatment C1 oxygen therapy was not market for oxygen use. Record review of Resident #1's Comprehensive Care Plan revised on 07/29/25 reflected no indication of oxygen use. Record review of Resident #1's electronic medical record on 09/16/25 revealed: 1- No physician's order for oxygen use for readmission on [DATE] to 09/16/2025 2- The MAR did not reflect oxygen use or setting. In an observation and interview on 09/16/25 at 10:37 AM revealed Resident#1 was lying in bed, on oxygen via nasal canula and his oxygen concentrator was beeping with the yellow alarm light flushing. Resident #1 stated he did not feel good. Resident #1's oxygen concentrator float/flow indicator device was not visible inside the flowmeter tube. Observation on 09/16/25 at 11:14 AM revealed LVN B responding to the Resident #1's call light. LVN B checked the oxygen concentrator and turned the knob until the float was visible in the flowmeter. LVN B adjusted the oxygen flow to 2 L/ minutes. Observation revealed LVN B asking Resident #1 how he was feeling, and he replied he was feeling better. Interview with LVN B revealed Resident #1 was on oxygen as needed, and some time Resident #1 liked to adjust the flow rate. LVN B stated, she reeducated Resident #1 not to adjust the oxygen rate for his safety. LVN B stated adjusting the oxygen flow too high or too low could affect the amount of oxygen the resident was receiving and his breathing quality. In interview on 09/16/25 at 2:29 PM the DON stated Resident #1's oxygen was as needed, and sometimes he played with the concentrator flowmeter. The DON stated her expectation was every resident with oxygen must have order, because oxygen was a medication that could be given by the physician order only. The DON stated the risk to Resident #1 for not having a physician's order for oxygen use was respiratory issue. Interview with the Administrator on 09/16/25 at 3:20 PM, she stated orders drive care and she expected nursing staff to obtain orders for care. The Administrator stated she expected Resident #1 to have orders for his oxygen use. Record review of policy titled, Consulting Physician/Practitioner Orders dated 09/28/2021, reflected Policy: The policy provide guidance on receiving and following physician orders. c. Carry out and implement physician orders d. Document resident response to physician order in the medical record as indicated . Record review of policy titled, Oxygen Administration date 01/05/2020, reflected Policy: To describe methods of delivering oxygen to improve tissue oxygenation.during a respirator emergency it is appropriate for nursing to administer oxygen immediately and then notify physician for orders and further clinical guidance. 1.Verify physician order 2. Orders should have when to call the physician parameters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interviews and record reviews the facility failed to provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in &sect;483.70(g) for 1 of 5 residents (Resident #1) reviewed for medication administration.<BR/>The Facility failed to ensure Resident #1 had received his medications as scheduled and as ordered by his physician.<BR/>This failure could place residents at risk of health complications.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet, dated 08/01/23, revealed he was a 67 -year-old male admitted on [DATE]. Relevant diagnoses Type 2 Diabetes Mellitus (high blood glucose), Major Depressive Disorder, Acute Kidney Failure, and Essential Hypertension (high blood pressure). <BR/>Record review of Resident #1's Minimum Data Set (MDS) on dated 05/24/23 revealed she had a Brief Interview for Mental Status (BIMS) score of 03 (severely mentally impaired and was not interviewable) and for Active Diagnosis, Resident #1 had diagnosis of Hypertension (high blood pressure), Depression, and Diabetes Mellitus (high blood glucose).<BR/>Review of Resident #1's Physician Orders dated 08/01/23 revealed Orders for the following:<BR/>Norvasc Tablet 10 MG (high blood pressure)<BR/>Record Review of Resident #1's Medication Administration Records for July 2023 documented by MA J revealed, the resident had missed his blood pressure medication on the following dates:<BR/>07/02/23 AM Schedule: Resident Refused<BR/>07/06/23 AM Schedule: Resident Refused<BR/>07/07/23 AM Schedule: Resident Refused<BR/>07/11/23 AM Schedule: Resident Refused<BR/>07/12/23 AM Schedule: Resident Refused<BR/>07/13/23 AM Schedule: Resident Refused<BR/>07/14/23 AM Schedule: Resident Refused<BR/>07/17/23 AM Schedule: Resident Refused<BR/>07/18/23 AM Schedule: Resident Refused<BR/>07/19/23 AM Schedule: Resident Refused<BR/>07/21/23 AM Schedule: Resident Refused<BR/>07/24/23 AM Schedule: Resident Refused<BR/>07/25/23 AM Schedule: Resident Refused<BR/>07/26/23 AM Schedule: Resident Refused<BR/>07/27/23 AM Schedule: Resident Refused<BR/>07/28/23 AM Schedule: Resident Refused<BR/>07/31/23 AM Schedule: Resident Refused<BR/>Interview with LVN O on 08/01/23 at 11:05 AM revealed she was the hall nurse for Resident #1. She stated the resident often refused a shower, but she was unaware the resident was refusing to take his medication because the Medication Aide did not advise her of this. She stated if a resident refused medication, the Medication Aide must notify the Hall nurse so that she can notify the physician, Responsible party, and attempt to persuade the resident into taking his medication. She advised the risk of the resident not taking his medication when scheduled could result in him having health complications.<BR/>Interview with MA J on 08/02/23 at 11:15 AM revealed, She stated she had been at the facility for almost a year. She stated the resident refused medication since she had been there, and she stated she had told a nurse about him not taking medication and the last time when she told her nurse was in May 2023. She stated she mentioned it a lot before but stopped doing so because she thought it was care planned. She advised she could not remember who she had spoken with. She stated the risk to the resident not taking his medication is possible increase in his blood pressure and causing a heart attack or stroke. She was asked the process if a resident refuses medication, was that they had to notify the nurse.<BR/>Interview with ADON on 08/01/23 at 11:20 AM revealed she was advised by the 100 Hall Nurse of the concerns regarding Resident #1's refusal of medication and it not being reported by the Medication Aide. She advised that staff are required to report to their Hall nurse anytime a resident refuses their medication. The ADON advised that this was the first-time hearing of the resident refusing to take medication. She advised the risk of residents not taking their medication when scheduled could result in the resident having a serious illness as a result of not taking the medication. She stated that the Medication Aide should have notified her nurse so that other attempts could be made to encourage the resident into taking the medication and they could also notify the Responsible party and his physician.<BR/>Interview with Administrator of 08/01/23 at 11:30 AM revealed she was present when the ADON was advised of Resident #1 refusing to take his medication throughout the month of July 2023. The Administrator advised that anytime a resident refused medication, the Medication Aide must notify their Hall nurse every time a resident refused medication because the Resident had a good rapport with some of the staff and someone could have convinced him into taking his medication. She advised the risk of the resident not getting his medication could result in him having increased health issues, especially if it involved medication to treat illnesses such as diabetes and high blood pressure. The Administrator advised that she did some research and found that the resident was refusing his evening medication but taking his morning medications. She advised that she spoke with the Resident's physician and was advised that the blood pressure medication would be changed to the mornings, since the resident appeared more willing to take his medication in the mornings and for all other medications that are required to be taken at night, they will use interventions to encourage the resident to take his scheduled medication.<BR/>Review of the Facility's policy on Medication - Treatment Administration and Documentation dated 02/10/20 revealed, Circle initials for medication or treatment that were not administered and document reason for the non-administration on the back of the MAR or TAR. Review each MAR and TAR after each medication and treatment administration is completed and prior to the end of the shift to validate documentation is completed and supports services provided accorded to physician orders.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. <BR/>1. The facility failed to ensure dish machine reached minimum of 120 degrees F for wash and rinse on 10/24/23.<BR/>2. The facility failed to ensure food in the kitchen's refrigerator and freezer were stored in sealed containers, labeled, and dated. The facility failed to ensure food item in refrigerator was not spoiled.<BR/>3. The facility failed to maintain cleanliness of the inside of the ice machine. <BR/>These failures could place residents at risk for food contamination and food-borne illness.<BR/>Findings included:<BR/>1. Observations on 10/24/23 at 10:07 AM revealed the Dietary Manager ran the dish machine with first two wash/rinse low temperature dish machine reading 100 temp F for wash and rinse. The third time dish machine ran cycle the temperature only reached 110 temp F for wash and rinse. Dietary Manager ran the dish machine two more times with 115 temperature F and 118 temperature. <BR/>Interview on 10/24/23 at 10:15 AM with the Dietary Manager stated it was a low temp dish machine which should reach at least 120 degrees F for wash and rinse. He looked at the temperature log on the wall and stated they had not checked the dish machine temperature yet this morning. The Dietary Manager stated there had been a couple of loads already ran through prior to checking the dish machine. He stated they will temporarily not use the dish machine until were are able to have it working properly. He stated it was important for the dish machine to reach at least minimum temperature to clean the dishes. <BR/>Interview on 10/26/23 at 8:48 AM with the Maintenance Director revealed dish machine representative came out on 10/24/23 to look at dish machine on 10/24/23 verifying the dish machine water temperature was not reaching minimum water temperature as required. He stated he had to replace the kitchen's water heater circulator pumps before able to get hot water at minimum temperatures. He stated he was not aware of any issues with the kitchen dish machine water temperatures until 10/24/23 when they contacted dish machine representative. Surveyor requested service order for dish machine. <BR/>2. Observation on 10/24/23 at 10:20 AM revealed 1 of 2 freezers had frozen meat not dated or labeled. <BR/>Observation on 10/24/23 at 10:21 AM revealed 1 of 2 refrigerator contained a sealed plastic food item with shredded purple and yellowish shredded produce labeled green cabbage not labeled or dated. No expiration date was on the item or date on the item.<BR/>Interview on 10/24/23 at 10:22 AM the Dietary Manager revealed the frozen meat was chicken which should have been labeled and dated when opened. The Dietary Manager stated he thought the item in the refrigerator was coleslaw and looked like it had turned bad. He stated he will throw it away. It should be labeled and dated so they know when item was open and received. He stated if food items were not dated when opened then they will not be able to know how long it will last. <BR/>3. Observation on 10/24/23 at 10:26 AM revealed ice machine in the kitchen had dark blackish stains and particles covering about four inch area on the left inner part above the ice. <BR/>Interview on 10/24/23 at 10:27 AM and 10:34 AM with the Dietary Manager revealed he had not noticed the blackish particles inside the ice machine. He stated it could drip down and contaminate the ice. He stated Maintenance had cleaned it last month when it was not working. He stated Maintenance usually cleaned it monthly at least. <BR/>Review of facility's policy Frozen and Refrigerated Foods Storage revised 12/5/17 reflected Items stored in the refrigerator must be dated upon receipt, unless they contain a manufacturer use by, sell by, best by date, or a date delivered .11. All refrigerated and frozen items in storage will contain a minimum label of common name of product and dated as noted above .<BR/>The facility did not provide a specific policy on the ice machine or the dish machineat the date and time of exit from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Resident #53, Resident #7, Resident # 26, and Resident # 220) of five residents observed for infection control in that: <BR/>CNA B failed to perform hand hygiene during incontinent care and failed to bag soiled wipes and briefs prior to placing them on the end of the bed for Residents # 53, #220, #26 and # 7.<BR/>Theses failure could place residents at risk for infection and cross contamination. <BR/>Findings included:<BR/>1. Review of Resident #53's face sheet dated 08/24/22 reflected a [AGE] year-old male, admitted to the facility on [DATE], and a readmission date of 08/01/22. His primary diagnosis included sepsis due to methicillin susceptible staphylococcus aureus (bacteria resistant to several widely used antibiotics), abscess of right hand and Huntington's disease (inherited condition in which nerve cells in the brain break down).<BR/>Observation on 08/24/22 at 09:25 AM revealed CNA B entered Resident #53's room to assist LVN C with wound care. CNA B washed her hands and donned gloves. CNA B held Resident #53's right arm and hand up while LVN C cut away the old dressing. CNA B grabbed the old dressing as it fell away and held it until LVN C could retrieve it and dispose of it in a biohazard bag. CNA B continued to hold the resident arm and hand while LVN C completed the wound care. CNA B, while wearing the same soiled gloves used to assist with the wound care, went to the resident's closet and retrieved a clean brief and laid it on the head of the bed, picked up the bed remote and lowered the resident's bed and then removed her soiled gloves and performed hand hygiene. CNA B re-gloved, raised the resident bed up and unfastened the resident's brief to reveal he had been incontinent of urine. CNA B then pushed the soiled brief down between the resident's legs toward his buttocks and took a wet wipe and wiped down each groin and then wiped up and down the shaft of the resident's penis trying to remove a white sticky substance. CNA B used the same wipe without changing the surface of the wipe with each swipe. CNA B then rolled the resident onto his side and picked up the clean brief with her soiled gloves and placed it under the dirty brief. CNA B proceeded to wipe the resident's buttocks from front to back, removed the soiled brief and placed it and the used wipes on the end the bed. While wearing the same soiled gloves, CNA B reached into the resident chest of drawers and retrieved a package of barrier wipe and applied the barrier cream to the resident's buttocks. CNA B then rolled the resident back onto his back, fastened the brief and pulled up the residents' pants. CNA B then picked up the soiled brief and wipes and placed them in the trash can, removed her gloves and performed hand hygiene. <BR/>2. Review of Resident #220's face sheet dated 08/24/22 reflected an [AGE] year-old male, admitted to the facility on [DATE]. His primary diagnosis included Chronic Obstructive Pulmonary disease, diabetes and history or COVID-19. <BR/>Observation on 08/24/22 at 09:50 AM revealed CNA B entered Resident #220's room to answer his call light. Resident #220 stated he needed to be changed. CNA B washed her hands and donned gloves and gathered wipes and a brief. Resident #220 stood up out of his wheelchair and started to lay down on the bed. CNA B told him to stand and turn around and she pulled down his pants and unfastened the resident's brief to reveal he had been incontinent of urine. CNA B then wiped the resident's anal area, revealing he was having a bowel movement. CNA B asked the resident if he thought he needed to go to the toilet to finish and he stated yes. Resident #220 ambulated to the bathroom. CNA B removed her gloves, washed her hands, and told the resident she would be back. CNA B returned to the room with a gait belt, washed her hands and put on clean gloves. CNA B had the resident stand up and proceeded to wipe the resident's buttocks from front to back and then took another wipe and wiped the residents front and placed a clean brief on the resident and pulled up his pants without changing gloves or performing hand hygiene. CNA B then placed a gait belt around the resident and had him stand at the sink to wash his hands. Resident #220 ambulated back to his wheelchair with CNA B holding onto the gait belt. CNA B then picked up the resident's O2 tubing and handed it to him. Resident #220 stated he was thirsty and needed a drink. CNA B then removed the gait belt from the resident and placed it in her pocket and reached for the resident's water pitcher, knocking the lid off. CNA B replaced the lid, still wearing the same gloves she had worn to provide incontinent care and handed the pitcher to the resident. CNA B then gathered the trash, removed her gloves, and washed her hands with soap and water. <BR/>3. Review of Resident #26's face sheet dated 08/24/22 reflected a [AGE] year-old female, admitted to the facility on [DATE]. Her primary diagnosis included dementia, epilepsy, and extended spectrum beta lactamase resistance (enzyme produced by some bacteria which causes some antibiotics not to work for treating bacterial infections)<BR/>Observation on 08/24/22 at 10:10 AM revealed CNA B entered Resident #26's room to provide incontinence care. CNA B washed her hands and donned gloves, gathered a brief and wipes and placed them on the bed side table. CNA B unfastened the resident's brief to reveal she had been incontinent of urine and had a large bowel movement. CNA B then pushed the soiled brief down between the resident's legs toward her buttocks and took a wet wipe and wiped down each groin and once down the middle. CNA B used the same wipe without changing the surface of the wipe with each swipe. CNA B then rolled the resident onto her side and picked up the clean brief with her soiled gloves and placed it under the dirty brief. CNA B proceeded to wipe the resident's buttocks from front to back, removed the soiled brief and placed it and the used wipes on the end the bed. While wearing the same soiled gloves, CNA B placed the soiled brief into the trash can by the door and reached into the resident chest of drawers and retrieved a tube of barrier wipe and applied the barrier cream to the resident's buttocks. CNA B then rolled the resident back onto her back and took another wipe and wiped again down the resident's groin, removing more bowel movement. CNA B then fastened the brief and covered the resident with sheet and blanket, put the tube of barrier cream back in the residents' chest of drawers, repositioned her bedside table and then removed her gloves and placed in the trash and washed her hands. CNA B then proceeded to provide incontinence care to the roommate, Resident #7. <BR/>4. Review of Resident #7's face sheet dated 08/24/22 reflected an [AGE] year-old female, admitted to the facility on [DATE]. Her primary diagnosis included Parkinson's disease, dementia, and left side hemiplegia (paralysis)<BR/>Observation on 08/24/22 at 10:15 AM revealed CNA B washed her hands and donned gloves, gathered a brief and wipes and placed them on Resident #7 bed side table. CNA B unfastened the resident's brief to reveal she had been incontinent of urine. CNA B then pushed the soiled brief down between the resident's legs toward her buttocks and took a wet wipe and wiped down each groin and once down the middle. CNA B used the same wipe without changing the surface of the wipe with each swipe. CNA B then rolled the resident onto her side and picked up the clean brief with her soiled gloves and placed it under the dirty brief. CNA B proceeded to wipe the resident's buttocks from front to back, removed the soiled brief and placed it and the used wipes on the end the bed, had the resident roll back on her back and fastened the clean brief. While wearing the same soiled gloves, CNA B placed the soiled brief into the trash can by the door, returned to the resident to adjust her clothing and took a clean wipe an washed the bottom of the residents' feet that were covered in with a black substance. CNA B then covered the resident with her bed covers, removed her gloves, and tied up the trash and washed her hands. <BR/>In an interview with CNA B on 08/24/22 at 10:05 AM revealed she had worked at the facility approximately 6 months. When asked when she was supposed to perform glove changes and hand hygiene during incontinence care she stated before you start and after you had completed care. She stated she was not aware she had to change her gloves during incontinence care. She stated she was taught the end of the bed was considered dirty, which was why she placed the soiled brief and wipes at the end of the bed until she had completed care. She stated she knew you were supposed to wipe from front to back and change the surface to the wipes each time, and stated she thought she had done that. She stated she had recently been in serviced on hand hygiene and knew the importance of hand hygiene to prevent infections. <BR/>Review of the facilities in-services on infection control, which covered the facilities hand hygiene policy, dated 08/04/22 revealed neither CNA B had attended. <BR/>In an interview with the DON on 08/24/22 at 1:00 PM revealed staff were to perform hand hygiene before incontinence care and during care they were to remove their gloves and perform hand hygiene when they went from dirty to clean and once, they completed care, they were to perform hand hygiene again. She stated they were always supposed to place dirty wipes and briefs and linens in a plastic bag. She stated failing to follow these procedures placed residents at risk of cross contamination and increased risk of urinary tract infections. She stated all staff were skills checked upon hire and again if training issues were identified. <BR/>In an interview with ADON A on 08/24/22 at 01:15 PM she stated staff were to perform hand hygiene when they entered a resident's room, after contact with any bodily fluid, and they were to change their gloves and perform hand hygiene during incontinent care when they went from dirty to clean. She stated they were never to place dirty linen on the floor or chairs in the room, stating it was to be always supposed to be bagged. She stated she observed CNA B during her skills checks off upon hire and she had performed the procedure correctly at that time. She stated by not following standard precautions with hand hygiene it placed residents at risk of infections and cross contamination. <BR/>Review of the facility's policy titled, Incontinence Care, dated February 2022, reflected, .Have all needed equipment at bedside on the over bed table wipes (at least 7), gloves (at least 3 pair), barrier cream, plastic bag or trash can .Wash hands and put on gloves Remove soiled clothing and brief and place the brief in the trash bag .Take off the gloves, put them in the trash bag. Wash your hands and put on new gloves Cleanse the peri area with wipes going front to back/clean to dirty. Separate the labia. Use a new wipe with ach stroke: Wipe one side, wipe the other side, wipe down the center and then once from hip bone to hip bone .Repeat cleansing until the resident is clean .take off the gloves, put them into the trash bag with the soiled brief and wipes .Wash your hands, put on gloves and apply protective ointment if needed and a clean brief .Remove gloves and wash your hands .Reposition the resident, offer fluids .Remove trash from room .Wash your hands .If performing incontinent care for a male resident .Take the wipe in one hand and gently grasp the penis shift .wipe the head of the penis beginning at the urethra opening working outward or away from the penis head, Cleanse in a circular motion away from the urethra. Use new wipe each time .Cleanse the penis shaft with wipe from the top of the shaft towards the rectum, including the scrotum .Using a new wipe with each stroke clean from the upper part of the leg to the hip <BR/>Review of the facility's policy titled, Infection Control Guidelines, dated February 2021, reflected, .Hand Hygiene Protocol .Staff shall use hand hygiene when coming on duty, between patient contacts, after handling contaminated objects, after PPE removal, and before going off duty .Staff shall wash their hands with an antiseptic preparation before performing patient care procedures and when providing .For routine care, staff shall wash their hands with soap and water or a waterless alcohol agent before and after patient contact .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident was free of any significant medication errors for 1 of 6 residents (Resident #1) reviewed for significant medication errors. <BR/>The facility failed to ensure Resident #1 was free of any significant medication errors by failing to ensure a resident received the correct prescribed intravenous (IV) medication, which resulted in the resident being given an IV medication that she had a known allergy to.<BR/>This failure resulted in a PNC IJ (Past Non-Compliance Immediate Jeopardy), the IJ (Immediate Jeopardy) started on 08/24/2023 and ended on 08/26/2023. The facility had corrected the IJ (Immediate Jeopardy) prior to entry for abbreviated survey. There was no resident in the facility on IV therapy, facility had completed staff in-service on medication administration and LVN A had been educated on medication administration prior to entry. <BR/>This failure could place residents at risk of complications from deterioration in health, potential for severe reaction, extended recoveries, hospitalizations, and death. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet dated 08/27/23 revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE] with diagnoses of acute cystitis (infection of the bladder), chronic kidney disease, cellulitis of right lower limb, pneumonia, hypertension, and anxiety disorder. Also, indicated Resident #1 had allergies to Piperacillin, Vancomycin, Tazobactam and Zosyn. <BR/>Record review of Resident #1's quarterly Minimum Data Set, dated [DATE], reflected Section C Brief Interview for Mental Status (BIMS) was 14, which indicated she did not have cognitive impairment. Section G indicated R#1 required extensive assistance with one-person physical assist for bed mobility, locomotion on and off the unit, dressing, eating and toilet use. <BR/>Record review of Resident #1's Care Plan undated reflected Resident #1 was on Meropenem IV antibiotic therapy related to urinary tract infection. Goal, The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Intervention, administer medication as ordered.<BR/>Record review of Resident #1's Order Summary dated 08/21/2023 reflected, Meropenem Intravenous Solution Reconstituted 1 GM (Meropenem) Use 1 gram intravenously every 8 hours for UTI (Urinary Tract Infection) for 7 Days<BR/>Record review of Resident #1's, August 2023 Medication Administration Record (MAR) indicated an order of Meropenem 1 GM (gram) to be reconstituted and administered every 8 hours. The medication was started on 08/21/2023 at 04:00pm. <BR/>Record review of Resident #1's progress notes dated 08/24/2023 at 10:09AM reflected, This nurse administered the wrong medication (Zosyn) NP notified .who gave the following orders. Benadryl 25 mg, Prednisone 40 mg and Pepcid 20 mg Further a note dated 08/24/2023 at 04:50 PM revealed, .redness noted to face, neck torso and back warm to touch hand and fingertips cool to touch and discolored B/P 78/52 NP in the facility notified of change in skin color NP assessed the resident . order received to transfer to hospital for eval and treatment .<BR/>Record review of the NP witness form with the date of interview on 08/25/2023 revealed, NP had gone to see Resident #1 for a follow up on UTI, IV pump was beeping LVN A walked after her. After the LVN A disconnected the IV tubing from Resident #1 it revealed a different name on the antibiotic bag, and it was a different medication (Zosyn) that the resident was allergic to. Mild flushing/purplish discoloration to both hands was noted. NP informed the residents primary care provider and orders were placed for the resident. LVN A reported of low B/P and IVF bolus was started but the B/P kept declining and at the time Resident #1 had widespread redness to her back, trunk, neck/face. Body was warm to touch by the extremities; hands, fingers and toes were cold and clammy and pale with purple discoloration. The resident condition was discussed by the primary care provider and the resident was transferred to the hospital. <BR/>In an interview on 08/27/2023 at 12:35 PM with LVN A he stated he was the nurse in charge for Resident #1. He stated on 08/24/2023 he had administered Resident #1's IV antibiotic around 10 am. LVN A stated when he went to disconnect the IV tubing the NP was in the room with the resident and LVN A realized he had administered the resident a wrong medication which she was allergic to. The NP assessed the resident and ordered Benadryl, Pepcid and prednisone for Resident #1. NP also instructed for the resident to be monitored closely and obtain the resident's vital signs every 15 minutes. LVN A stated the resident was also administered IV (Intravenous) fluids due to low blood pressure, but it did not improve and the NP who was still in the facility. Resident #1 was then transferred to the local hospital for evaluation and treatment. LVN A stated he acknowledged his mistake, he stated he failed to check and make sure he picked the right medication and administered to the right resident. He stated even before starting the IV antibiotic he was supposed to double check again to make sure he was administering the right medication, but he didn't. LVN A stated administering the wrong medication to the resident which she was allergic to could have caused severe allergic reactions and even death. LVN A stated after the incident he received disciplinary action, he was in-serviced on medication administration, and he had a training to complete before returning to work. <BR/>In an interview on 08/27/2023 at 12:48 PM with ADON revealed she was made aware of the incident on 08/24/2023 around lunch time. Immediately the ADON went and checked on another resident who was on antibiotic therapy on the same hall that LVN A was in charge and revealed the resident had received the right medication. ADON stated Resident #1 was monitored closely until it was determined she was to be transferred to the local hospital. ADON stated she expected the nurse to administer the medication to the right resident and right order. The ADON stated administering wrong medications that the resident was allergic to could cause death and severe allergic reactions. <BR/>In an interview on 08/27/2023 at 1:35 PM with the Administrator revealed she was made aware of the incident on 08/24/2023 on the day it happened, and she started the investigation. Administrator reported the incident HHS on 08/26/2023. Administrator stated LVN A reported to her on 08/24/2023 that he had administered the wrong medication to Resident #1, and the resident was allergic to the medication that was administered. The NP was with Resident #1 on 08/24/2023 at the time it was identified Resident #1 received the wrong medication. NP assessed the resident and ordered medication for the resident. The resident did not display any acute distress, but she had redness to her body and later her blood pressure dropped. NP recommended the resident to be transferred to the local hospital due to the decline in her blood pressure. LVN A received disciplinary action, he was in-serviced on medication administration and had to complete medication administration training. Administrator stated she expected LVN A to administer the right medication to the right patient. She stated administering the wrong medication could cause severe allergic reactions and even death to a resident who was allergic to the medication. There was no resident in the facility on IV therapy. Administrator stated after the incident all the medication aide and nurses were in-serviced on medication administration. <BR/>Review of the facility policy dated 01/09/2014, titled Medication - Treatment Administration and Documentation Guideline reflected, 1. Verify labels accurately reflect the physician orders on the Electronic Medication Administration Record (EMAR) and Electronic Treatment Administration Record (ETAR) prior to administering patient medications and treatments.<BR/>2. Verify administration accuracy by checking the medication with the EMAR three (3) times.<BR/>Measures that were put in place after the incident and the records were provided and reviewed. <BR/>All medication aide and nurses were in-serviced on medication administration on 08/24/2023 <BR/>LVN A will complete a four-week med pass with the ADON <BR/>LVN A will complete a training on medication administration <BR/>Two nurses will clarity the orders before medication administration <BR/>LVN A received a disciplinary action dated 08/24/2023 <BR/>During an interview on 08/27/2023 between 12:00 PM and 2:30 PM with the charge nurses who were on duty revealed they had been in-serviced on 08/24/2013 on medication administration. <BR/>Review of IV therapy administration revealed the nurses had completed the training together with LVN A dated 08/27/2023<BR/>On 08/27/2023 at 3:15 PM, the administrator was notified of the PNC IJ.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interviews and record reviews the facility failed to provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in &sect;483.70(g) for 1 of 5 residents (Resident #1) reviewed for medication administration.<BR/>The Facility failed to ensure Resident #1 had received his medications as scheduled and as ordered by his physician.<BR/>This failure could place residents at risk of health complications.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet, dated 08/01/23, revealed he was a 67 -year-old male admitted on [DATE]. Relevant diagnoses Type 2 Diabetes Mellitus (high blood glucose), Major Depressive Disorder, Acute Kidney Failure, and Essential Hypertension (high blood pressure). <BR/>Record review of Resident #1's Minimum Data Set (MDS) on dated 05/24/23 revealed she had a Brief Interview for Mental Status (BIMS) score of 03 (severely mentally impaired and was not interviewable) and for Active Diagnosis, Resident #1 had diagnosis of Hypertension (high blood pressure), Depression, and Diabetes Mellitus (high blood glucose).<BR/>Review of Resident #1's Physician Orders dated 08/01/23 revealed Orders for the following:<BR/>Norvasc Tablet 10 MG (high blood pressure)<BR/>Record Review of Resident #1's Medication Administration Records for July 2023 documented by MA J revealed, the resident had missed his blood pressure medication on the following dates:<BR/>07/02/23 AM Schedule: Resident Refused<BR/>07/06/23 AM Schedule: Resident Refused<BR/>07/07/23 AM Schedule: Resident Refused<BR/>07/11/23 AM Schedule: Resident Refused<BR/>07/12/23 AM Schedule: Resident Refused<BR/>07/13/23 AM Schedule: Resident Refused<BR/>07/14/23 AM Schedule: Resident Refused<BR/>07/17/23 AM Schedule: Resident Refused<BR/>07/18/23 AM Schedule: Resident Refused<BR/>07/19/23 AM Schedule: Resident Refused<BR/>07/21/23 AM Schedule: Resident Refused<BR/>07/24/23 AM Schedule: Resident Refused<BR/>07/25/23 AM Schedule: Resident Refused<BR/>07/26/23 AM Schedule: Resident Refused<BR/>07/27/23 AM Schedule: Resident Refused<BR/>07/28/23 AM Schedule: Resident Refused<BR/>07/31/23 AM Schedule: Resident Refused<BR/>Interview with LVN O on 08/01/23 at 11:05 AM revealed she was the hall nurse for Resident #1. She stated the resident often refused a shower, but she was unaware the resident was refusing to take his medication because the Medication Aide did not advise her of this. She stated if a resident refused medication, the Medication Aide must notify the Hall nurse so that she can notify the physician, Responsible party, and attempt to persuade the resident into taking his medication. She advised the risk of the resident not taking his medication when scheduled could result in him having health complications.<BR/>Interview with MA J on 08/02/23 at 11:15 AM revealed, She stated she had been at the facility for almost a year. She stated the resident refused medication since she had been there, and she stated she had told a nurse about him not taking medication and the last time when she told her nurse was in May 2023. She stated she mentioned it a lot before but stopped doing so because she thought it was care planned. She advised she could not remember who she had spoken with. She stated the risk to the resident not taking his medication is possible increase in his blood pressure and causing a heart attack or stroke. She was asked the process if a resident refuses medication, was that they had to notify the nurse.<BR/>Interview with ADON on 08/01/23 at 11:20 AM revealed she was advised by the 100 Hall Nurse of the concerns regarding Resident #1's refusal of medication and it not being reported by the Medication Aide. She advised that staff are required to report to their Hall nurse anytime a resident refuses their medication. The ADON advised that this was the first-time hearing of the resident refusing to take medication. She advised the risk of residents not taking their medication when scheduled could result in the resident having a serious illness as a result of not taking the medication. She stated that the Medication Aide should have notified her nurse so that other attempts could be made to encourage the resident into taking the medication and they could also notify the Responsible party and his physician.<BR/>Interview with Administrator of 08/01/23 at 11:30 AM revealed she was present when the ADON was advised of Resident #1 refusing to take his medication throughout the month of July 2023. The Administrator advised that anytime a resident refused medication, the Medication Aide must notify their Hall nurse every time a resident refused medication because the Resident had a good rapport with some of the staff and someone could have convinced him into taking his medication. She advised the risk of the resident not getting his medication could result in him having increased health issues, especially if it involved medication to treat illnesses such as diabetes and high blood pressure. The Administrator advised that she did some research and found that the resident was refusing his evening medication but taking his morning medications. She advised that she spoke with the Resident's physician and was advised that the blood pressure medication would be changed to the mornings, since the resident appeared more willing to take his medication in the mornings and for all other medications that are required to be taken at night, they will use interventions to encourage the resident to take his scheduled medication.<BR/>Review of the Facility's policy on Medication - Treatment Administration and Documentation dated 02/10/20 revealed, Circle initials for medication or treatment that were not administered and document reason for the non-administration on the back of the MAR or TAR. Review each MAR and TAR after each medication and treatment administration is completed and prior to the end of the shift to validate documentation is completed and supports services provided accorded to physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure one (Resident #1) of three residents reviewed for pressure ulcers received treatment and care in accordance with professional standards of practice in that:<BR/>1. Resident #1 admitted with a pressure ulcer on 12/02/22 and the facility failed to perform and document a wound assessment, notify the physician, and obtain wound care orders until six days later on 12/08/22.<BR/>2. The facility failed to ensure Resident #1 was provided with wound care to promote healing until six days after admission on [DATE] when he was assessed by the Wound Care Physician (WCP) with an unstageable deep tissue injury to the sacrum. (Unstageable-full thickness tissue loss covered by extensive necrotic (dead skin tissue) tissue or eschar (Eschar-dead tissue that falls off (sheds) from healthy skin). (Deep Tissue Injury-Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal (outer layer of skin) separation revealing a dark wound bed or blood-filled blister).<BR/>It was determined a past non-compliance Immediate Jeopardy existed from 12/02/22 to 12/08/22. The Immediate Jeopardy was determined to have been removed on 05/01/23 due to the facility's implemented actions that corrected the non-compliance.<BR/>These failures could affect residents with impaired skin integrity and residents at risk for impaired skin integrity of developing life-threatening infection, which could manifest into other health complications, pain, worsening pressure ulcers and a decreased quality of life.<BR/>Findings included: <BR/>Review of Resident #1's closed clinical records revealed an admission MDS assessment dated [DATE]. The assessment reflected the resident was a [AGE] year-old male with an admission date of 12/02/22. Diagnoses included cerebrovascular accident (stroke), seizure disorder and respiratory failure. The MDS assessment reflected the resident received nutrition via a gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) and utilized a tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs). He required extensive physical assistance of two people for bed mobility, dressing and personal hygiene. Section C related to cognitive patterns was blank. Resident #1 had one Stage IV pressure ulcer that was present on admission, (Stage IV-full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed), (Slough-a mass of dead tissue separating from an ulcer). <BR/>Review of Resident #1's undated admission Record reflected a discharge date of 01/05/23.<BR/>Review of Resident #1's admission assessment dated [DATE] reflected he had open wounds. There was no documented assessment, location, description, or characteristics of the wounds in the admission assessment. <BR/>Review of Resident #1's admission progress notes dated 12/02/22 and timed 6:44 p.m. documented by LVN A revealed the resident was comatose, not responding to verbal stimuli and he had two small open areas to the coccyx (coccyx-small triangular bone at the base of the spinal column). There was no documented assessment, description, or characteristics of the open areas in the progress notes. <BR/>Review of Resident #1' clinical records revealed there was no documented wound assessment until the WCP visit on 12/08/23, six days after the resident admitted to the facility.<BR/>Review of Resident #1's baseline care plan dated 12/03/22 reflected Resident #1 had no skin issues, and his skin was intact.<BR/>Review of Resident #1's care plan dated 12/08/22 revealed he admitted with a pressure ulcer and was at risk for infection, pain, and a decline in functional abilities. The goal was for the pressure ulcer to show signs of healing through the next review date with a target date of 03/08/23. Interventions included providing wound care per physician's orders, routinely evaluating, and documenting the wound dimensions, drainage, and condition of surrounding tissue. <BR/>Interview with the TN on 05/01/23 at 2:41 p.m., he stated he was not on duty when Resident #1 admitted to the facility and did not see the resident's pressure ulcer until 12/05/22. The TN stated he was unable to recall what the pressure ulcer looked like, but he would check his notes.<BR/>Interview with LVN A on 05/01/23 at 3:10 p.m., she stated she was the admitting nurse for Resident #1 on 12/02/22 and completed the admission assessment. She stated she did not recall what the open areas looked like just that they were small and did not amount to much. She stated the procedure was to notify the TN when a resident admitted with a wound. LVN A stated she was unable to recall if she had informed the TN of Resident #1's open areas or if she had notified the physician. She stated she recalled the TN being in the facility at the time of Resident #1's admission and the TN was responsible for assessing/documenting and taking care of wounds.<BR/>Interview on 05/01/23 at 3:52 p.m. with the TN, he stated the admitting nurse was responsible for assessing and documenting a full wound assessment to include a description of the wound and calling the physician to obtain wound care orders. <BR/>Review of Resident #1's weekly WCP notes/assessments revealed the following:<BR/>12/08/22- initial visit-he was assessed with an unstageable deep tissue injury measuring 3.5 centimeter in length, 4.0 centimeters in width and 0.1 centimeters in depth. The assessment reflected a deep tissue injury was noted in and around the wound. <BR/>12/14/22-he was assessed with a Stage IV pressure ulcer (Stage IV -Full thickness tissue loss with exposed bone, tendon, or muscle) to the sacrum that measured 8.0 centimeters in length, 5.5 centimeters in width and 0.8 centimeters in depth. The wound's progress was assessed as having deteriorated. <BR/>12/21/22-he was assessed a Stage IV pressure ulcer to the sacrum that measured 7.0 centimeters in length, 8.5 centimeters in width and 1.3 centimeter in depth. The wound's progress was assessed as having deteriorated. Resident #1's sacral wound was swabbed to test for the presence of pathogens on 12/21/22. (Pathogen- a bacterium, virus, or other microorganism that can cause disease).<BR/>12/28/22-he was assessed with a Stage IV pressure ulcer to the sacrum that measured 5.5 centimeter in length, 5.5 centimeters in width and 0.2 centimeters in depth. The wound's progress was assessed as having improved. The WCP notes reflected results of the swab test performed on 12/21/22 revealed the presence of the pathogens enterococcus faecalis, Bacteroides fragil and staph hemolyticus. <BR/>Review of Resident #1's consolidated physician orders dated from 12/02/22 to 01/05/23 revealed the following:<BR/>12/08/22-Treatment order for hydrogel gel w/silver once a day to sacrum.<BR/>12/28/22- The antibiotic Augmentin 875-125 milligrams one tablet was ordered to be administered two times a day for ten days for wound healing.<BR/>Review of Resident #1's MARS/TARS dated 12/2022 revealed the wound care order dated 12/08/22 had been transcribed to start on 12/09/22 but the wound care orders were not implemented by the facility until 12/10/22. <BR/>Interview with the TN on 05/02/23 at 9:30 a.m., he stated he was unable to locate any additional assessments of Resident #1's pressure ulcer prior to the WCP visit on 12/08/22. He stated he usually completed and documented a full skin assessment for newly admitted residents. The TN stated he recalled observing the resident's wound on 12/05/22 but was unable to recall exactly what it looked like. He recalled removing the foam dressing from the resident's wound, there was only one area, and he thought the wound was a nickel sized, dark black colored, deep tissue injury. He stated he replaced the same foam dressing and could not recall if he provided wound care for Resident #1 prior to the WCP visit on 12/08/22. He further stated his thinking had been that the WCP was coming to the facility in a few days and could evaluate the wound and provide wound care orders. The TN further stated he did not call the physician to obtain wound care orders and realized he made a mistake and did not know what happened during that time as he usually notified the physician and obtained wound care orders. <BR/>Interview with the Administrator and DON on 05/02/23 at 10:15 a.m. they stated they had provided in-service training to all licensed nursing staff on 05/01/23 related to wound assessments, obtaining wound care orders and the facility's skin/wound P/P. A QAPI audit was performed for all residents assessed to be at risk for pressure ulcers was completed on 05/01/23 to ensure orders, treatments, and dietary interventions were in place. <BR/>Interview with the DON on 05/02/23 at 2:14 p.m., she stated she had not been aware Resident #1 had no documented wound assessment on admission or that there were no orders or evidence of wound care until the WCP visited on 12/08/22. She stated her expectations were for nurses to assess residents' wounds and document a full assessment to include exactly what they see to include a full description, location and to call the physician for wound care orders. <BR/>Interviews with the DON on 05/02/23 at 5:15 p.m., she stated it was important to provide wound care and assess pressure ulcer/wounds to prevent deterioration of the wound and to provide continuity of care. The DON stated if residents' wounds were not assessed and wound care was not provided the resident could experience pain, infection and/or worsening of the wound.<BR/>Interview with the DON on 05/04/23 at 9:48 a.m., she stated the ADONs were responsible for following up to ensure admission assessments to include wound assessments were completed and wound care orders had been obtained. She stated the ADON responsible for Resident #1's hall was on vacation at the time of the resident's admission and ADON B was responsible for following up on all new admissions. The DON stated she did not know why the lack of an assessment and treatment orders for Resident #1 were missed during the clinical a.m. meetings other than he fell through the cracks and there was no follow through.<BR/>Interview with ADON B on 05/04/23 at 10:16 a.m., she stated the ADONs were responsible for ensuring admission paperwork was completed. She stated she was responsible for all new admission follow-ups when ADON C was on vacation. She stated an admission checklist was used to ensure all admission orders, assessments and paperwork was completed. She stated she could not recall if she had used the checklist to follow-up on Resident #1's admission and if she had she would have seen the admission assessment reflected the resident had a wound and that would have driven her to check to ensure there were orders and a full wound assessment. ADON B further stated new admissions were discussed in the a.m. meeting to ensure all admission orders, assessments and paperwork were completed and she did not know how Resident #1's lack of a wound assessment and wound care orders were missed.<BR/>Review of the facility's P/P entitled Pressure Injury Prevention and Management dated 10/24/22 reflected in part: Policy: The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The facility shall establish and utilize a systematic approach for pressure ulcer prevention and management, including prompt assessment and treatment. The attending physician will be notified of the presence of a new pressure injury upon identification.<BR/>Review of the facility's P/P entitled Skin Prevention and Management Guidelines revised 04/13/23 reflected in part: Guideline Statement: The facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries.<BR/>Review of the facility's P/P entitled Skin Assessment/Evaluation revised 04/13/23 reflected in part: Remove any dressings, using clean technique, unless contraindicated or ordered to remain in place, and note findings. Documentation of skin assessment includes a description of the wound to include measurements, color, type of tissue in wound bed, drainage, odor, and pain.<BR/>The facility's P/P entitled admission Policy revised 02/10/21 included completing clinical evaluations, conducting a complete physical examination, a head-to-toe body audit and documenting findings.<BR/>Review of the facility's action plan to include education material, training records, and audits related to skin assessments and wound care orders revealed the facility implemented the following interventions:<BR/>QAPI skin prevention audits completed for all residents with Braden scale (Assessment for predicting the risk for pressure ulcer development) scores of twelve or less pressure indicating risk for impaired skin integrity, to ensure orders, treatments, and other interventions to include nutritional support provided. <BR/>In-service training provided on 05/01/23 to all licensed nursing staff on facility skin management P/P, skin assessments and wound care orders to included:<BR/>1. All nurses must complete a head-to-toe assessment on all new and re-admitted residents. <BR/>2. Describe what the wound looks like, if there is drainage, what color or an odor.<BR/>3. If the resident comes without an order for any wounds, if the wound nurse is not present, call the MD to obtain a treatment order.<BR/>4. Notify the wound nurse, DON, and on-call about any new orders.<BR/>5. admission audit tool for all newly and readmitted residents to ensure skin assessment, physician notified, and wound care orders completed and WCP referral to be provided to DON before a.m. meeting. <BR/>6. Weekly monitoring of admission audits for one month with a monthly summary.<BR/>Interviews were conducted on 05/02/23 from 10:29 a.m. to 10:42 a.m., at 2:40 p.m. and from 4:40 p.m. to 4:50 p.m. with licensed nursing staff LVN D, LVN E, LVN F, LVN G and RN H.<BR/>Interviews were conducted on 05/04/23 from 10:16 a.m. to 10:48 a.m. with the TN, ADON B and ADON C. The nursing staff were able to accurately summarize the facility's skin management P/P related to wound assessments and wound care orders they received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to, in accordance with State and Federal laws, ensure all drugs were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to these drugs, to meet the needs of each resident, for 1 (Resident #1) of four residents reviewed for medication storage.<BR/>The facility failed to ensure Resident #1 did not have wound treatment medications and unsecured medications in his room on 01/04/23.<BR/>This deficient practice could place residents at risk of, not being monitored for their medications, adverse reactions, and drug diversion. <BR/>Findings included:<BR/>Review of Resident #1's face sheet dated 01/04/23 reflected Resident #1 was a [AGE] year-old male admitted on [DATE] to the facility with diagnoses that included obesity, chronic hepatitis C, hyperlipidemia, hypokalemia, depression and peripheral vascular disease.<BR/>Review of Resident #1's quarterly MDS assessment dated [DATE] reflected he had a BIMS of 13 indicating he was cognitively intact.<BR/>Review of Resident #1's care plan reflected on 10/18/22 with target date of 04/06/23 that Resident #1 had potential for the development of a pressure ulcer. The comprehensive care plan did not reflect Resident #1 could self-administer his medications and keep medications in his room. <BR/>Review of Resident #1's January 2023 electronic physician order indicated Triamcinolone Acetonide Ointment (used help to relieve redness, itching, swelling, or other discomfort caused by skin condition) 0.1% apply to both legs topically every day shift wound. Silvadene Cream (used to prevent and treat wound infections) 1% apply to leg wound topically one time daily. Lidocaine Ointment (used to cause numbness or loss of feeling) 5% apply to wounds topically every 4 hours as needed for wounds.<BR/>Review of Resident #1's MAR/TAR for January 2023 reflected the resident was given Triamcinolone Acetonide Ointment 0.1% and Silvadene Cream 1% on the following dates: 01/01-01/03/23. <BR/>Observation and interview on 01/04/23 at 11:30 AM revealed Resident # 1 had 2 tubes of Lidocaine Ointment, 1 tubes of Triamcinolone Acetonide Ointment, and 2 tubes of Silvadene Cream in his unlocked bedside table drawer. Each had Resident #1's name written on it. There were no facility staff in resident's room. Resident #1 stated LVN A gave them to him, and Resident #1 said he uses each of the medications two times a day but that he only used a small amount of each medication cream. <BR/>An interview on 01/04/23 at 9:24 AM with LVN A revealed he did give Resident #1 medications and supplies to keep in his room to self-treat his wounds on the weekends. LVN A stated that the resident prefers to do his own treatments on the weekends. So on Fridays LVN A made sure he had the supplies he needed. LVN A stated he did not know if the resident was able to self-treat or not. LVN A stated the risk of having medications in a resident's room could result in drug being mishandled. <BR/>An interview on 01/04/23 at 10:34 AM with the ADON revealed Resident #1 should not have medications in his room and did not self-administer his medications. The ADON stated the nurses should not leave a resident's room without taking medications with them. The ADON stated that the risk of leaving medications in a resident room could result in another resident having access to unprescribed medication. <BR/>An interview on 01/04/23 at 12:30 PM with the DON revealed she observed the following medications: 2 tubes of Lidocaine Ointment, 1 tubes of Triamcinolone Acetonide Ointment and 2 tubes of Silvadene Cream in Resident #1's room. The DON stated she would address leaving the medications in Resident #1's room with LVN A. The DON stated that her expectation was for no medications to be left in a Resident's room. The DON stated the risk of having medications in a resident's room could result unauthorized access to a medication.<BR/>An interview on 01/04/23 at 2:16 PM with the ADM revealed LVN A should not have left medications in Resident #1's room. She stated Resident #1 should not have medications left in his room and she would take care of it. <BR/>Review of the facility's policy Medication Storage dated 01/20/21 reflected 1. General guidelines: a. All drugs and biologicals are stored in locked compartments (for example medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature. B. Only authorized personnel will have access to the keys to locked compartment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that nurses were able to demonstrate competency in the provision of skills and techniques necessary to care for three (Resident #53, Resident #220, and Resident # 26) of four residents reviewed for incontinent care in that:<BR/>CNA B failed to follow the facility's procedure for appropriate incontinence care for Resident #53, Resident #220, and Resident #26 during incontinent care to prevent the risk of cross contamination and infection. <BR/>This failure could place the residents at risk for urinary tract infection and skin breakdown.<BR/>Findings included:<BR/>1. Review of Resident #53's face sheet dated 08/24/22 reflected a [AGE] year-old male, admitted to the facility on [DATE], and a readmission date of 08/01/22. His primary diagnosis included sepsis due to methicillin susceptible staphylococcus aureus (bacteria resistant to several widely used antibiotics), abscess of right hand and Huntington's disease (inherited condition in which nerve cells in the brain break down).<BR/>Review of Resident #53's quarterly MDS assessment dated [DATE] reflected resident was moderately cognitively impaired with a BIMs of 9. He required extensive one-to-two-person assistance with ADLs and was always incontinent of bowel and bladder. <BR/>Record review of Resident #53's care plan revised on 04/07/22, reflected, Resident is incontinent of bowel/bladder related to disease process, physical limitations .check frequently for wetness and soiling .and change as needed .briefs or incontinence products as needed for protection. Apply barrier cream to skin after incontinent episodes .<BR/>Observation on 08/24/22 at 09:25 AM revealed CNA B entered Resident #53's room to assist LVN C with wound care and then provided incontinence care. CNA B washed her hands and donned gloves. After the completion of the wound care by LVN C, CNA B, while wearing the same soiled gloves used to assist with the wound care, went to the resident's closet and retrieved a clean brief and laid it on the head of the bed, picked up the bed remote and lowered the resident's bed and then removed her soiled gloves and performed hand hygiene. CNA B re-gloved, raised the resident's bed up and unfastened the resident's brief to reveal he had been incontinent of urine. CNA B then pushed the soiled brief down between the resident's legs toward his buttocks and took a wet wipe and wiped down each groin and then wiped up and down the shaft of the resident's penis trying to remove a white sticky substance. CNA B used the same wipe without changing the surface of the wipe with each swipe. CNA B then rolled the resident onto his side and picked up the clean brief with her soiled gloves and placed it under the dirty brief. CNA B proceeded to wipe the resident's buttocks from front to back, removed the soiled brief and placed it and the used wipes on the end the bed. While wearing the same soiled gloves, CNA B reached into the resident chest of drawers and retrieved a package of barrier wipe and applied the barrier cream to the resident's buttocks. CNA B then rolled the resident back onto his back, fastened the brief and pulled up the residents' pants. <BR/>2. Review of Resident #220's face sheet dated 08/24/22 reflected an [AGE] year-old male, admitted to the facility on [DATE]. His primary diagnosis included Chronic Obstructive Pulmonary disease, diabetes and history or COVID-19. <BR/>Review of Resident #220's admission MDS assessment dated [DATE] reflected resident was moderately cognitively impaired with a BIMs of 9. He required limited one person assistance with ADLs and was frequently incontinent of bowel and bladder. <BR/>Record review of Resident #220's care plan revised on 08/16/22, reflected, Resident is occasionally incontinent of bowel/bladder related to benign prostatic hyperplasia (noncancerous enlargement of the prostate gland) activity intolerance .check frequently for wetness and soiling .and change as needed .Assist to toilet as needed .<BR/>Observation and interview on 08/24/22 at 09:50 AM revealed CNA B entered Resident #220's room to answer his call light. Resident #220 stated he needed to be changed. CNA B washed her hands and donned gloves and gathered wipes and a brief. Resident #220 stood up out of his wheelchair and started to lay down on the bed. CNA B told him to stand and turn around and she pulled down his pants and unfastened the resident's brief to reveal he had been incontinent of urine. CNA B then wiped the resident's anal area, revealing he was having a bowel movement. CNA B asked the resident if he thought he needed to go to the toilet to finish and he stated yes. Resident #220 ambulated to the bathroom. CNA B removed her gloves, washed her hands, and told the resident she would be back. CNA B returned to the room with a gait belt, washed her hands and put on clean gloves. CNA B had the resident stand up and proceeded to wipe the resident's buttocks from front to back and then took another wipe and wiped the residents front and placed a clean brief on the resident and pulled up his pants without changing gloves or performing hand hygiene. CNA B then placed a gait belt around the resident and had him stand at the sink to wash his hands. Resident #220 ambulated back to his wheelchair with CNA B holding onto the gait belt. CNA B then picked up the resident's O2 tubing and handed it to him. Resident #220 stated he was thirsty and needed a drink. CNA B then removed the gait belt from the resident and placed it in her pocket and reached for the resident's water pitcher, knocking the lid off. CNA B replaced the lid, still wearing the same gloves she had worn to provide incontinent care and handed the pitcher to the resident. CNA B then gathered the trash, removed her gloves, and washed her hands with soap and water. <BR/>3. Review of Resident #26's face sheet dated 08/24/22 reflected a [AGE] year-old female, admitted to the facility on [DATE]. Her primary diagnosis included dementia, epilepsy, and extended spectrum beta lactamase resistance (enzyme produced by some bacteria which causes some antibiotics not to work for treating bacterial infections)<BR/>Review of Resident #26's quarterly MDS assessment dated [DATE] reflected resident was cognitively intact with a BIMs of 14. She required extensive one-to-two-person assistance with ADLs and was always incontinent of bowel and bladder. <BR/>Record review of Resident #26's care plan revised on 08/23/22, reflected, Resident is incontinent of bowel/bladder related to her refusal to get out of bed .Monitor resident q 2 hrs. and prn as needed to ensure resident is clean and odor free at all times .briefs or incontinence products as needed for protection. Apply barrier cream to skin after incontinent episodes .<BR/>Observation on 08/24/22 at 10:10 AM revealed CNA B entered Resident #26's room to provide incontinence care. CNA B washed her hands and donned gloves, gathered a brief and wipes and placed them on the bed side table. CNA B unfastened the resident's brief to reveal she had been incontinent of urine and had a large bowel movement. CNA B then pushed the soiled brief down between the resident's legs toward her buttocks and took a wet wipe and wiped down each groin and once down the middle. CNA B used the same wipe without changing the surface of the wipe with each swipe. CNA B then rolled the resident onto her side and picked up the clean brief with her soiled gloves and placed it under the dirty brief. CNA B proceeded to wipe the resident's buttocks from front to back, removed the soiled brief and placed it and the used wipes on the end the bed. While wearing the same soiled gloves, CNA B placed the soiled brief into the trash can by the door and reached into the resident chest of drawers and retrieved a tube of barrier wipe and applied the barrier cream to the resident's buttocks. CNA B then rolled the resident back onto her back and took another wipe and wiped again down the resident's groin, removing more bowel movement. CNA B then fastened the brief and covered the resident with sheet and blanket, put the tube of barrier cream back in the residents' chest of drawers, repositioned her bedside table and then removed her gloves and placed in the trash and washed her hands <BR/>In an interview with CNA B on 08/24/22 at 10:05 AM revealed she had worked at the facility approximately 6 months. When asked when she was supposed to perform glove changes and hand hygiene during incontinence care she stated before you start and after you had completed care. She stated she was not aware she had to change her gloves during incontinence care. She stated she was taught the end of the bed was considered dirty, which was why she placed the soiled brief and wipes at the end of the bed until she had completed care. She stated she knew you were supposed to wipe from front to back and change the surface to the wipes each time, and stated she thought she had done that. She stated she had recently been in serviced on hand hygiene and knew the importance of hand hygiene to prevent infections. <BR/>Review of CNA B's competency check completed on 03/10/22 reflected she met criteria for hand hygiene, incontinence care, peri-care male, and female and non-sterile glove use.<BR/>Review of the facility's in-services on infection control, which covered the facility's hand hygiene policy, dated 08/04/22 revealed CNA B had attended. <BR/>In an interview with the DON on 08/24/22 at 1:00 PM revealed staff were to perform hand hygiene before incontinence care and during care they were to remove their gloves and perform hand hygiene when they went from dirty to clean and once, they completed care, they were to perform hand hygiene again. She stated they were always supposed to place dirty wipes and briefs and linens in a plastic bag. She stated failing to follow these procedures placed residents at risk of cross contamination and increased risk of urinary tract infections. She stated all staff were skills checked upon hire and again if training issues were identified. <BR/>In an interview with ADON A on 08/24/22 at 01:15 PM she stated staff were to perform hand hygiene when they entered a resident's room, after contact with any bodily fluid, and they were to change their gloves and perform hand hygiene during incontinent care when they went from dirty to clean. She stated they were never to place dirty linen on the floor or chairs in the room, stating it was to be always supposed to be bagged. She stated she observed CNA B during her skills checks off at the time of her hire and she had performed the procedure correctly at that time. She stated by not following standard precautions with hand hygiene it placed residents at risk of infections and cross contamination. <BR/>Review of the facility's policy titled, Incontinence Care, dated February 2022, reflected, .Have all needed equipment at bedside on the over bed table wipes (at least 7), gloves (at least 3 pair), barrier cream, plastic bag or trash can .Wash hands and put on gloves Remove soiled clothing and brief and place the brief in the trash bag .Take off the gloves, put them in the trash bag. Wash your hands and put on new gloves Cleanse the peri area with wipes going front to back/clean to dirty. Separate the labia. Use a new wipe with ach stroke: Wipe one side, wipe the other side, wipe down the center and then once from hip bone to hip bone .Repeat cleansing until the resident is clean .take off the gloves, put them into the trash bag with the soiled brief and wipes .Wash your hands, put on gloves and apply protective ointment if needed and a clean brief .Remove gloves and wash your hands .Reposition the resident, offer fluids .Remove trash from room .Wash your hands .If performing incontinent care for a male resident .Take the wipe in one hand and gently grasp the penis shift .wipe the head of the penis beginning at the urethra opening working outward or away from the penis head, Cleanse in a circular motion away from the urethra. Use new wipe each time .Cleanse the penis shaft with wipe from the top of the shaft towards the rectum, including the scrotum .Using a new wipe with each stroke clean from the upper part of the leg to the hip

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Resident #53, Resident #7, Resident # 26, and Resident # 220) of five residents observed for infection control in that: <BR/>CNA B failed to perform hand hygiene during incontinent care and failed to bag soiled wipes and briefs prior to placing them on the end of the bed for Residents # 53, #220, #26 and # 7.<BR/>Theses failure could place residents at risk for infection and cross contamination. <BR/>Findings included:<BR/>1. Review of Resident #53's face sheet dated 08/24/22 reflected a [AGE] year-old male, admitted to the facility on [DATE], and a readmission date of 08/01/22. His primary diagnosis included sepsis due to methicillin susceptible staphylococcus aureus (bacteria resistant to several widely used antibiotics), abscess of right hand and Huntington's disease (inherited condition in which nerve cells in the brain break down).<BR/>Observation on 08/24/22 at 09:25 AM revealed CNA B entered Resident #53's room to assist LVN C with wound care. CNA B washed her hands and donned gloves. CNA B held Resident #53's right arm and hand up while LVN C cut away the old dressing. CNA B grabbed the old dressing as it fell away and held it until LVN C could retrieve it and dispose of it in a biohazard bag. CNA B continued to hold the resident arm and hand while LVN C completed the wound care. CNA B, while wearing the same soiled gloves used to assist with the wound care, went to the resident's closet and retrieved a clean brief and laid it on the head of the bed, picked up the bed remote and lowered the resident's bed and then removed her soiled gloves and performed hand hygiene. CNA B re-gloved, raised the resident bed up and unfastened the resident's brief to reveal he had been incontinent of urine. CNA B then pushed the soiled brief down between the resident's legs toward his buttocks and took a wet wipe and wiped down each groin and then wiped up and down the shaft of the resident's penis trying to remove a white sticky substance. CNA B used the same wipe without changing the surface of the wipe with each swipe. CNA B then rolled the resident onto his side and picked up the clean brief with her soiled gloves and placed it under the dirty brief. CNA B proceeded to wipe the resident's buttocks from front to back, removed the soiled brief and placed it and the used wipes on the end the bed. While wearing the same soiled gloves, CNA B reached into the resident chest of drawers and retrieved a package of barrier wipe and applied the barrier cream to the resident's buttocks. CNA B then rolled the resident back onto his back, fastened the brief and pulled up the residents' pants. CNA B then picked up the soiled brief and wipes and placed them in the trash can, removed her gloves and performed hand hygiene. <BR/>2. Review of Resident #220's face sheet dated 08/24/22 reflected an [AGE] year-old male, admitted to the facility on [DATE]. His primary diagnosis included Chronic Obstructive Pulmonary disease, diabetes and history or COVID-19. <BR/>Observation on 08/24/22 at 09:50 AM revealed CNA B entered Resident #220's room to answer his call light. Resident #220 stated he needed to be changed. CNA B washed her hands and donned gloves and gathered wipes and a brief. Resident #220 stood up out of his wheelchair and started to lay down on the bed. CNA B told him to stand and turn around and she pulled down his pants and unfastened the resident's brief to reveal he had been incontinent of urine. CNA B then wiped the resident's anal area, revealing he was having a bowel movement. CNA B asked the resident if he thought he needed to go to the toilet to finish and he stated yes. Resident #220 ambulated to the bathroom. CNA B removed her gloves, washed her hands, and told the resident she would be back. CNA B returned to the room with a gait belt, washed her hands and put on clean gloves. CNA B had the resident stand up and proceeded to wipe the resident's buttocks from front to back and then took another wipe and wiped the residents front and placed a clean brief on the resident and pulled up his pants without changing gloves or performing hand hygiene. CNA B then placed a gait belt around the resident and had him stand at the sink to wash his hands. Resident #220 ambulated back to his wheelchair with CNA B holding onto the gait belt. CNA B then picked up the resident's O2 tubing and handed it to him. Resident #220 stated he was thirsty and needed a drink. CNA B then removed the gait belt from the resident and placed it in her pocket and reached for the resident's water pitcher, knocking the lid off. CNA B replaced the lid, still wearing the same gloves she had worn to provide incontinent care and handed the pitcher to the resident. CNA B then gathered the trash, removed her gloves, and washed her hands with soap and water. <BR/>3. Review of Resident #26's face sheet dated 08/24/22 reflected a [AGE] year-old female, admitted to the facility on [DATE]. Her primary diagnosis included dementia, epilepsy, and extended spectrum beta lactamase resistance (enzyme produced by some bacteria which causes some antibiotics not to work for treating bacterial infections)<BR/>Observation on 08/24/22 at 10:10 AM revealed CNA B entered Resident #26's room to provide incontinence care. CNA B washed her hands and donned gloves, gathered a brief and wipes and placed them on the bed side table. CNA B unfastened the resident's brief to reveal she had been incontinent of urine and had a large bowel movement. CNA B then pushed the soiled brief down between the resident's legs toward her buttocks and took a wet wipe and wiped down each groin and once down the middle. CNA B used the same wipe without changing the surface of the wipe with each swipe. CNA B then rolled the resident onto her side and picked up the clean brief with her soiled gloves and placed it under the dirty brief. CNA B proceeded to wipe the resident's buttocks from front to back, removed the soiled brief and placed it and the used wipes on the end the bed. While wearing the same soiled gloves, CNA B placed the soiled brief into the trash can by the door and reached into the resident chest of drawers and retrieved a tube of barrier wipe and applied the barrier cream to the resident's buttocks. CNA B then rolled the resident back onto her back and took another wipe and wiped again down the resident's groin, removing more bowel movement. CNA B then fastened the brief and covered the resident with sheet and blanket, put the tube of barrier cream back in the residents' chest of drawers, repositioned her bedside table and then removed her gloves and placed in the trash and washed her hands. CNA B then proceeded to provide incontinence care to the roommate, Resident #7. <BR/>4. Review of Resident #7's face sheet dated 08/24/22 reflected an [AGE] year-old female, admitted to the facility on [DATE]. Her primary diagnosis included Parkinson's disease, dementia, and left side hemiplegia (paralysis)<BR/>Observation on 08/24/22 at 10:15 AM revealed CNA B washed her hands and donned gloves, gathered a brief and wipes and placed them on Resident #7 bed side table. CNA B unfastened the resident's brief to reveal she had been incontinent of urine. CNA B then pushed the soiled brief down between the resident's legs toward her buttocks and took a wet wipe and wiped down each groin and once down the middle. CNA B used the same wipe without changing the surface of the wipe with each swipe. CNA B then rolled the resident onto her side and picked up the clean brief with her soiled gloves and placed it under the dirty brief. CNA B proceeded to wipe the resident's buttocks from front to back, removed the soiled brief and placed it and the used wipes on the end the bed, had the resident roll back on her back and fastened the clean brief. While wearing the same soiled gloves, CNA B placed the soiled brief into the trash can by the door, returned to the resident to adjust her clothing and took a clean wipe an washed the bottom of the residents' feet that were covered in with a black substance. CNA B then covered the resident with her bed covers, removed her gloves, and tied up the trash and washed her hands. <BR/>In an interview with CNA B on 08/24/22 at 10:05 AM revealed she had worked at the facility approximately 6 months. When asked when she was supposed to perform glove changes and hand hygiene during incontinence care she stated before you start and after you had completed care. She stated she was not aware she had to change her gloves during incontinence care. She stated she was taught the end of the bed was considered dirty, which was why she placed the soiled brief and wipes at the end of the bed until she had completed care. She stated she knew you were supposed to wipe from front to back and change the surface to the wipes each time, and stated she thought she had done that. She stated she had recently been in serviced on hand hygiene and knew the importance of hand hygiene to prevent infections. <BR/>Review of the facilities in-services on infection control, which covered the facilities hand hygiene policy, dated 08/04/22 revealed neither CNA B had attended. <BR/>In an interview with the DON on 08/24/22 at 1:00 PM revealed staff were to perform hand hygiene before incontinence care and during care they were to remove their gloves and perform hand hygiene when they went from dirty to clean and once, they completed care, they were to perform hand hygiene again. She stated they were always supposed to place dirty wipes and briefs and linens in a plastic bag. She stated failing to follow these procedures placed residents at risk of cross contamination and increased risk of urinary tract infections. She stated all staff were skills checked upon hire and again if training issues were identified. <BR/>In an interview with ADON A on 08/24/22 at 01:15 PM she stated staff were to perform hand hygiene when they entered a resident's room, after contact with any bodily fluid, and they were to change their gloves and perform hand hygiene during incontinent care when they went from dirty to clean. She stated they were never to place dirty linen on the floor or chairs in the room, stating it was to be always supposed to be bagged. She stated she observed CNA B during her skills checks off upon hire and she had performed the procedure correctly at that time. She stated by not following standard precautions with hand hygiene it placed residents at risk of infections and cross contamination. <BR/>Review of the facility's policy titled, Incontinence Care, dated February 2022, reflected, .Have all needed equipment at bedside on the over bed table wipes (at least 7), gloves (at least 3 pair), barrier cream, plastic bag or trash can .Wash hands and put on gloves Remove soiled clothing and brief and place the brief in the trash bag .Take off the gloves, put them in the trash bag. Wash your hands and put on new gloves Cleanse the peri area with wipes going front to back/clean to dirty. Separate the labia. Use a new wipe with ach stroke: Wipe one side, wipe the other side, wipe down the center and then once from hip bone to hip bone .Repeat cleansing until the resident is clean .take off the gloves, put them into the trash bag with the soiled brief and wipes .Wash your hands, put on gloves and apply protective ointment if needed and a clean brief .Remove gloves and wash your hands .Reposition the resident, offer fluids .Remove trash from room .Wash your hands .If performing incontinent care for a male resident .Take the wipe in one hand and gently grasp the penis shift .wipe the head of the penis beginning at the urethra opening working outward or away from the penis head, Cleanse in a circular motion away from the urethra. Use new wipe each time .Cleanse the penis shaft with wipe from the top of the shaft towards the rectum, including the scrotum .Using a new wipe with each stroke clean from the upper part of the leg to the hip <BR/>Review of the facility's policy titled, Infection Control Guidelines, dated February 2021, reflected, .Hand Hygiene Protocol .Staff shall use hand hygiene when coming on duty, between patient contacts, after handling contaminated objects, after PPE removal, and before going off duty .Staff shall wash their hands with an antiseptic preparation before performing patient care procedures and when providing .For routine care, staff shall wash their hands with soap and water or a waterless alcohol agent before and after patient contact .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain from hospice the election form and the physician certification and recertification of the terminal illness specific to each patient for one (Residents#28) of three residents reviewed for hospice care.<BR/>The facility failed to obtain the required hospice documentation of the physician certification of terminal illness and hospice election form from Hospice G for Resident#28. <BR/>These failures could result in services and treatments not being coordinated.<BR/>Findings included: <BR/>Review of Resident#28's Significant Change MDS assessment dated [DATE] reflected Resident#28 was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses were Bradycardia (slow heart rate), hypertension, and dementia. <BR/>Review of Resident#28's Comprehensive Care Plan last revised 07/21/2022 reflected Resident#28 had terminal prognosis and was admitted into Hospice G. <BR/>Review of Resident#28's Consolidated Physician Orders dated 08/24/2022 reflected Resident#28 had a physician order dated 07/24/22 to admit Resident#28 to Hospice G.<BR/>Review of Resident #28's Hospice G book reflected Resident #28 was admitted [DATE]/2022 to Hospice G. The Hospice G book for Resident#28 did not reflect Hospice G physician certification of terminal illness and hospice election form for Resident#28.<BR/>In an interview on 08/25/ 2022 at 10:17 PM, the Administrator stated she did not know the documentation requirements for residents on Hospice. She stated she would contact hospice G for the documentations to be faxed to the facility. She stated she did not know who was responsible assure these documents were in the resident's medical records.<BR/>In an interview on 08/24/2022 at 2:23 PM, the DON revealed she did not know the documentation requirements needed for hospice residents. She stated she did not know who was responsible assure these documents were in the resident's medical records.<BR/>Review of facility's policy Coordination of Hospice Services dated November 2017 reflected, when a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest physical, mental, and psychosocial well- being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to, in accordance with State and Federal laws, ensure all drugs were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to these drugs, to meet the needs of each resident, for 1 (Resident #1) of four residents reviewed for medication storage.<BR/>The facility failed to ensure Resident #1 did not have wound treatment medications and unsecured medications in his room on 01/04/23.<BR/>This deficient practice could place residents at risk of, not being monitored for their medications, adverse reactions, and drug diversion. <BR/>Findings included:<BR/>Review of Resident #1's face sheet dated 01/04/23 reflected Resident #1 was a [AGE] year-old male admitted on [DATE] to the facility with diagnoses that included obesity, chronic hepatitis C, hyperlipidemia, hypokalemia, depression and peripheral vascular disease.<BR/>Review of Resident #1's quarterly MDS assessment dated [DATE] reflected he had a BIMS of 13 indicating he was cognitively intact.<BR/>Review of Resident #1's care plan reflected on 10/18/22 with target date of 04/06/23 that Resident #1 had potential for the development of a pressure ulcer. The comprehensive care plan did not reflect Resident #1 could self-administer his medications and keep medications in his room. <BR/>Review of Resident #1's January 2023 electronic physician order indicated Triamcinolone Acetonide Ointment (used help to relieve redness, itching, swelling, or other discomfort caused by skin condition) 0.1% apply to both legs topically every day shift wound. Silvadene Cream (used to prevent and treat wound infections) 1% apply to leg wound topically one time daily. Lidocaine Ointment (used to cause numbness or loss of feeling) 5% apply to wounds topically every 4 hours as needed for wounds.<BR/>Review of Resident #1's MAR/TAR for January 2023 reflected the resident was given Triamcinolone Acetonide Ointment 0.1% and Silvadene Cream 1% on the following dates: 01/01-01/03/23. <BR/>Observation and interview on 01/04/23 at 11:30 AM revealed Resident # 1 had 2 tubes of Lidocaine Ointment, 1 tubes of Triamcinolone Acetonide Ointment, and 2 tubes of Silvadene Cream in his unlocked bedside table drawer. Each had Resident #1's name written on it. There were no facility staff in resident's room. Resident #1 stated LVN A gave them to him, and Resident #1 said he uses each of the medications two times a day but that he only used a small amount of each medication cream. <BR/>An interview on 01/04/23 at 9:24 AM with LVN A revealed he did give Resident #1 medications and supplies to keep in his room to self-treat his wounds on the weekends. LVN A stated that the resident prefers to do his own treatments on the weekends. So on Fridays LVN A made sure he had the supplies he needed. LVN A stated he did not know if the resident was able to self-treat or not. LVN A stated the risk of having medications in a resident's room could result in drug being mishandled. <BR/>An interview on 01/04/23 at 10:34 AM with the ADON revealed Resident #1 should not have medications in his room and did not self-administer his medications. The ADON stated the nurses should not leave a resident's room without taking medications with them. The ADON stated that the risk of leaving medications in a resident room could result in another resident having access to unprescribed medication. <BR/>An interview on 01/04/23 at 12:30 PM with the DON revealed she observed the following medications: 2 tubes of Lidocaine Ointment, 1 tubes of Triamcinolone Acetonide Ointment and 2 tubes of Silvadene Cream in Resident #1's room. The DON stated she would address leaving the medications in Resident #1's room with LVN A. The DON stated that her expectation was for no medications to be left in a Resident's room. The DON stated the risk of having medications in a resident's room could result unauthorized access to a medication.<BR/>An interview on 01/04/23 at 2:16 PM with the ADM revealed LVN A should not have left medications in Resident #1's room. She stated Resident #1 should not have medications left in his room and she would take care of it. <BR/>Review of the facility's policy Medication Storage dated 01/20/21 reflected 1. General guidelines: a. All drugs and biologicals are stored in locked compartments (for example medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature. B. Only authorized personnel will have access to the keys to locked compartment.

Based on interview and record review, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed for qualifications of Social Worker.<BR/>1. <BR/>The facility, licensed for 144 beds, did not employ a full-time social worker from 3/26/25 to 6/11/25.<BR/>This failure could place residents at risk of social service and psychosocial needs not being met.<BR/>The findings included:<BR/>Record review of the facility's Daily Census Report, dated 6/10/25, noted the facility had a total licensed bed capacity of 144. <BR/>Record review of the Facility Summary Report from the Texas Unified Licensure Information Portal (TULIP) date 06/06/25 noted the facility had a total licensed capacity of 144 beds.<BR/>Record review of an undated document titled Job Details reflected the Previous Social Worker was employed from 7/11/23 to 3/26/25. <BR/>In an interview on 6/10/25 at 2:37 PM, ADON B stated the facility did not have a social worker and had not had a social worker since the end of March. ADON B stated the Previous Social Worker left on vacation and decided not to return to work. <BR/>In an interview on 6/10/25 at 2:51 PM, the DON stated there was not a social worker currently employed by the facility and that the social work duties were divided up between different staff members. The DON stated she did not believe it was a risk to the residents due to herself and the Administrator who covered the social worker duties. <BR/>In an interview on 6/10/25 at 5:05 PM, the Administrator stated the social worker duties were divided between herself and the DON. The Administrator stated she did not think it was a risk to not have a social worker because she and the DON spoke with the residents daily and all appointments were automatically scheduled by a third party. The Administrator continued to state if a resident had an issue arise which required a social worker the resident would tell her about it or a staff member. The Administrator also stated she was advised by her corporate leadership she should contact a social worker from another facility to assist if needed. The Administrator stated she had not contacted another facility's social worker for assistance.<BR/>Record review of the facility's policy titled Social Services Department Policies and Procedures dated 12/97 reflected:<BR/> If the social worker is on leave or the position is vacant, the Administrator will develop a plan to cover the department duties.

Based on record review, interviews, and facility policy review, the facility failed to ensure a quarterly trust fund statement was provided to the resident's for 3 (Resident #2, Residnet # 3 and Resident #4) of 28 residents reviewed for personal funds.,<BR/>The facility failed to provide quarterly statements to the residents receiving insurance funds.<BR/>This failure could place the residents at risk for not having access to their insurance funds and not having their personal needs met. <BR/>Findings included:<BR/>Record review of an undated list of residents provided by the ADM revealed that 28 residents received healthcare insurance funds . The list included Resident #2, Resident #3 and Resident #4 .The facility did not have evidence of the residents statements. <BR/>An interview with the ADM on 02/06/23 at 10:58 am revealed each of the 28 residents listed received insurance funds each quarter of the year . The ADM created an online account for each of the residents. She was able to access the resident funds and buy items. The ADM stated only one resident had access to the funds, there were 27 residents that did not have access to their funds. She stated some of the residents were not able to decide which items to be purchased because of issues with decision making. The ADM did not communicate with those residents' representatives. The ADM revealed only one resident was informed of the funds available. The ADM did not communicate the availability of the funds to the 27 remianing residents. She stated one resident of the 28 handled his own funds and made his own purchases. The ADM revealed that, she was informed the funds of $350 for each resident was available. The ADM stated she used the funds to purchase briefs and toothpaste of all residents of the facility . She had no evidence of the items purchased, she had no receipts. The ADM did not have balances for each resident. She did not inform the 27 residents of the balance or the amount spent. She handled all aspects of the funds.<BR/>An interview with Resident #2 on 02/06/23 at 1:17 pm revealed she was not aware of insurance funds available to purchase items for herself. The resident stated no one at the facility informed her of the balance remaining or the funds spent .<BR/>An interview with Resident #3 on 02/06/23 at 1:31 pm revealed he was not aware of insurance funds provided quarterly. The facility had not informed him of items that could have been purchased.<BR/>An interview with Resident #4 on 02/06/23 at 2:09 pm revealed the resident had no knowledge of insurance funds provided quarterly. <BR/>Record Review of the facility's Statement of Resident Rights revealed <BR/>You have the right to; 12. Manage your own finances or to delegate that responsibility to another person. 13. Access money and property you have deposited with the facility and to an accounting of your money and property deposited with the facility.

Based on observation, interview, and record review the facility failed to ensure all patient care equipment was in safe operating condition for three (Residents #5, #10, and #46) of 12 residents reviewed for wheelchair maintenance.<BR/>The facility failed to properly maintain wheelchairs for Residents#5, #10, and #46.<BR/>This failure could place residents at risk for skin tears and discomfort.<BR/>Findings included:<BR/>Observation on 08/24/22 at 11:00 AM revealed the arm rest pad on Resident 5's wheelchair was missing from the wheelchair.<BR/>Observation on 08/24/22 at 11:15 AM revealed that both armrest on Resident 46's wheelchair, the vinyl was cracked with the foam beneath exposed.<BR/>Observation on 08/24/22 at 11:17 AM revealed that the right arm rest on Resident #10's wheelchair, the plastic support beneath the vinyl cover was broken and the foam was missing. There was no injury to the resident. <BR/>In an interview on 08/24/22 at 2:00 PM with the Maintenance Manager he stated he does the repairs on resident's medical equipment and that staff write the needed repair in the maintenance log at the nurse's station. He was not aware of the needed repairs. <BR/>In an interview on 08/25/22 at 7:45 AM with the DON, she stated when a resident's wheelchair needed repair staff write the need in the maintenance log at the nurse's station.<BR/>In an interview on 08/25/22 at 7:46 AM with the Administrator, she stated the Maintenance person repairs resident medical equipment. She stated staff write the need in the maintenance logbook. She stated she also notifies maintenance of needed repair using the TELS system which messages him on his phone of the need. <BR/>In an interview on 08/25/22 at 8:10 AM with LVN D, she stated when a resident had a wheelchair that needed repair, she would write the need in the maintenance log at the nurse's station.<BR/>In an interview on 08/25/22 at 8:11 AM with CNA F, she stated when a resident's wheelchair needed repair, she writes the need in the maintenance log at the nurse's station. <BR/>In an interview on 08/25/22 at 8:15 AM with ADON A, she stated when a resident had a wheelchair that needed repair, she would write the need in the maintenance log at the nurse's station.<BR/>In an interview on 08/25/22 at 8:17 AM with LVN E, she stated when a resident had a wheelchair that needed repair, she would write the need in the maintenance log at the nurse's station.<BR/>In an interview on 08/25/22 at 8:18 AM with LVN C, he stated when a resident had a wheelchair that needed repair, she would write the need in the maintenance log at the nurse's station.<BR/>A review of the facility policy entitled, Maintenance Inspection with a date of 04/11/22 indicated, 5. The maintenance repair long will be reviewed daily to identify items for inspection and or repair.<BR/>A review of the previous two months of the maintenance work orders revealed there were none that indicated resident's wheelchairs were in need of repairs.